Introduction of a Uniform Outpatient Remuneration System in Germany - Models for System Transition. ihea 2013 Sydney, July 10, 2013

Transcription

1 Introduction of a Uniform Outpatient Remuneration System in Germany - Models for System Transition ihea 2013 Sydney, July 10, 2013 Session: Paying Doctors Anke Walendzik, Jürgen Wasem, Gerald Lux, Lennart Weegen and Florian Buchner 1

2 Overview 1. Background: The German health insurance system and remuneration in outpatient physician care 2. Data 3. Modelling scenarios of the transformation of health insurance system 4. Modelling potential remuneration losses for these scenarios 5. Developing models of recompensation for remuneration losses and its distribution to regions and physician practices 6. Discussion and conclusion 2

3 Background 1: German Dual Health Insurance System Health Insurance System Insured persons Financing Outpatient physician remuneration Statutory Health Insurance (SHI) About 90% of population, obligatory for employed persons up to a certain income; obligation to contract for SHI mainly by income-related contributions, riskadjustment scheme; payas-you-go method of funding Uniform Value Scale (EBM), budgeted 2-level-system Private Health Insurance (PHI) Mainly attractive for persons with higher incomes, younger age, better health and no/smaller families; mainly no obligation to contract for PHI Risk-related not incomerelated premia; capital funding method Fee Schedule for Physicians (GOÄ), not budgeted, about 230% of SHI-remuneration Lehrstuhl für Medizinmanagement Universität Duisburg-Essen 3

4 Background 2: Reform Discussion Critical discussion of incentives of the dual fee schedule: Allocations of means not according to morbidity but to insurance status Differences in access to outpatient care manifested in different waiting times Remuneration differences between physicians depending not on services but on percentage of private patients Critical discussion of the dual insurance system as a whole from a distributional point of view Richer and healthier persons can extract themselves from financial solidarity Interest in broader financing basis for statutory health insurance At least two political parties planning a uniform health insurance system in Germany 4

5 Data 2008 age and sex specific cost profiles of the German statutory health funds for the German risk adjustment procedure by the German Federal Insurance Office, adjusted to long term care insured by the Federal Financial Supervisory Authority the middle population estimation of the Federal Statistical Office (FSO) in Germany up to Mortality table of the Association of Private Health Insurance For the distribution models additionally: KM6-statistics of statutory health funds, Microcensus 2007, overall remunerations of the regions of statutory health insurance physicians by their federal association 5

6 Modelling Scenarios of the Transformation of Health Insurance System Lehrstuhl für Medizinmanagement Universität Duisburg-Essen 6

7 Transition Scenarios for Health Insurance 1. All former PHI-insured persons at once change into the new insurance system; no new PHI-insurance possible 2. All former PHI-insured persons stay in the PHI-system, no new PHIinsurance possible 3. Option period for PHI-insured persons to change into the new insurance system, no new PHI-insurance possible (Two further models with special conditions for state employees, which weren t modelled using empirical data) 7

8 Modelling Potential Remuneration Losses for these Scenarios Lehrstuhl für Medizinmanagement Universität Duisburg-Essen 8

9 Assumptions for Modelling Physician Remuneration Losses New system adopts the SHI-remuneration level Remuneration losses basing on former SHI services Age and sex specific expenditures of former PHI-insured persons are modelled according to those of SHI-insured persons Factor 2.3 for the relation of PHI to SHI remuneration Remuneration Losses basing on age and sex specific services for: former PHI-insured persons and for those potentially changing into the PHI-system in the future under old conditions but not being able to in the new system Transition Scenario 3: 20% of former PHI-insured up to the age of 50 and 50% of former PHI-insured persons over this age change into the new insurance system during optional period 9

10 Potential Remuneration Losses Scenario 1 Scenario 2 Scenario 3 Remuneration Losses in Mio Total Remuneration in Mio Remuneration Losses % ,8% 0,0% 0,0% ,1% 0,2% 5,0% ,4% 0,4% 5,3% ,2% 4,7% 9,5% 10

11 Developing Models of Recompensation for Remuneration Losses and its Distribution to Regions and Physician Practices Lehrstuhl für Medizinmanagement Universität Duisburg-Essen 11

12 Recompensation of Remuneration Losses for Outpatient Physicians? Arguments pro: Former decisions to invest on base of confidence in system continuity Present remuneration level necessary to preserve high level of medical care Arguments contra: Other groups in the health system don t get financial guarantees in case of changes in the health system. In future, for the continuity of the PHi-system ist might be necessary in any case to cut differences in remuneration: lower reference scenario Possible solutions: Partly recompensation, limited time of recompensation, degressive recompensation, Exclusion of new physician practices settling after the reform 12

13 Models for the Distribution of a Potential Recompensation: Potential Aims Accuracy in fitting the regional and personal losses in physician remuneration Maintainance of regional relations in remuneration of the SHI-system Allocation of means according to the morbidity of the population Promotion of innovative care models Trade-offs between the aims! 13

14 Models for the Distribution of a Potential Recompensation: Regional Distribution Model A: Distribution of recompensation according to the remuneration losses in the regions Individual physician practice can be fully recompensated Continuity of allocative effects of former dual remuneration system Model B: Distribution of recompensation according to the former regional distribution of overall remunerations in the SHI-system Continuity of former regional remuneration relations Continuity of allocative effects or former SHI-System Modell C: Distribution of recompensation according to national cost weights of an estimation model using diagnoses and demographic data Step towards a model of distribution of overall remunerations according to morbidity 14

15 Models for the Distribution of a Potential Recompensation: Regional Distribution Model D: Use of recompensation to introduce a distribution of overall remuneration according to morbidity Stronger version of orientation towards patient morbidity than model C Strong redistribution effects to be expected Model E: Use of recompensation to promote selective contracting by the health insurance funds Possibility of different regional setting Distribution to the singular physician practices can be modelled accordingly. 15

16 Models for the Distribution of a Potential Recompensation: Some Results in Mio 2010 Modell 1A Modell 1B Schleswig-Holstein Hamburg Niedersachsen Bremen Nordrhein-Westfalen Hessen Rheinland-Pfalz Baden-Württemberg Bayern Saarland Berlin Brandenburg Mecklenburg-Vorpommern Sachsen Sachsen-Anhalt Thüringen Bund

17 Conclusions Dependent on the version of the transition scenario a full recompensation of remuneration losses yields additional costs for the new health insurance system from about 100 to million in the introduction years Distribution of a potential recompensation depends on the weighing of different aim dimensions. Possibly direct recompensation of concrete physicians` remuneration losses may play a role in the beginning of the system transition process, while other models of distribution taking into account the need of patients will be more important lateron. 17

18 Thank you for your attention Contact: Dr. Anke Walendzik 18