The governance structure in Germany
The governance structure in Germany
Legal Framework for Health Care established by
Law, the Ferderal Ministry of Health and the state authorities
Statutory (“Public”) Health Insurance
- level of 16 states in germany-
The governance structure in Germany –
The history of using quasi-governmental entities
in health care and the function of the
German Federal Joint Committee (G-BA)
Collective and single
selective contracting
C. Sickness
funds
Health Care Markets and Regulations in the Netherlands and Germany
session in Washington D.C.
GP´s and
specialists
B. (state)
Hospital
organisation
A. (state)
Physicians‘
organisation
Growing
outpatient care
facilities
Patient / Insuree
Speaker: Rainer Hess, LL.D, Federal Joint Committee
• Standard care: free choice of provider
• Possibility of choice: GP binded treatment – integrated
network – DMP - reimbursement
Rainer Hess, LL.D, February 4, 2009
Slide 1
Rainer Hess, LL.D, February 4, 2009
Slide 2
The governance structure in Germany
Legal Framework for Health Care established by
law and the Ministry of Health
Legal Framework for Health Care established by
law and the Ministry of Health
Statutory (“Public”) Health Insurance
- Federal level C. Federal
Sickness
Fund
Assoc.
Federal fee
schedule and
framework
The governance structure in Germany
“Decision Platform”
for defining
the services
Federal Joint Committee (G-BA)
C.
delivered as public
health care
A.
C. Federal
Sickness
Fund
Assoc.
B. Federal
Hospital
organisation
A. Federal
Physicians‘
organisation
B.
DRG-schedule
B. Federal
Hospital
organisation
A. Federal
Physicians‘
organisation
Rainer Hess, LL.D, February 4, 2009
Slide 3
Rainer Hess, LL.D, February 4, 2009
Slide 4
The governance structure in Germany
The governance structure in Germany
Legal Framework for Health Care established by
law and the Ministry of Health
Federal Joint - Committee
Federal Joint Committee (G-BA)
delivered as public
health care
C.
A.
B.
Advisory
membership
C. Federal
Sickness
Fund
Assoc.
B. Federal
Hospital
organisation
A. Federal
Physicians‘
organisation
Patient
Organisations
“Decision Platform“
for defining
the services
13 members with right to vote
independent chairman
2 independent members
5
Deputies of
Federal
sickness
fund
organisation
5
Deputies of
providor
organisations
max. 5 patient-substitutes
(right to bring in motions but not to vote)
Rainer Hess, LL.D, February 4, 2009
Slide 5
Rainer Hess, LL.D, February 4, 2009
Slide 6
The governance structure in Germany
Legal Framework for Health Care established by
law and the Ministry of Health
The governance structure in Germany
Federal Joint Committee (G-BA)
GBA
Plenary-Assembly
Patient
Organisations
“Decision Platform“
for defining
the services
C.
delivered as public
health care
A.
B.
Advisory
membership
Commissioning
Subcommittees:
Pharmaceuticals;
Remedies;
Psychotherapy;
dental care; etc.
Subcommittees:
(Cost)-BenefitAssessment;
Managed care
structures
C. Federal
Sickness
Fund
Assoc.
Institute
for Quality
and Efficiency
(IQWiG)
Subcommittees:
QualityAssurance;
Requirementsplanning
Advisory role
B. Federal
Hospital
organisation
A. Federal
Physicians‘
organisation
Rainer Hess, LL.D, February 4, 2009
Slide 8
The governance structure in Germany
The governance structure in Germany
Legal Framework for Health Care established by
law and the Ministry of Health
Federal Joint Committee (G-BA)
as public
health care
•Normative function of the G-BA by legal binded directives to
Patient
organisations
„Negotiation Platform“
for defining the
services delivered
C.
A.
Advisory
membership
B.
Commissioning
A. Federal
Physicians‘
organisation
Statements,
expert-hearing
Rainer Hess, LL.D, February 4, 2009
Other interest groups
B. Federal
Hospital
organisation
social insured people.
•Competitive function of the sickness funds by selective contracts
Statements,
right to sue
C. Federal
Sickness
Fund
Assoc.
Industry, other
health care professionals
Institute
for Quality
and Efficiency
(IQWiG)
guarantee equal excess to necessary healthcare packages for all
Slide 9
with providers to find the best way of efficient care for their insured
members.
Rainer Hess, LL.D, February 4, 2009
The governance structure in Germany
Slide 10
The governance structure in Germany
Legal Framework for Health Care established by
law and the Ministry of Health
•
Benefit-package decisions must be justified by an evidencebased process to determine whether services, pharmaceuticals or
objectives: morbidity, mortality and life-quality.
Federal Joint Committee (G-BA)
as public
health care
C.
A.
B.
Advisory
membership
Commissioning
Evidence based assessments in Germany only could be used to
C. Federal
Sickness
Fund
Assoc.
Institute
for Quality
Assurance
(IQUA)
costly innovation has a significant additional benefit, the sickness
funds must pay for it (rationalizing not rationing).
A. Federal
Physicians‘
organisation
B. Federal
Hospital
organisation
Advisory
board
Rainer Hess, LL.D, February 4, 2009
Slide 11
Rainer Hess, LL.D, February 4, 2009
Slide 12
Scientific-orgnisations
Patient-organisations
select the most appropriate (efficient) service etc. from others; if a
Health care professionals
•
Patient
organisations
technologies are medically effective to reach patient relevant
„Negotiation Platform“
for defining the
services delivered
The governance structure in Germany
The governance structure in Germany
G-BA = legal consequences
•G-BA is authorised by law to issue directives which are binding
on sickness funds, the insured population, panel physicians and
•Directives can define requirements for the qualifications of providers the
hospitals.
structure of delivery of services and the quality of services.
•Where involved as a “third-party”, industry must accept reduced
•Directives define preventive programmes for vaccination, early diagnoses
profitability in their market position, if the directive is in accordance with
(screening) of cancer, paediatric illnesses and a
the standard of medical science (according to federal fee criteria).
health-check.
•Directives can reduce or exclude sickness fund benefits if the
•Directives recommend DMP for chronicle illnesses to the ministry.
assessment does not prove medical necessity and efficiency.
(www.g-ba.de)
Rainer Hess, LL.D, February 4, 2009
Slide 13
Rainer Hess, LL.D, February 4, 2009
Slide 14