Securing medical provision in a multi-level system of self-governance

Organisation of Health care

Illustration: Landarzt gesucht

Germany is a classic case of the “Bismarck”-ideal-type of a healthcare system. Access to healthcare is assured by Statutory Health Insurance (SHI) for about 90 % of the population. Policies concerning outpatient medical provision unfold in a complex setting. Most of the legal framework is part of federal law. Many policy decisions are implemented by federal and regional bodies of self-governance. A directive issued by the Federal Joint Committee (G-BA) constitutes the framework for regional planning of medical provision. It defines overall ratios of inhabitants per physician for different types of planning districts (from urban to rural) and for both general practitioners (GPs) and various groups of specialists. These ratios are deemed by federal law to represent an adequate level of supply.

The 17 associations of panel doctors (“Kassenärztliche Vereinigungen” – KVs) are key actors on the regional level. KVs guarantee the provision of SHI-physician services within their region and are responsible for regional planning of supply. They have to apply appropriate measures in case of “under-supply” (i.e. persistent shortfall in the relevant number of GPs of more than 25 % or that of specialists of more than 50 % per planning district). KVs also close planning districts to new physicians in case of “over-supply” (i.e. 110 % of adequate supply).

Shortage of physicians as a looming problem

Until the end of the 1990s a key policy problem in medical provision had been the steady increase in the number of physicians. But there has been a shift in the German policy debate in the early 2000s when evidence on the actual state of provision received more attention and key actors increasingly referred to new data to present their case. Physician associations began to warn of a looming shortage of physicians (“Ärztemangel”). Health Insurance Funds (HIFs) responded by stressing regional differences in medical provision and pressed for well tailored answers to very diverse problems. Debate on these issues gradually shaped a bundle of new policy problems. The most relevant federal health acts dealing with these problems are the 2011 “Supply Structure Act” and the 2015 “Supply Strengthening Act”.

Policy strategies

As of 2011 a policy strategy of decentralisation can be detected. Planning has now been geared more closely to local needs, first of all by downsizing planning districts. These areas may also be modelled irrespective of communal borders to allow for more flexibility. The impact of regional demography on demand for medical care is now taken into account as well. Furthermore, KVs may deviate from general provisions of the planning directive to account for regional needs. Another element in this strategy is to strengthen the role of the “Bundesländer” in regulation and planning.

A second strategy in response to problems of regional provision is to create incentives to physicians practicing in disadvantaged areas. Federal health policy gradually extended the set of measures a KV could take in case of “under-supply”. Since 2004 KVs may grant special supplements to physicians in areas concerned. Further financial incentives for these physicians came into effect following the 2011 “Supply Structure Act” (e.g. physicians in disadvantaged districts may now exceed the regular limits to remunerated services). In addition some disincentives to work in “less attractive” places were also abolished (e.g. compulsory residence in the district of practice).

Cautious steps to the effect of a gradual reorganisation of medical provision have been taken as well. Federal health policy seeks to create and strengthen alternatives to the private solo practice as the most common form of provision. As of 2011 KVs have been instructed to allow more physicians working in hospitals, rehabilitation or long term care to participate in outpatient care (remunerated through the KV-budget) in case of “under-supply”. And another example of the cautious reorganisation promoted by the debate on problems of medical provision: Since 2016 KVs are obliged to run service centres arranging specialist appointments for HIF-members within a timeframe defined by federal law. Outpatients failing to obtain a specialist appointment in time (and within acceptable distance) may now receive specialist treatment in a hospital nearby at the expense of the KV-budget.

Continuing debate

Some long-standing characteristics of the German healthcare system are still contributing to current problems of medical provision in disadvantaged regions, like the strict separation of sectors of provision, different remuneration of physician services within the SHI-scheme and in private practice, the preservation of the ideal of self-employed doctors (mostly working in solo-practices) and the physician-centeredness in medical supply. The evolving debate on regional problems in medical provision, however, has added new momentum and additional arguments to seek a reorganisation of the German healthcare system in many respects.

DFG-ANR Project RegMedProv