Orgnisation of the health care system in Germany. Virus Hepatitis Prevention Board Berlin, 13. October Johannes Hallauer, HU Berlin

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1 Orgnisation of the health care system in Germany Virus Hepatitis Prevention Board Berlin, 13. October 2003 Johannes Hallauer, HU Berlin

2 German tree of life Age stratification in 5-year age groups Age <= 5 German Empire 1910 Federal Republic of Germany Estimate! Men Women Inhabitants 64.9 million 81.0 million 72.4 million GLOBUS 2150: Statistisches Bundesamt

3 Birth rates 1960 to 2000

4 Mean life expectantcy in Germany Women Men Germany 1910 (former) West Germany (former) East Germany Statistisches Jahrbuch 1995 Age

5 Demographic development in Germany Patients in Age (years) 9. Koordinierte Bevölkerungsprognose StBA / Variante 2a/2001

6 Development of nursing insurance Number of persons receiving nursing care* in Germany in millions ,9 0,7 0, ,1 0,9 0,3 1,4 1,1 0,4 2,4 1,9 0, year Nursing level 1 mild Nursing level 2 moderate Nursing level 3 severe *Recipients of private and social nursing insurance benefit D/W 2001

7 Gesundheits-Hitliste über die medizinische Versorgung in den 191 Mitgliedsstaaten WHO Weltgesundheitsreport vom 21. Juni 2000 Rang Land Frankreich Italien San Marino Andorra Malta Singapur Spanien Oman Österreich Japan Norwegen Portugal Monaco Griechenland Island Luxemburg Niederlande Großbritannien Irland

8 Schweiz Belgien Kolumbien Schweden Zypern Deutschland Saudi-Arabien Ver. Arab. Emirate Israel Marokko Kanada Finnland Australien Chile Dänemark Dominica Costa Rica USA

9 Political System in Germany Legislation BUNDESTAG congress federal government coalition SPD + Greens Federal election 09/2002 Passes bills 16 state governments BUNDESRAT senate fed. states with SPD/Greens or CDU/CSU/FDP governments Approves bills concerned with interests of federal states Law Execution and Supervision Federal Administration ex. ex. > drug drug registration > insurance control control > Federal Federal Work Work Office Office Self Administration ex. > physicians fees > drug budgeting > collective settlements State Administrations ex. ex. > GMP GMP supervision > licensing of of professions > fiscal fiscal authorities

10 Social Insurance System in Germany Solidarity Principle: Benfits independent of indiv. contribution Mandatory enrollment with very little exceptions Organized and managed by corporate bodies, governement sets legal frame Contribution rates related to gross income (salaries) Payroll contribution rates (payed 50% by employer and employee each) ~ 20% 20% 7% 7% Ø 14% 14% 2% 2% Pension funds Unemployment Statutory Health Insurance Long-term-Care Insurance Mandatory enrollment for employees earning /mth Early retirement and rising life expectancy challenge the current financing system Unemployment rates (~10%) are a major focus in political discussion Mandatory enrollment for employees earning less /month Coverage also for unemployed or family members Statutory Insurance against costs of long-term-care follows SHImembership

11 Health Care Expenditure Germany

12 Distrubution of Health care cost Germany in Million in ; 45% ; 22% 7968 ; 8% 3539 ; 3% ; 22% Ärzte Zahnärzte Arzneien, Verband- Heil-u.Hilfsmittel A th k 4) Zahnersatz Krankenhausbehandl 1)

13 Vergleich Deutschland - USA Krankenhausdaten 1999 Kosten Deutschland: 602 DM / Pflegetag DM / KH-Fall 1.237,53 DM KH- Kosten / EW / a KH verbrauchen 34 % Gesundheitsausgaben Quelle: Krankenhausreport 2001, eigene Berechnungen Kosten USA: DM / Pflegetag DM / KH-Fall 1.714,82 DM KH- Kosten / EW / a KH verbrauchen 37 % Gesundheutsausgaben Quelle: Health, United States, CDC 2001, eigene Berechnungen

14 Comparison - USA Germany Hospital data 1999 Deutschland 68,8 Betten / EW 81,8 % Bettenauslastung 10,4 Tage Verweildauer KH-Fälle/ Pflegetage/ ,7 % KH < 200 Betten 12,0 % KH > 500 Betten USA 30,0 Betten / EW 66,1 % Bettenauslastung 4,6 Tage Verweildauer KH-Fälle/ Pflegetage/ % KH < 200 Betten 4,5 % KH > 500 Betten Quelle: Health, United States, CDC 2001 Quelle: Krankenhausreport 2001

15 Health Care Decision Structure Supervision, setting legal frame Federal MoH Negative List Registration Authorities Supervisory Authorities 16 State MoH Self Administration Federal Federal assoc. assoc. of of of SHI-accredited of sick funds physicians Fixed Reference Joint Prices (FRP) Joint commission commission Federal Commission of of Physicians and Sick Funds (BÄK) global expenditure volume definition of FRP groups aut-idem formulations prescription guidelines (AMR) Regional assoc. of SHI-accredited physicians Regional Prescription Recommendations contracts contracts Regional sick funds associations regional prescription goals individual drug cost guidelines prescription recommendations utilization reviews/audits

16 Siloed HC system Deter- Determinedby mined by Healthcare System driven by bycomponent management Physicians Physicians association association : : sick sick fund fund associations associations Physicians Physicians association association : : sick sick fund fund associations associations Regional Regional MoH MoH ( Länder ( Länder ) Länder ) + + Hospitals Hospitals : : sick sick funds funds Long-term care care insurance Benefits Benefits and and contribution contribution rates rates legally legally defined, defined, no no negotiations negotiations Physician salaries Drugs In patient care 15,9% of GKV exp. 15,5% of GKV exp. 32,4% of GKV exp. No interaction Long-term Care Trade Trade off off between between physician physician income income and and drug drug budgets budgets Separate Separate budget budget Separate Separate budget budget

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