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User charges for physician visits

Country: 
Deutschland
Partner Institute: 
Bertelsmann Stiftung, Gütersloh
Survey no: 
(6)2005
Author(s): 
Sebastian Hesse, Sophia Schlette
Health Policy Issues: 
Pflege, Zugang, Vergütung
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein ja ja nein nein

Abstract

According to a survey from the Bertelsmann Foundation (?Gesundheitsmonitor 2005?) the introduction of co-payments for physicians visits in Germany in January 2004 has resulted in the politically intended reduction of the number of consultations made. However, unwanted effects, such as the avoidance of visits in the group of patients with a lower health status and with a lower income are also observed.

Purpose of health policy or idea

User charges for physicians visits were introduced as part of the "Statutory Health Insurance Modernization Act" of 2004. This comprehensive health care reform was negotiated between the Red-green government (Social-Democrats/ Green Party) and the Christian Democrats (CDU/CSU). One of the central aims of this reform was to contain costs in the German health care system.
User charges have been introduced in several countries to shift the financial burden to the patients/consumers and to discourage them from unnecessary physician visits (Donaldson/Gebhardt 2004). User charges especially aim on reducing physician visits regarding petty diseases.

 

Main points

Main objectives

  • contain costs
  • reduce physician visits regarding petty disease
  • increase patients awarness of health care costs

 

Groups affected

Patients, Physicians, Sickness funds

 Suchhilfe

Characteristics of this policy

Innovationsgrad traditionell traditionell innovativ
Kontroversität unumstritten recht kontrovers kontrovers
Strukturelle Wirkung marginal recht fundamental fundamental
Medienpräsenz sehr gering recht hoch sehr hoch
Übertragbarkeit sehr systemabhängig systemneutral systemneutral

Political and economic background

User charges for physicians visits were introduced as part of the "Statutory Health Insurance Modernization Act" of 2004. This comprehensive health care reform had been negotiated between the red-green coalition government (social democrats / Green Party) and the opposition party (christian democrats). One of the central aims of this reform was to contain costs in the German health care system.
User charges have been introduced in several countries to shift the financial burden to the patients/consumers and to discourage them from unnecessary physician visits (Donaldson/Gerard 2004). User charges especially aim on reducing physician visits regarding petty diseases.

Germans see their doctor more often than other EuropeansIn Germany physician claims data for 2000 show that statutory insured patients saw a physician at least 7.8 times per year. This data may rather underestimate actual outpatient utilization since it documents only the first visit per quarter while all subsequent visits at the same physician are not reflected in the claims data. According to various surveys, the number of visits to ambulatory physicians has been higher than in the physician claims data and increased in the past decade. Between 1999 and 2002, the average rate of visits to office-based physicians was reported from 9.5 to 11.5 per year, varying by survey. International comparisons indicate that Germany has a higher number of outpatients contacts per person and year compared to the average of 6.2 for 15 Western EU member states.

One problem with user charges is that it is difficult to say whether unnecessary or necessary visits are avoided. Another phenomenon that could occur with the introduction of user charges is that patients forego physician visits in an early stage of a disease and wait until treatment becomes inevitable. This would translate to even more visits and treatment, putting an even higher financial burden on the system. Introducing user charges shifts to a certain extend the judgement whether a disease is severe or not from the physician to the patient.

While there may not have been much disagreement among politicians with regard to introducing user charges, the same cannot be said about the other stakeholders involved.

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein ja ja nein nein

Initiators of idea/main actors

  • Regierung
  • Leistungserbringer
  • Kostenträger
  • Patienten, Verbraucher
  • Politische Parteien

Approach of idea

The approach of the idea is described as:
renewed: Not new in the international context, but new for Germany - at least for ambulatory care. Copayments in hospitals exist since several years in the German system

Stakeholder positions

While there may not have been much disagreement among politicians with regard to introducing user charges, the same cannot be said about the other stakeholders involved. For them the user charges were highly controversial. Such stakeholders include some policy makers and other interest groups within the system, like patients representatives, and consumer advocacy organizations. Criticism persistently focused on the social aspect of user charges.

Actors and positions

Description of actors and their positions
Regierung
Ministry of Health and Social Securitysehr unterstützendsehr unterstützend stark dagegen
Leistungserbringer
Physician Associationsehr unterstützendneutral stark dagegen
Kostenträger
Sickness fundssehr unterstützendunterstützend stark dagegen
Patienten, Verbraucher
Patient advocacy groupssehr unterstützendstark dagegen stark dagegen
Politische Parteien
Christian Democratssehr unterstützendsehr unterstützend stark dagegen

Actors and influence

Description of actors and their influence

Regierung
Ministry of Health and Social Securitysehr großsehr groß kein
Leistungserbringer
Physician Associationsehr großgroß kein
Kostenträger
Sickness fundssehr großgroß kein
Patienten, Verbraucher
Patient advocacy groupssehr großgering kein
Politische Parteien
Christian Democratssehr großsehr groß kein
Ministry of Health and Social Security, Christian DemocratsSickness fundsPhysician AssociationPatient advocacy groups

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

According to the new German user charge legislation, effective since January 2004, adults have to pay ten Euros everytime they see a GP or specialist in ambulatory care. In fact prior this reform, Germany was one of the few countries without any kind of co-payments or user charges in the ambulatory care sector.

This user charge, the so called Praxisgebühr, is valid for a quarter of a year, provided that the patient gets a referral to see another physician- typically a specialist from the physician s/he consulted first. If the patient sees another physician without a referral, s/he must pay another user charge of ten Euros in the same quarter.

Ceiling for cost-sharingThe reform additionally increased co-payments for inpatient care and for pharmaceuticals.

Aiming to limit the financial burden for patients the overall ceiling for cost-sharing was newly defined:

No one should pay more than two percent of his or her annual gross income and the chronically ill and those living on social subsidies  do not have to pay more than one percent of their annual gross income.

Furthermore there are several exemptions to the co-payment rules:

  • Children under 18 are excluded from co-payments
  • All preventive medical checkups are excluded
  • Prevention/checkups during pregnancy are excluded

Monitoring and evaluation

Did this reform attempt achieve its goal?To be able to analyse changes in physician contacts first of all a distinction between two types of physicians visits has to be made: One way of looking at it are cases. Did the overall number of patients visiting a physician go down? Another way of looking at it is to ask whether a single patient went less often to see his physician (practice-visits).

Results from the "Gesundheitsmonitor" (Health Monitor), a survey instrument from the Bertelsmann Foundation interviewing a representative panel of 1000 insurees twice a year show that:

  1. Overall the number of physician visits came down after the reform and the number of referrals increased.
  2.  The number of insurees who did not see any physician decreased between the period of spring 2003 and spring 2005.
  3. The number of overall patient visits (cases) remained more or less constant. However, the number of specialist visits decreased. Patient visits in primary care have not been reduced.
  4. The overall more meaningful number of practice visits per patient decreased by eight percent in the time between spring 2003 and spring 2005. The physician group most affected were internal specialists and General Practitioners. 

 This actually underlines the well known moral hazard theorem that states that patients avoid physician visits to save costs. What is surprising is that notably the number of those patients who used to see their physician more than ten times in one year decreased while the number of patients who vistited their physician four to five times increased. Following the moral hazard theorem this is an unusal observation as one would expect that "high-users" should not be affected because they are likely to see a physician in any quarter and cannot save any money by reducing physician visits. Those with only few visits should show stronger reactions and it would be expected that they rethink a visit or maybe postpone it until the beginning of the next quarter.    

Did co-payments lead to the avoidance of important physicians visits?According to the moral hazard theorem important physicians visits are not postponed or avoided in relation to the existence of user-charges because they are said to have a very low elasticity of demand.

The Gesundheitsmonitor asks: "How would you describe your health status?" and  "Do you suffer from a chronic disease because of which you see a physician at least once in a quarter and have to take medication on a regular basis?"These questions were combined with other questions regarding the number of physician visits before and after the introduction of co-payments inquiring whether the reduction was related to the "Praxisgebühr".  Data from the Gesundheitsmonitor show a reduction in the number of physicians visits for the group of patients who judged their own health status as bad. From 2003 and 2005 the number of physician visits in this group decreased from 23 to 16 visits per year. However, the reduction in this patient group was lower than in other groups but increased with every survey round whereas it decreased in other patient groups. Between 15 and 20 percent in the group with lower health status reduced the number of visits due to the co-payments.

Both results suggest that patients with a lower health status reduced their number of physician visits since the "Praxisgebühr" in Germany has been introduced. However it can not be said whether patients avoided only unnecessary visits or as well important ones. Basically it can be expected that the overall reduction carries the danger that important physician visits could as well have been avoided.

However, this can only be said on the basis of indicative survey responses; not based on empirical data analysis.

Did reactions differ by income groups?Always following the moral hazard theorem, user charges should lead to a rather strong reduction in visits in low-income groups. As mentioned above a ceiling in relation to annual gross income was introduced. No one should pay more than two percent of his/her gross income (one percent for the chronically ill and the least well-off). Nevertheless, results from the "Gesundheitsmonitor" show that the highest proportion of patients avoiding a physicians visit falls within the lowest income group (37 percent compared to the average of 28 percent). Higher income groups tend more to postpone their visists.

Interestingly, the reduction was highest in the population under age 35. That shows that older patients are not reacting as much to the reform compared to younger patients.

Expected outcome

The introduction of user charges for physician visits in Germany clearly has an effect on the reduction of phycisian visits made. However, unwanted effects, such as the avoidance of visits in the group of patients with a lower health status can also be observed. In addition, low-income groups have a higher rate of avoidance than the higher income groups. Unfortunately a distinction between necessary and unnecessary visits cannot be made on the basis of the Gesundheitsmonitor data but the overall number of reduced visits indicate that as well important ones were avoided.

Finally the findings of the Gesundheitsmonitor do not entirely support the moral hazard theorem. The data implies that the avoidance of physicians visits is not entirely related to income because income-groups under 500€ per month show the same effect as groups earning between 3000-5000€ per month.  

Hence critical aspects from a medical perspective and a social effect of the "Praxisgebühr" can be observed and should be carefully scrutinized over time. Furthermore, it can be stated that the policy instruments introduced to make the user charges more socially adjusted are not as equitable as they were intented to be.

Impact of this policy

Qualität kaum Einfluss neutral starker Einfluss
Gerechtigkeit System weniger gerecht System weniger gerecht System gerechter
Kosteneffizienz sehr gering high sehr hoch

References

Sources of Information

Gebhardt, Birte. Zwischen Steuerungswirkung und Sozialverträglichkeit - eine Zwischenbilanz zur Praxisgebühr aus Sicht der Versicherten. Gesundheitsmonitor 2005 . Die ambulante Versorgung aus Sicht von Bevölkerung und Ärzteschaft. Gütersloh, Verlag Bertelsmann Stiftung, 2005 (in German only)

Glossary on the German health care reform: Das Glossar zur Gesundheistreform: Praxisgebühr. www.die-gesundheitsreform.de/glossar/praxisgebuehr.html (in German only)

Donaldson, Cam, Gerard, Karen. Economics of health care financing: The visible hand. Palgrave Mcmillan, Houndmills 2004

Grabka, Markus M., Jonas Schreyögg, and Reinhard Busse. Die Einführung der Praxisgebühr und ihre Wirkung auf die Zahl der Arztkontakte und die Kontaktfrequenz - eine empirische Analyse. Discussion Papers 506. Berlin: German Institute for Economic Research, 2005. www.diw.de/deutsch/produkte/publikationen/diskussionspapiere/docs/papers/dp506.pdf (abstract in English).

Author/s and/or contributors to this survey

Sebastian Hesse, Sophia Schlette

Empfohlene Zitierweise für diesen Online-Artikel:

Sebastian Hesse, Sophia Schlette. "User charges for physician visits". Health Policy Monitor, November 2005. Available at http://www.hpm.org/survey/ger/a6/1