Privatisation in German Health Care
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1 Johann Wolfgang Goethe-University Frankfurt Institut für Medizinische Soziologie Prof. Dr. Dr. Thomas Gerlinger Privatisation in German Health Care PRESOM-Workshop Privatisation Health & Pensions Vienna, May
2 Contents 1. Main Characteristics of the German Health Care System 2. Recent Trends in German Health Care Policy 3. Privatisation in German Health Care 1. Health Care Delivery 2. Health Care Costs and Risks 4. Effects on the European Social Model 5. Conclusions Institut für Medizinische Soziologie 2
3 Health Care Delivery System (1) free choice of doctor in ambulatory care direct access to specialists in ambulatory care hospitals (almost completely) excluded from ambulatory care strong segmentation of sectors Institut für Medizinische Soziologie 3
4 Health Care Delivery System (2) ambulatory care provided by single, office-based doctors (going for profit) hospital sector: pluralism of ownership public (cities, counties, Länder, some cases: federal government), non-profit (charitable associations, churches) private (mainly large corporations) Institut für Medizinische Soziologie 4
5 Benefit Package prevention of disease und health promotion measures screening for disease treatment of disease (ambulatory medical care, dental care, drugs, nonphysiciancare, medical devices, inpatient/hospital care, nursing care at home, certain cash benefits (e.g. sick pay) Institut für Medizinische Soziologie 5
6 Health Care Financing and Insurance 88 % social health insurance 74 % mandatory insurance 14 % voluntary insurance 10 % private health insurance Institut für Medizinische Soziologie 6
7 Social Health Insurance financing by contributions some 240 sickness funds mandatory membership for employees with a gross income less than 47,700 per year (2007) contributions based on income only contributions dependent on income and not risk contributions (almost) shared equally between the insured and their employers Institut für Medizinische Soziologie 7
8 Private Health Insurance run by private insurance companies access for civil servants, self-employed and those earning more than (2007) premiums vary with age, sex and medical history direct payment, reimbursement by insurers Institut für Medizinische Soziologie 8
9 Health Care Regulation strong fragmentation of the regulatory system corporatism collective contracts between sickness funds and social health insured accredited doctors (Kassenärztliche Vereinigungen) Institut für Medizinische Soziologie 9
10 German Health Policy since the 1990s Change of paradigmas introduction of elements of competition first steps to liberalise the collective contract system liberalization of contractual relations (between social health insurance funds and doctors)(kassenärztliche Vereinigungen) in order to modernise the health delivery structure raising of co-payments ( individual responsibility ) Institut für Medizinische Soziologie 10
11 Privatization of Hospitals (1) Hospitals by ownership 1991 and 2005 Ownership /- (total) (%) (total) (%) (total) Public % Non-Profit % Private ,6 % Total % Institut für Medizinische Soziologie 11
12 Privatization of Hospitals (2) Hospitals Beds 1991 and /- (total) Ownership 1991 (total) 1991 (%) 2004 (total) 2004 (%) Public % Non-Profit % Private % Total % Institut für Medizinische Soziologie 12
13 Medical Service Centers interdisciplinary medical institutions outpatient care opened up to private investment of large corporations (e.g. joint-stock companies) Institut für Medizinische Soziologie 13
14 Privatisation of Costs (1) raise of existing co-payments: usually 10 % of the costs, at least 5 and 10 for each prescription in-patient-care out-patient-care Drugs remedie therapeutical appliances Institut für Medizinische Soziologie 14
15 Privatisation of Costs (2) introduction of new co-payments consultation charge of 10 each quarter of the year for inpatient care and another 10 for each additional specialists consultation without referral by a general practitioner exclusion of certain benefits (e.g. off-presciption drugs) from the benefits catalogue Institut für Medizinische Soziologie 15
16 Consultation after Implementing the Consultation Charge in 2004 Did you dispense with a consultation in the first quarter of 2004 or did you postpone it to the second quarter due to the consultation charge? 2004 unemployed less than and more Total 20,9 % 19,2 % 13,3 % 9,4 % 8,2 % 11,7 % Institut für Medizinische Soziologie 16
17 SHI-Contributions in 2006 Average contribution rate: 14.2 % 0.90 % insured (dentures, sick pay) Remainder: equally shared by insured and employers 6,65 % insured 6,65 % employers 7.55 % insured 6.65 % employers Institut für Medizinische Soziologie 17
18 Pivatisation of costs (3) implicit rationing growing share of people with private health insurance choice models for co-payment in the social health insurance Institut für Medizinische Soziologie 18
19 Effects on the European Social Model privatisation affecting the mode of regulation corporatist regulation (collective contracts) European Treaty/ECJ: ban of abuse of market power does competition law apply to sickness funds? ECJ up to now: no reason: sickness fund are no undertakings will this ruling be maintained in the light of most recent steps towards further privatisation? Institut für Medizinische Soziologie 19
20 Conclusions new welfare mix in health care: privatization of costs and risks increasing social inequality perhaps/probably: increasing health divide penetration of health care by private capital (large corporations) shift of power from public to private institutions Institut für Medizinische Soziologie 20
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