|Health financing reform idea: health fund|
|Implemented in this survey?|
On October 25, 2006, the German government presented a comprehensive health care reform bill. The law is due to come into force in April 2007 and aims to promote competition in health insurance and health care delivery, to increase efficiency, and to improve quality through more incentives for better coordination of care. However, with the legislative process still ahead, discussions are ongoing: the envisioned health fund has been postponed to 2009.
The "Statutory Health Insurance Competition Strengthening Act" (SHI-CSA), due to come into force in April 2007, aims to strike a balance between the need for reform and the explicit commitment to safeguard universal access to essential health care regardless of the ability to pay. Key elements of the planned health care reform are:
More competition in health insurance and health care delivery
Changes under the new legislation are to promote competition and increase choice in all areas of the health care sector. Specifically, the law is to
Financial incentives include the extension of start-up financing for population-oriented integrated care until the end of 2007, a new remuneration system for physicians, the possibility for sickness funds to negotiate discount prices with drug manufacturers.
Non-financial incentives include among others the option for selective contracting between sickness funds and providers, the obligation for public and private health insurers to offer a basic health insurance package to non-insured individuals, the new portability clause in the private health insurance market.
Health insurers, providers, patients
|Medienpräsenz||sehr gering||sehr hoch|
Degree of innovation / Structural or systemic impact: Several ideas that would have had a fundamental structural or systemic impact such as plans to incorporate private health insurers into the health fund have been considerably watered down, postponed or abandoned altogether. Political debates and interest groups lobbying have forestalled more ambitious reforms envisioned by health policy experts.
Degree of controversy / Public visibility: Ideas for health care reform have been debated intensely between and within political parties, health care providers, sickness funds, employer associations and other stakeholders since March 2006. Media coverage has been extraordinarily intense.
Transferability: Some of the proposed reform measures such as incentives for integrated care, selective contracting, etc. could be transferred to countries with similar health care systems. However, measures that aim at changing the role of private health insurance or the organisational structure of the Federal Joint Committee are strongly system-dependent.
The grand coalition declared health care reform one of its top priorities for 2006. With regard to health care the coalition agreement of November 2005 stipulates among others
|Implemented in this survey?|
The government declared health care reform one of its top priorities in March 2006. The main purpose of this reform is to increase efficiency and quality of health care through competition in health insurance and health care delivery. The main driving force behind this idea is the government. Other stakeholders such as sickness funds, provider associations, and private health insurers also see the need for reform but they strongly oppose structural changes proposed by the government (see section "Stakeholder positions").
Many ideas put forward in this reform proposal follow earlier legislation and plans (c.f. HPM reports "Integration of care after 2004 reform act", "Proposals for SHI reform") in that they aim at increasing, and reconciling, quality and competition.
In July 2006, the grand coalition published a framework paper containing the main ideas for reform such as the health fund (see HPM report "Health financing reform idea: health fund"), incentives for integrated care contracts, etc. At the end of October 2006, after long debate, a cabinet draft of the health care reform act was introduced into parliament for discussion and amendments.
Struggling for consensus within the grand coalition
Many of the ideas put forward in the framework paper and the cabinet draft have been (and still are) subject to heavy debate among the governing parties, Christian Democrats and Social Democrats. Especially with regard to health care financing the coalition partners hardly find common ground. Whereas Social Democrats would like to see more solidarity in the system (e.g. income-based health insurance contributions, inclusion of private health insurers into the health fund), Christian Democrats favor individual responsibility (e.g. flat-rate health premiums, retention of full-cover private health insurance) (see also HPM report "Proposals for SHI reform").
Reform with a price - not a win-win-win outcome
Stakeholders such as private health insurers, sickness funds, and health professional associations strongly opposed many of the reform proposals that would have changed fundamentally their status quo. Private health insurers for example successfully prevented their inclusion into the health fund. This would have meant for them either to enter into competition with statutory sickness funds or to confine themselves to selling complementary health insurance.
Sickness funds criticize that the health fund as laid down in the cabinet proposal does not help solving the revenue problem. They estimate that in 2007, sickness funds will incur a deficit of 7 billion Euros. In their opinion, more tax revenues and the broadening of the contribution income base will be necessary to secure long-term sustainability of the health care system.
Federal structures constitute major obstacle
Leaders of the wealthier, CDU-led federal states have opposed amongst other aspects the new risk adjustment mechanism. They fear that their states will have to pick up the additional financial burden. Since the federal states need to agree to the reform bill in the upper house of parliament, their dissent could endanger ratification of the new health care law.
Health policy experts criticize lack of technical solutions
Health policy experts have criticized the government for conceding too easily to interest group pressure. They argue that the current reforms are not based on health care needs and technical evidence-based assessment.
|Ministry of Health||sehr unterstützend||stark dagegen|
|Leaders of federal states||sehr unterstützend||stark dagegen|
|Christian Democrats||sehr unterstützend||stark dagegen|
|Social Democrats||sehr unterstützend||stark dagegen|
|Opposition parties||sehr unterstützend||stark dagegen|
|Bundesrat||sehr unterstützend||stark dagegen|
|Physicians||sehr unterstützend||stark dagegen|
|Statutory health insurers||sehr unterstützend||stark dagegen|
|Private health insurers||sehr unterstützend||stark dagegen|
|Health policy experts||sehr unterstützend||stark dagegen|
In late October, he cabinet draft of the SHI-CSA entered the parliamentary hearing process. It is now being discussed by the parliamentarian groups, health policy experts, interest groups, and the federal states. The final reading of the bill will probably take place at the end of January 2007.
It is expected that both the upper house (representatives of the federal states) and the lower house of parliament will propose several amendments to the health care bill. Modifications and changes touch upon the risk adjustment mechanism, the role of private health insurance, the organisation of the Federal Joint Committee, and others.
Both Bundestag und Bundesrat need to ratify the bill. Therefore, their influence in the legislative process is quite strong. Since health care reform is such a controversial issue, it is not foreseeable at the moment if the law will be indeed ratified as planned in April 2007.
|Ministry of Health||sehr groß||kein|
|Leaders of federal states||sehr groß||kein|
|Christian Democrats||sehr groß||kein|
|Social Democrats||sehr groß||kein|
|Opposition parties||sehr groß||kein|
|Statutory health insurers||sehr groß||kein|
|Private health insurers||sehr groß||kein|
|Health policy experts||sehr groß||kein|
Key players in the implementation process will be those affected most fundamentally, i.e. sickness funds, private health insurers, and health care providers. They all complain that they were not adequately involved in the preparatory process.
The SHI-CSA bill includes some incentives to improve access, quality and efficiency of health care such as the incentives for integrated care, selective contracting, and the right to basic health insurance.
However, differing political views, power games between political decision-makers, and intense lobbying of politicians by various stakeholder groups have forestalled far-reaching reforms. Especially in the area of health care financing, debate will continue. All in all, the current bill does not live up to the expectations of health policy experts and the public because reforms are not based on health care needs and technical evidence-based assessment.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
The incentives for integrated care can improve the quality of health care services. By 30 September 2006, 3000 integrated care contracts had been signed and it is expected that this number will rise further.
The reforms will increase the level of equity since every individual will have a guaranteed right to health insurance.
Cost-efficiency might improve if sickness funds make use of their greater contracting freedom (i.e. selective contracting with providers that offer services at lower prices than other providers, the possibility for sickness funds to negotiate discount prices with drug manufacturers).
|Health financing reform idea: health fund|
Process Stages: Idee
Reviewer: Sophia Schlette