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A healthy choice für everyone!THE HEALTHCARE REFORM:
A healthy choice for everyone!
KEEPING GERMANY HEALTHY
Dear Fellow Citizens,
in the future, you can continue to count on receivingthe medical care that you need, regardless of your age or income. It took a great deal of effort to preservethis social achievement, but we have succeeded. Thenew healthcare reform took effect on 1st January2004. This paves the way for finding solutions tourgent problems, lowering healthcare contributions,reducing expenditure, and promoting competition forhigher quality and more efficiency in our healthcaresystem.
Economic common sense, a spirit of cooperation, and health-conscious be-haviour will now be rewarded. The false incentives that contributed to thewasting of resources have been eliminated. We want every euro that entersthe statutory health insurance system to be of maximum benefit to our patients.
We all have to work together to achieve this common objective: doctors andpharmacists, hospitals and statutory health insurance funds, unions and associa-tions – and patients, too. We have given patients more choices and a far greatersay in health matters, and with the new family doctor system, we have giventhem someone they can depend on when it comes to medical matters. Askyour doctor or pharmacist, and obtain information from your health insurance fund. Find out how you can get the best care possible. And above all,make use of available prevention and early detection programmes to stayhealthy. After all, nothing is more precious than your health.
Ulla SchmidtMinister of Health and Social Security CONTENTS:
What are the benefits of the healthcare reform? More involvement
The patient receipt/The digital health card More powerful patient representation/The patient ombudsman More quality
The family doctor system/Medical treatment centres/ The Institute for Quality and Cost-Effectiveness More efficiency
New reference-price regulations for medications/ No price controls for over-the-counter products/Mail-order drugs/Panel doctors’ associations and health insurance funds Fighting corruption/Statutory health insurance OUR HEALTHCARE SYSTEM:
Strong, but in need of improvement
Our healthcare system is strong. The modern welfare state is built on theconcept of statutory health insurance, and it remains one of the greatestachievements of our society. It guarantees that everyone who falls ill,regardless of age or income, receives appropriate care, and that this care isin keeping with advances in medical technology. We intend to maintain thissystem.
However, this safety net should not simply be taken for granted. First of all,societal framework conditions have completely changed and, secondly, within this system itself, not everything is running as smoothly as it should.
By 2050, there will only be an average of 1.7 employed individuals for every
pensioner. In 2001, there were 3.8 employees contributing to the system for
every retiree. What’s more, advances in medical technology continue to
push costs higher. This means that without sweeping reforms, statutory
health insurance fund contributions will continue to rise in the future or
services will have to be reduced. We want to avoid these developments.
Low-quality care despite high expenditure
Statutory healthcare contributions put more than €140 billion a year – a huge
amount of money – at the disposal of the statutory health insurance system.
Yet there remain significant quality deficiencies in this system. Experts have
identified a number of problems. Some patients receive more care and medi-
cations than they need, others receive too little, and some are given the
wrong type of care. This is detrimental to patient health, and creates unne-
cessary costs. These problems are a result of insufficient coordination of
medical treatment. The system does not adequately address the needs of
patients. We want to change that.
Patients faced with a maze of options
The healthcare system is there for the patients, but it also confronts them with
a maze of options. What is the right form of treatment? Which medications will
really help me? Am I getting the best advice? Patients have to hope and trust
that they receive only the very best and most effective care from doctors,
hospitals and pharmacies. They also have to assume that the development of
new medications by pharmaceutical companies is in their best interest. But
only well-informed patients can judge for themselves, take decisions, and
share in assuming responsibility for their health. We want patients to onceagain be the focus of our system. Healthcare must always include patientparticipation.
This means that in order to preserve the solidary character of our healthcaresystem, it was necessary to focus our financial resources on essential carewhile eliminating the deficiencies in the system. All of the services providedby our healthcare system, and every reform that changes it, must measure upto the same objective: they have to benefit the patients! What are the benefits of the healthcare reform?
The healthcare reform makes it easier for patients to obtain informationand to play an active role in the treatment process. A key component isincreased transparency of healthcare services and costs.
The healthcare reform guarantees improvements in the quality of careprovided. It actively promotes better cooperation among all sectors ofthe healthcare system.
The healthcare reform creates incentives that promote health andcost-consciousness on all sides. This encourages competition andallows for the creation of efficient structures.
Patients have more to say than “Ahhhh”!
Did your doctor clearly explain the nature of your last illness and thesuggested means of treatment? Have you ever received a receipt from your doctor? Have you ever received a full account of your vaccinations, allergies,laboratory test results, diagnoses, and medications? The focus is on you
Most of us are prepared to make a majoreffort when it comes to maintaining ourhealth or recovering from an illness.
Unfortunately, this aspect is often ig-nored in our healthcare system. Manypatients are treated without being con-sulted or given explanations. Thus, theycannot play an active role in the treat-ment process, and they make little con-tribution to the process of healing theirillness.
Since the purpose of the system is to serve the patients, they should be thefocus of all forms of treatment. Patients can only take responsibility for theirown health if they are informed of the risks and benefits of a given treatment,or they can at least ask their doctor important questions concerning that treatment.
The healthcare reform guarantees this. It provides a clear overview of allmedical services, and an improved basis for doctor-patient relationships thatare based on mutual trust and cooperation. It also improves the rights ofparticipation for patients’ associations, and provides for a patient ombuds-man who looks after the patient’s rights. By giving patients a comprehensiveunderstanding of the healthcare system, it allows them to make valid judge-ments and act in a manner that is both health and cost-conscious.
THE PATIENT RECEIPT:
A better understanding of the services provided
As a patient, you now have a better overview of the services provided byyour doctor and the costs of these services. Upon request a clearlyunderstandable list of the services and costs will be given to you by yourdoctor, dentist or hospital.
Patients can choose between what is known as a daily receipt after visiting their doctor, or they can opt to receive a final report at the end ofeach quarter. The report clearly lists all services rendered, and what theycost. This serves to inform everyone concerned and to enhance trustbetween doctors and patients. Such transparency is a prerequisite forsuccessful treatment, and it contributes to a patient-doctor relationshipthat is based on mutual trust and cooperation.
THE DIGITAL HEALTH CARD:
Your own health at a glance
You will soon have full access to all your health records. In 2006, a digitalhealth card will replace the current health insurance card. This card willcontain all patient information and the required data for writing digitalprescriptions. Patients can also opt to have important personal health informationplaced on the card. This data can range from medications taken to emer-gency information such as blood type, allergies, and chronic diseases.
Patients decide for themselves how much information should be savedand who will have access to it. To ensure confidentiality, only authorisedpersonnel with a digital health professional card will have access to thisinformation. This is the second “key” required to access the contents ofthe card.
THE INSUREE BONUS:
Prevention saves you money
Patients who take an active role in protecting their health and put the servicesof the healthcare system to good use are now eligible for a bonus from theirhealth insurance fund. For example, they can have regular check-ups as partof an early detection or prevention programme. Patients who sign up for thefamily doctor system and take part in prevention programmes or special pro-grammes for the chronically ill can also qualify for a bonus from their healthinsurance fund.
Each statutory health insurance fund will decide on the details of its own version of the bonus system. As a “reward”, patients may receive reductionsin their co-payments and practice fees. Or their insurance contributions maybe reduced. There may also be other bonuses including prizes. There aremany ways of motivating people to take an active role in maintaining theirhealth, or to act responsibly when they are ill. Each health insurance fundoffers its own solutions. You can compare their offers to find the one that bestsuits your needs. In the end, you decide.
You know where your insurer spends your money
You should know exactly where your health insurance fund spends your contributions. Each year, the statutory health insurance funds are required topublish a final report in their member magazines. These reports list, forexample, the expenditure for hospital treatment, medications, admin-istration and personnel costs, etc. The report also lists the salaries, pensionplans and all bonuses received by board members.
STRONGER PATIENT REPRESENTATION:
Advocating the interests of patients
All committees are required to take into account the interests of theirpatients when important decisions are taken that affect them. As a result,organisations representing patient rights are directly involved in thedecision-making process, for example, patients’ associations, associationsfor people with disabilities, and self-help organisations. This will affect theoutcome of such important issues as whether or not new therapies and drugtreatments are effective and should thus be paid for by the health insurancefunds.
THE PATIENT OMBUDSMAN:
Patients are included in decision-making
The new patient ombudsman appointed towards the end of 2003 at theFederal level, ensures that closer attention is paid to the interests of patients.
She will work to further the rights of patients and to create more opportuni-ties for patients to have an impact on the healthcare system.
The patient ombudsman helps improve transparency in the health-caresystem and works closely with patient associations and organisations tobring the interests of patients to the attention of the public. You can alsoaddress questions and complaints to this new representative.
More competition means better quality for you!
Prior to your last surgery, were you able to compare and find outwhich hospital in your area has the best success rate for that parti-cular procedure? Does your general practitioner know about other doctors or ther-apists that you see, does he know about their diagnoses, and are thetherapies coordinated to achieve maximum results? Has your health insurance fund ever offered you a reward for regularcheck-ups or other preventive measures? Quality assurance and improvement
Germany already has what it takes to assure top-quality health-care: highlytrained physicians, state-of-the-art medical equipment, nationwide hospitalcare, and first-rate pharmaceuticals. However, the existing possibilities of ourefficient healthcare system have not always been used in such a way and soconsistently that they have been of genuine benefit to our patients. In otherwords, we have tolerated far too much poor quality in the system. In manyareas, there is insufficient cooperation among doctors, hospitals and otherproviders of medical care. Our medical care system lacks quality assurance.
We can no longer accept this. The healthcare system needs more competitionto improve quality.
Our healthcare reform will changestructures so that all sectors of the health-care system will be able to cooperatemore effectively. In addition, we willmake sure that there is more qualityassurance in doctors’ practices andhospitals. This will result in better careand treatment for patients.
THE FAMILY DOCTOR SYSTEM:
Visiting your family doctor is the right first step, and it
can save you money
Health insurance funds are required to offer members a family doctorsystem. This means that patients can choose a family doctor as their primarysource of care. This family doctor is the first port of call for patients, and itallows him to remain informed on all aspects of their treatment. He knowsthe health history of all patients, advises them, and consults with them con-cerning therapeutic options. Patients who first go to their family doctor whenthey fall ill may enjoy a number of financial advantages. Health insurancefunds have the option of rewarding patients with bonuses for participating inthe family doctor system.
MEDICAL TREATMENT CENTRES:
Improved cooperation for better treatment quality
More cooperation between physicians, therapists and other healthcare per-sonnel will be actively promoted. A common understanding and coordinationconcerning the course of an illness, the treatment objectives and therapies isclearly in the best interests of the patient. The staff of medical treatment centres work hand in hand, making it possible to coordinate drug treatmentand avoid duplicate examinations. Consequently, patiens receive specialmedical care from a single source. This results in a speedier recovery.
OUTPATIENT HOSPITAL TREATMENT:
Better care for chronically ill patients
Hospital outpatient wards will be able to offer highly specialised medical ser-vices. Hospitals will also assume responsibility for specialist care in structuredtreatment programmes for the chronically ill. This spares these patients theextra burden of travelling back and forth between the hospital and an out-side specialist for regular visits.
More trust thanks to proven quality
Patients usually have difficulty judging the level of quality of a doctor’s work.
Since there are no general standards, they have to depend on subjectiveimpressions. The healthcare reform guarantees that the principles of qualitymanagement will be consistently applied in doctor’s practices and hospitals.
An internal quality management system will be introduced in all doctors’practices and hospitals. This means that every doctor and every hospital willhave to monitor the efficiency of their work according to specific quality criteria. The panel doctors’ associations will also be required to continuouslymonitor the quality of doctors’ practices or hospitals and take measures toimprove results. On top of that, they will have to submit regular reports ontheir efforts.
Doctors are required to regularly take part in continuing education pro-grammes to ensure that their treatment methods are in line with medicaladvances. This requirement is now more precisely defined: continuing edu-cation must be totally independent of any commerial interests. In otherwords, product-related events will no longer be recognised as continuingeducation. Doctors who fail to meet these standards of continuing educa-tion will be penalised with reduced fees or possibly the revocation of their medical licences.
THE INSTITUTE FOR QUALITY AND COST-EFFECTIVENESS:
The watchdog of the healthcare system
Health insurance funds, hospitals and doctors will establish a common, non-governmental institute. This institute will work as a scientific service for thehealthcare community. It will examine and evaluate the benefits of drugsbased on the current state of medical science. Treatment methods, surgical procedures and treatment recommendations for specific illnesses(guidelines) will also be evaluated. Moreover, the Institute’s work will givephysicians a dependable source of information.
All of this information will be written in plain language so that patients canunderstand it and use it as a basis for consultations with doctors. The role of the institute could thus be compared with that of a “consumerwatchdog”.
The institute will also shed light on a number of issues, including why thehealth insurance funds pay for some medical services and not for others. Untilnow, it has been difficult for outsiders to understand why one therapy ormedication is covered by the insurance, and yet another is not reimbursed. Inthe future, the scientific studies and results that are the basis for these deci-sions will be available to all the insured and patients.
Keeping quality affordable!
Has your pharmacist ever recommended less expensive medicationsor smaller packages? Have you ever seen headache tablets on sale? Have you ever thought of ordering your medication on the Internetand having it delivered by post? New health and cost-consciousness
International comparisons have revealed that our healthcare system is simplytoo inefficient. In terms of the cost of healthcare, we rank third in the world,behind the US and Switzerland, but when it comes to quality, we usuallyachieve an average performance in most areas. Why is this? In the past, thevarious service sectors of our healthcare system have often worked separately,instead of hand in hand. Each part of the system is interested in preserving itsown economic interests. It goes without saying that this is not in the interestsof patients.
All that is about to change. The healthcare reform creates incentives that willpromote health and cost-consciousness on all sides. It promotes cooperationbetween outpatient and in-patient care, and fosters the coordinated exchangeof information among doctors, pharmacists, hospitals and therapists to create more efficient structures. Our goal is to ensurethat every euro spent actually benefitspatients. We will eliminate those factors fromour healthcare system that push up costs, further root out corruption, and work towardmore competition in the pharmaceuticaltrade. “What does this medication cost? Whyis it necessary and what does it do? What is the alternative?” Ask your pharmacist! Thebottom line is that competition can only workif you get involved and become more criticaland cost-conscious.
NEW REFERENCE-PRICE REGULATIONS FOR MEDICATIONS:
Rewards only for real innovations
Over the past five years, expenditure for pharmaceuticals has risen at adisproportionate rate. The reasons for this cannot be purely medical. This iswhy referenceprices are now only waived for medications that result in a realimprovement in the medical treatment of patients. We will no longer payexcessive prices for “pseudo innovations” that are nothing more thanminor modifications of existing medications.
We will continue to promote and reward the development of innovativemedicines – but we refuse to support research whose sole purpose is todetect minimal differences in active ingredients so that these can be “paten-ted” to justify exorbitant prices. Research should result in real therapeuticbenefits, not just more high-priced patent-protected drugs.
NEW FEES FOR PHARMACISTS:
Cost-effectiveness takes priority
Pharmacists no longer earn more money by selling medications that aremore expensive. Regardless of the size of the package or its price, pharma-cies now receive the same allowance for each prescription medication,namely the new standard dispensing fee of €8.10 per package. This promoteseconomical behaviour and helps reduce costs. To offset investment costs,the pharmacy also receives a small supplemental percentage of the whole-sale price.
An added benefit of this policy is that it fosters the pharmacists in their role asconsultants. It is in their own best interests to recommend a good inexpensivemedication. The customer is satisfied, and the pharmacist earns the sameamount of money. It is also in your interest to play a more active role becauseyour share of the cost of the medication is no longer calculated according tothe size of the package, but solely according to the price tag.
NO PRICE CONTROLS FOR OVER-THE-COUNTER PRODUCTS:
Now it pays to compare
The prices for over-the-counter medications and products are no longerregulated by law but subject to open competition. Every pharmacy is free toset the prices for individual items as high or low as it wants. As a patient or acustomer, your decision to buy in a given pharmacy shows just what youthink of its prices. After all, there is a difference between paying €3.20 and€4.10 for a medication.
Lifting these price regulations will clearly affect consumer behaviour.
Pharmacies will compete by offering low prices in addition to high-quality ser-vice. With increased competition in the sector, it is safe to assume that the pricesfor many over-the-counter medications and products will fall significantly.
More competition with ordering online or by post
Similar to other European countries, mail-order sales of prescription drugsare now legal in Germany. This means that community pharmacies have tocompete with mail-order pharmacies. Mail-order pharmacies will of coursehave to meet the same high standards with regard to consumer protectionand drug safety as your local pharmacy.
PANEL DOCTORS’ ASSOCIATIONS AND HEALTH INSURANCE FUNDS:
Leaner management and more efficiency
The organisational structures of the health insurance funds and service providers will be more flexible and more efficiently managed. Panel doctors’associations are bound by law to guarantee that there is nationwide medicalcare. In 2004, several smaller organisations will be consolidated into largerones. This will help save money and increase cost-effectiveness.
In the past, a number of different committees discussed and coordinatedhealth care provision on the Federal level. Now there is only one joint FederalCommittee with members representing the panel doctors and dentists, thestatutory health insurers and the hospitals. Patients’ participation is ensuredthrough their representatives on the committee. The latter’s main role is tohelp determine treatment specifications by means of guidelines. This elimi-nates the confusing, unnecessary bureaucracy and creates more transparencyand efficiency.
Crackdown on fraud
Corruption and fraud are serious problems for the statutory health insurancefunds. Ultimately, the patients have to pay the price of corruption throughhigher insurance contributions. Action is now being taken to expose and punishthis type of misconduct. To rectify this situation, health insurance funds,panel doctors’ associations, and panel dentists’ associations are required toset up special units to crack down on misconduct.
STATUTORY HEALTH INSURANCE:
Keeping a lid on administration costs
In 2002, the administrative costs of the statutory health insurance fundsamounted to over €8 billion. This comes to €157 per member, or 5.6 percent of the total amount spent in the healthcare system. Administrativecosts in the healthcare sector have soared over the past few years, now a“lid” is being kept on them. This means that if a health insurance fund’s administrative expenditure per member is more than 10 per cent above thenational average, it will be frozen.
A systematic financing reform
Reducing health insurance contributions, new
co-payments and sharing responsibility – it all pays off!
The modernisation of the dated structures in our healthcare system goeshand in hand with the right to greater involvement and better quality oftreatment for patients. The steering effects of the healthcare reform havealready led to reductions in member contributions to the statutory healthinsurance. Contributions will be further reduced by 2007.
In order for the reform to succeed, it is essential that we all do our part tosupport the project. This means that patients will also have new financialresponsibilities. From 2006, there will be an extra sick pay contribution of 0.5 per cent. The new co-payment regulations have been conceived in sucha way that no one is overburdened.
Nevertheless, sharing the financial responsibilities does not just entail anextra burden. It also means that patients have far more control over theirown co-payments. Patients who act in a health-conscious manner benefitfrom the reform. And since more competition in the healthcare system alsoresults in more freedom of choice, it pays to compare price and performancewhen choosing a health insurance fund or purchasing medications.
A SYSTEMATIC FINANCING REFORM
Compare price and performance!
Health insurance funds:
Compare and participate in the bonus systems
Health insurance funds can now give you a bonus when you Regularly go for prevention and early-detection check-ups Take part successfully in a quality-assured prevention programme Sign up for the family doctor system, or a special programme forchronically ill patients, or integrated care, thus opting for an espe-cially high quality of treatment Shop around to find the health insurance fund that offers you thebest service with the right bonus system: lower co-payments, reduceddoctors’ practice fees, reduced contributions, prizes and other bonuses.
Ask your pharmacist and shop around
When buying medications, it pays to shop around.
When buying an over-the-counter drug like headache tablets, com-pare prices. Every pharmacy can set its own prices. Look around tosee which pharmacy has the lowest prices for a particular drug, andcheck the prices of online mail-order pharmacies.
When you are purchasing a prescription drug and your doctor hasnot prescribed a specific brand, ask your pharmacist if there is aninexpensive drug that has the same effect. You will save moneybecause your co-payment will no longer be calculated in terms ofthe size of the package, but only according to the price of the drug.
New co-payment and financing regulations –
the most important changes at a glance
A co-payment of 10 per cent will be charged for all health services. However,
this fee will not exceed €10. The minimum fee will be €5, but if the cost is
under €5, the patient will pay the actual cost.
All co-payments made are taken into consideration with regard to the payment ceilings, thus it is important to save all co-payment receipts The annual amount of co-payments made by each member shall notexceed 2 per cent of his or her gross income Chronically ill patients will have a payment ceiling of 1 per cent of theirgross income Families will be granted special exemptions for spouses (€4,347 in 2004)and children (€3,648 each in 2004) The payment ceiling for social assistance recipients will be calculatedexclusively according to the standard rate received by the head of thehousehold; therefore exemptions cannot be estimated Exemption for children and young people
Children and adolescents up to and including the age of 18 are exempt from
co-payments (excluding travel costs).
Full contribution rate on retirement benefits
Until they reach the income threshold, pensioners are required to pay the full
contribution based on their retirement benefits and other retirement income
Patients who actively look after their health and take part in quality-assured
prevention programmes are eligible for a financial bonus from their health
insurance fund. This could be an exemption from co-payments or a reduction
in member contributions, and it also applies to members who take part in the
family doctor system, a programme for chronically ill patients, or integrated care.
NEW CO-PAYMENTS AND FINANCING REGULATIONS
What has changed
How it has changed
and early detection, andvaccinations are exemptfrom the doctor’s practicefees.
Prescription drugs and
A medication costs €75.
The co-paymentamounts to 10 per cent ofthe price, or €7.50.
A medication costs €120.
The co-payment is the€10 maximum.
Remedies and home
and maximum fee is €10.
The co-payment shall notexceed the cost of themedical device.
cent of the daily costs,however, the minimum feeis €5 and the maximumfee is €10.
What has changed
How it has changed
Inpatient care and
for mothers and
a maximum of 28 days acalendar year.
Benefits and services provided by statutory health insurance funds
– OTC drugs
private lifestyle (forexample, Viagra) are no thirds of the price of non-prescription drugs.
– Funeral grant
– Birth grant
from the list of servicesprovided by the statutoryhealth insurance funds.
– Artificial insemination
This will be reduced fromfour to three attempts,with 50 per cent of the costscovered by the healthinsurance funds. The agerange for women is limitedto between 25 and 40years, and the upper agelimit for men is 50 years.
NEW CO-PAYMENTS AND FINANCING REGULATIONS
What has changed
How it has changed
– Eyeglasses and
including the age of 18, aswell as for visually handicapped individuals.
– Travel costs
€ 5 must be paid. This alsoapplies to travel costs forchildren and adolescents.
– Maternity allowance
– Birth control
– Sick pay when a child
in three stages to a totalincrease of one euro percigarette packet by2005.
the majority of cases.
Consequently, patients zed type of tooth replacement treatmentwithout relinquishingtheir claim to a fixed subsidy from the healthinsurance plan.
– Sick pay
and half by the employee,will be reduced by0,5 percentage points.
If you have any questions:
Freecall information hotline
Mondays to Thursdays, 8.00 a.m.– 8.00 p.m.
Health insurance/healthcare reform: 0800/1515 159 Information for people with disabilities / 2003 – The European Year of People with Disabilities: 0800/1515 152 Service for the deaf and hearing impaired
Bundesministerium für Gesundheit und Soziale Sicherung Public Relations Department11017 Berlin, Germany Revised: January 2004
To order this publication:
Adress: Bundesministerium für Gesundheit und Soziale Sicherung Text telephone/fax for the deaf and hearing impaired:
E-mail: [email protected] / [email protected] Concept and text:
Ahrens & Behrent Agentur für Kommunikation, Berlin
Zum goldenen Hirschen
The new england journal of medicinel e g a l i s s u e s i n m e d i c i n e The Right to Health and the Nevirapine Case in South Africa Thanks to activists in South Africa, the right to healthas a human right has returned to the internationalstage, just as it was being displaced by economistswho see health through the prism of a globalized One of the most controversial actions of the So