Liecker Self Government and Outpatient Care 2010
Content
Self Government and Outpatient Care in German Statutory Health Insurance (SHI)
Dr. Bodo Liecker, MPH
Department of Strategic Healthcare Management
Visit of the British Delegation g 10th May 2010 in Hamburg/Germany
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
1
Social Insurance Health Spendings Social Insurance
Statutory y Pension Insurance
Statutory y Unemployment Insurance
Statutory y Health Insurance SHI
Statutory y Long term care Insurance
Statutory y Accident Insurance
SHI (without administration costs): 160 bn EUR (2009) Other Statutory Insurances (without administration costs): 27 bn EUR (2008) Private Health Insurance: 25 bn EUR (2008) Private Households: 35 bn EUR (2008) G Government t and d Public P bli Institutions: I tit ti 13 bn b EUR (2008) Employers: 11 bn EUR (2008)
P i t and Private d Public P bli Institutions I tit ti
Source: Federal Statistical Office (Apr 2010), www.destatis.de/jetspeed/portal/cms/Sites/destatis/Internet/EN/Navigation/Homepage__NT.psml SHI data: Ministry for Health www.bmg.bund.de/, in English: www.bmg.bund.de/EN/Ministerium/ministry__node.html?__nnn=true
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
2
Self Government Principles
Steering-Levels in Statutory Health Insurance
Ministry of Health, overall framework, law ("Books of social soc a law") a ) Negotiate framework/guidelines, details and implementation Act under the conditions diti given i
Macro-Level (Government) Associations Level Micro-Level (Individuals, (Individuals single actors)
2
Self Government Principles
The Principle of Self-Government
Framework is given by Government and Ministry of Health Implementation and detailing is up to self-government institutions of
sickness funds and providers
SHI in Germany is based on corporatism: health provision contracts
are negotiated between the associations of sickness funds and the associations i ti of f providers id
Membership in associations and contracts are mandatory for single
sickness funds and single providers
2
Self Government on Federal Level Players - Defining Framework/Guidelines
Players on Federal Level (In(In and Outpatient Care)
Association of all Health Insurance Funds in SHI Associations of Health Care Providers Outpatient care KBV
Head Organisation of the regional Statutory Health Insurance Physicians associations
Inpatient care DKG
German Hospital Association
GKVSpitzenverband p
Head Organisation Statutory Health Insurance
KZBV
Head Organisation g of the regional Statutory Health Insurance Dentists associations
2
Self Government on Federal Level Defining Framework/Guidelines in Outpatient Care
Players on Federal Level (Outpatient Care)
Association of all Health Insurance Funds in SHI Associations of Health Care Providers
GKVSpitzenverband p
Head Organisation Statutory Health Insurance
KBV
Head Organisation g of the regional Statutory Health Insurance Physicians associations
GKV-Spitzenverband: www.gkv-sv.de, in English: www.gkv-spitzenverband.de/Statutory_health_insurance.gkvnet KBV: www.kbv.de
2
Self Government on Federal Level Defining Framework/Guidelines in Outpatient Care
The Principles and Issues of Self Government in Outpatient Care
GKV-SV
Head Organisation St t t H lth Statutory Health Insurance
KBV negotiate nationwide F Framework k
National Association St t t Statutory H lth Health Insurance Physicians
Basic Contract Doctor-SHI and payment Catalogue of Benefits
►
2
Self Government on Federal Level Defining the Catalogue of Benefits
Catalogue of Benefits - who decides ?
Picture by G-BA
Federal Joint Commitee
authorised by law to issue legally binding directives p providers, SHI funds and p p patients represents uses extern and impartial assesment (IQWiG) main decision criteria are: evidence, costs/benefits and harm
Picture by Gemeinsamer Bundesausschuss: www.g-ba.de, in English: www.g-ba.de/institution/sys/english/
2
Self Government on Federal Level Defining the Catalogue of Benefits
Decision Making Body - "Plenum" Plenum
Federal Joint Committee 13 Voting Members: 3 Impartial Members 5 Members SHI (GKV SV) (GKV-SV) 5 Members Provider (2 DKG) (2 KBV) (1 KZBV) 5 Members Patientorganisations 5 Non Voting Members:
2
Self Government on federal level Duties Responsibilities and Doctors Payment Duties,
Negotiating basic components of the relationship doctors - SHI
GKV-SV
Head Organisation St t t Statutory H lth Health Insurance
KBV negotiate nationwide F Framework k
National Association St t t Statutory H lth Health Insurance Physicians
Basic Contract Doctor-SHI and payment Catalogue of Benefits
►
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Basic Contract - Duties and Responsibilities Basic Contract Doctor-SHI Doctor SHI
"Arzt-/Ersatzkassenvertrag (EKV)"
autorisation for treatment forms (e.g. prescriptions) and documentation opening duration of doctor's practice, visits at patients home collecting practice fees sanctions
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Principles of Doctors Payment Committee for Rating g Doctors‘ Services
6 Voting Members: additional 3 Voting Impartial Members* 3 Members SHI (GKV-SV) (GKV SV) 3 Members KBV
* if GKV-SV GKV SV and d KBV reach no agreement
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Principles of Doctors Payment Committee for Rating g Doctors‘ Services "Bewertungsausschuss"
classifies l ifi the h price i f for each hd doctors service* i * [i [in points] i ] defines each single outpatient service* negotiate basic point value defines broad renumeration Uniform Fee Shedule
("einheitlicher Bewertungsmaßstab") maßstab )
2
Self Government on Federal Level The Uniform Fee Shedule
Service Here: Stress-ECG S CG Definition of Service
Fee Schedule Item
Number of Points Special Accounting Rules
Here: an additional ECG (13 250) is not allowed if point-value is 3,5048 Ct, d t ‘ payment doctor‘s t is i 19,80 19 80 € (incl. office-rent, material, wages,...)
2
Self Government on Federal Level The Uniform Fee Shedule
g Directives for ... The Uniform Fee Shedule with Accounting all Physicians
medical certificates, certificates records care at night/weekend / emergency visit at patients home screening and early detection
Note: accounting period is allways the quarter of the year
General Practitioners
principle: basic rate + supplementary fees • Basic rates are graded to the age • supplementary fee: chronical ill patients selected special services: longtime ECG, spirometry...
Specialists
principle: basic rate + special services • Basic rates are graded to the age different fee items for each group
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
3
Self Government on State Level Players
Regional Players - Negotiating the regional contracts State L Level
Landesverbände der Krankenkassen
Negotiating Organisations of the Health Insurance Funds (SHI) in State
KV
Association of Statutory Health I Insurance Ph i i Physicians i St in State t
Regional Basic Contract Doctor Doctor-SHI SHI Additional Services Regional Point Value / Medical Fee Shedule in Euro Supply of Pharmaceuticals Feasibility Checks
3
Self Government on State Level Regional Rules of Renumeration
Merits in points
(EBM - Uniform Fee Shedule)
Kassenärztliche Vereinigung (KV)
Association of Statutory H lth Insurance I Ph i i Health Physicians in State Rules for the distribution of renumeration for example:
• extrabudgetary/budgetary i t ti interventions • General Practitioners/ Specialists point value adjusting j g •p
Doctor
Compensation Package (members x capitation) Single g SHI Fund Single SHI Fund Single SHI Fund
State Le S evel
Doctor Doctor
Doctor Doctor Doctor
Payment: point value x point sum (single Physician)
up to individual/section standardised maximum
3
Self Government on State Level Regional Rules of Renumeration
Previous:
SHI funds pay a overall remuneration (capitation x SHI-Members) to
KVen, based on the needs and outpatient services in 1993 Payment for out out-patient-care patient care independent on the state of health The overall renumeration varies analogous with the wage growth (maximum) not with the changed needs for medical services
Consequence:
Payments y do not meet the real needs No compatibility with the new financial terms (morbidity adjusted risk
Future:
structure compensation scheme, Gesundheitsfonds (health care stock))
Payment will depend on patient's state of health
3
Self Government on State Level Regional Rules of Renumeration
Merits in €
(EBM - Uniform Fee Shedule)
Kassenärztliche Vereinigung (KV)
Association of Statutory H lth Insurance I Ph i i Health Physicians in State Rules for the distribution of renumeration for example:
• extrabudgetary/budgetary i t ti interventions • General Practitioners/ Specialists point value adjusting j g •p
Doctor
(calculated Individual needs of each insured x point value) Single g SHI Fund Single SHI Fund Single SHI Fund
State Le S evel
Doctor Doctor
Doctor Doctor Doctor
Payment: merits in € (single physician) up p to individual standardised maximum (depending on morbidity)
Thank you for your attention!
www.tk-online.de tk li d
Dr. Bodo Liecker, MPH
Department of Strategic Healthcare Management
Visit of the British Delegation g 10th May 2010 in Hamburg/Germany
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
1
Social Insurance Health Spendings Social Insurance
Statutory y Pension Insurance
Statutory y Unemployment Insurance
Statutory y Health Insurance SHI
Statutory y Long term care Insurance
Statutory y Accident Insurance
SHI (without administration costs): 160 bn EUR (2009) Other Statutory Insurances (without administration costs): 27 bn EUR (2008) Private Health Insurance: 25 bn EUR (2008) Private Households: 35 bn EUR (2008) G Government t and d Public P bli Institutions: I tit ti 13 bn b EUR (2008) Employers: 11 bn EUR (2008)
P i t and Private d Public P bli Institutions I tit ti
Source: Federal Statistical Office (Apr 2010), www.destatis.de/jetspeed/portal/cms/Sites/destatis/Internet/EN/Navigation/Homepage__NT.psml SHI data: Ministry for Health www.bmg.bund.de/, in English: www.bmg.bund.de/EN/Ministerium/ministry__node.html?__nnn=true
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
2
Self Government Principles
Steering-Levels in Statutory Health Insurance
Ministry of Health, overall framework, law ("Books of social soc a law") a ) Negotiate framework/guidelines, details and implementation Act under the conditions diti given i
Macro-Level (Government) Associations Level Micro-Level (Individuals, (Individuals single actors)
2
Self Government Principles
The Principle of Self-Government
Framework is given by Government and Ministry of Health Implementation and detailing is up to self-government institutions of
sickness funds and providers
SHI in Germany is based on corporatism: health provision contracts
are negotiated between the associations of sickness funds and the associations i ti of f providers id
Membership in associations and contracts are mandatory for single
sickness funds and single providers
2
Self Government on Federal Level Players - Defining Framework/Guidelines
Players on Federal Level (In(In and Outpatient Care)
Association of all Health Insurance Funds in SHI Associations of Health Care Providers Outpatient care KBV
Head Organisation of the regional Statutory Health Insurance Physicians associations
Inpatient care DKG
German Hospital Association
GKVSpitzenverband p
Head Organisation Statutory Health Insurance
KZBV
Head Organisation g of the regional Statutory Health Insurance Dentists associations
2
Self Government on Federal Level Defining Framework/Guidelines in Outpatient Care
Players on Federal Level (Outpatient Care)
Association of all Health Insurance Funds in SHI Associations of Health Care Providers
GKVSpitzenverband p
Head Organisation Statutory Health Insurance
KBV
Head Organisation g of the regional Statutory Health Insurance Physicians associations
GKV-Spitzenverband: www.gkv-sv.de, in English: www.gkv-spitzenverband.de/Statutory_health_insurance.gkvnet KBV: www.kbv.de
2
Self Government on Federal Level Defining Framework/Guidelines in Outpatient Care
The Principles and Issues of Self Government in Outpatient Care
GKV-SV
Head Organisation St t t H lth Statutory Health Insurance
KBV negotiate nationwide F Framework k
National Association St t t Statutory H lth Health Insurance Physicians
Basic Contract Doctor-SHI and payment Catalogue of Benefits
►
2
Self Government on Federal Level Defining the Catalogue of Benefits
Catalogue of Benefits - who decides ?
Picture by G-BA
Federal Joint Commitee
authorised by law to issue legally binding directives p providers, SHI funds and p p patients represents uses extern and impartial assesment (IQWiG) main decision criteria are: evidence, costs/benefits and harm
Picture by Gemeinsamer Bundesausschuss: www.g-ba.de, in English: www.g-ba.de/institution/sys/english/
2
Self Government on Federal Level Defining the Catalogue of Benefits
Decision Making Body - "Plenum" Plenum
Federal Joint Committee 13 Voting Members: 3 Impartial Members 5 Members SHI (GKV SV) (GKV-SV) 5 Members Provider (2 DKG) (2 KBV) (1 KZBV) 5 Members Patientorganisations 5 Non Voting Members:
2
Self Government on federal level Duties Responsibilities and Doctors Payment Duties,
Negotiating basic components of the relationship doctors - SHI
GKV-SV
Head Organisation St t t Statutory H lth Health Insurance
KBV negotiate nationwide F Framework k
National Association St t t Statutory H lth Health Insurance Physicians
Basic Contract Doctor-SHI and payment Catalogue of Benefits
►
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Basic Contract - Duties and Responsibilities Basic Contract Doctor-SHI Doctor SHI
"Arzt-/Ersatzkassenvertrag (EKV)"
autorisation for treatment forms (e.g. prescriptions) and documentation opening duration of doctor's practice, visits at patients home collecting practice fees sanctions
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Principles of Doctors Payment Committee for Rating g Doctors‘ Services
6 Voting Members: additional 3 Voting Impartial Members* 3 Members SHI (GKV-SV) (GKV SV) 3 Members KBV
* if GKV-SV GKV SV and d KBV reach no agreement
2
Self Government on Federal Level Duties Responsibilities and Doctors Payment Duties,
Principles of Doctors Payment Committee for Rating g Doctors‘ Services "Bewertungsausschuss"
classifies l ifi the h price i f for each hd doctors service* i * [i [in points] i ] defines each single outpatient service* negotiate basic point value defines broad renumeration Uniform Fee Shedule
("einheitlicher Bewertungsmaßstab") maßstab )
2
Self Government on Federal Level The Uniform Fee Shedule
Service Here: Stress-ECG S CG Definition of Service
Fee Schedule Item
Number of Points Special Accounting Rules
Here: an additional ECG (13 250) is not allowed if point-value is 3,5048 Ct, d t ‘ payment doctor‘s t is i 19,80 19 80 € (incl. office-rent, material, wages,...)
2
Self Government on Federal Level The Uniform Fee Shedule
g Directives for ... The Uniform Fee Shedule with Accounting all Physicians
medical certificates, certificates records care at night/weekend / emergency visit at patients home screening and early detection
Note: accounting period is allways the quarter of the year
General Practitioners
principle: basic rate + supplementary fees • Basic rates are graded to the age • supplementary fee: chronical ill patients selected special services: longtime ECG, spirometry...
Specialists
principle: basic rate + special services • Basic rates are graded to the age different fee items for each group
Agenda g
1 Social Insurance 2 Self Government on Federal Level
Principles of Self Government Players aye s Catalogue of Benefits Duties, D ties Responsibilities and Doctors Payment Pa ment
3 Self Government on State Level
Players g Rules of Renumeration Regional
3
Self Government on State Level Players
Regional Players - Negotiating the regional contracts State L Level
Landesverbände der Krankenkassen
Negotiating Organisations of the Health Insurance Funds (SHI) in State
KV
Association of Statutory Health I Insurance Ph i i Physicians i St in State t
Regional Basic Contract Doctor Doctor-SHI SHI Additional Services Regional Point Value / Medical Fee Shedule in Euro Supply of Pharmaceuticals Feasibility Checks
3
Self Government on State Level Regional Rules of Renumeration
Merits in points
(EBM - Uniform Fee Shedule)
Kassenärztliche Vereinigung (KV)
Association of Statutory H lth Insurance I Ph i i Health Physicians in State Rules for the distribution of renumeration for example:
• extrabudgetary/budgetary i t ti interventions • General Practitioners/ Specialists point value adjusting j g •p
Doctor
Compensation Package (members x capitation) Single g SHI Fund Single SHI Fund Single SHI Fund
State Le S evel
Doctor Doctor
Doctor Doctor Doctor
Payment: point value x point sum (single Physician)
up to individual/section standardised maximum
3
Self Government on State Level Regional Rules of Renumeration
Previous:
SHI funds pay a overall remuneration (capitation x SHI-Members) to
KVen, based on the needs and outpatient services in 1993 Payment for out out-patient-care patient care independent on the state of health The overall renumeration varies analogous with the wage growth (maximum) not with the changed needs for medical services
Consequence:
Payments y do not meet the real needs No compatibility with the new financial terms (morbidity adjusted risk
Future:
structure compensation scheme, Gesundheitsfonds (health care stock))
Payment will depend on patient's state of health
3
Self Government on State Level Regional Rules of Renumeration
Merits in €
(EBM - Uniform Fee Shedule)
Kassenärztliche Vereinigung (KV)
Association of Statutory H lth Insurance I Ph i i Health Physicians in State Rules for the distribution of renumeration for example:
• extrabudgetary/budgetary i t ti interventions • General Practitioners/ Specialists point value adjusting j g •p
Doctor
(calculated Individual needs of each insured x point value) Single g SHI Fund Single SHI Fund Single SHI Fund
State Le S evel
Doctor Doctor
Doctor Doctor Doctor
Payment: merits in € (single physician) up p to individual standardised maximum (depending on morbidity)
Thank you for your attention!
www.tk-online.de tk li d
