5.3 Primary / ambulatory care
Ambulatory health care is mainly provided by private for-profit providers, including physicians, dentists, pharmacists, physiotherapists, speech and language therapists, occupational therapists, podologists and technical professions (see section 4.2). Acute care and long-term care are commonly provided by non-profit or for-profit providers employing nurses, assistant nurses, carers for the elderly, social workers and administrative staff (see section 5.8).
Patients have free choice of physicians, psychotherapists (since 1999), dentists, pharmacists and emergency room services. Although patients covered by SHI may also choose other health professionals, access to reimbursed care is available only upon referral by a physician. About half of all SHI-affiliated physicians work in primary care (Table5.1). Family practitioners are not gatekeepers in Germany, although their coordinating competences have been strengthened in recent years.
According to data from the Federal Association of SHI Physicians for 2012, 141 038 of the 348 695 active physicians worked in ambulatory care. Of these, a minority (5641 (4%)) practised solely for private patients, while 121 189 worked as SHI-accredited physicians and a further 9 193 as salaried physicians (Table5.1). The practice premises, equipment and personnel are financed by the physicians. Depreciation of investments is sought through reimbursement from sickness funds, private health insurers and, to a small but increasing degree, by patients directly (see section 3.7.2).
Solo practices are also the dominant form of ambulatory physician care in eastern regions, where during the period of the former German Democratic Republic, until 1989, public polyclinics were the dominant deliverers of ambulatory services, in conjunction with local community dispensaries and company-based health care services. As part of the institutional transfer of the old West German health care system into the new Länder in the eastern part, these forms of care were quickly given up in favour of entrepreneurial solo practices after reunification. Only a few polyclinics continued to exist in the eastern part after reunification, initially on an exemption basis (see section 2.2).
Interdisciplinary care was reintroduced from 2004 at medical treatment centres, which may be owned by companies, non-profit organizations or independent professionals but have to be headed by a physician and comply with regulations as members of the regional associations of SHI physicians. The number of such treatment centres increased between 2004 and 2012 from 70 to 1814. Whereas 241 SHI-accredited physicians worked in the centres in 2004, the number had increased to 10 020 by 2012. Since 2005, the number of salaried physicians at the centres has increased more rapidly than the number of SHI-accredited physicians working there on a self-employed basis. While in 2005 the ratio of salaried physicians to SHI-accredited physicians was roughly even, it was 2:1 in 2007 and 4:1 in 2012 (Kassenärztliche Bundesvereinigung, 2014).
Ambulatory physicians offer almost all specialties; the most frequent ones are listed in Table5.1 together with their development between 1990, the year in which needs-based planning of physician density was introduced, and 2012. During this same period, the total share of SHI-accredited physicians increased by 36%. However, the strength of this trend varied according to specialty: whereas the share of physicians qualified in general practice or working as practitioners increased by 0.2%, the share of all specialists increased by 64%.
Despite efforts by the federal government to improve the status of family practice in the ambulatory care sector, the number of specialists has increased more rapidly than that of family physicians since the 1990s and family physicians fell to less than 31% of all private-practice physicians in 2002. However, since qualified internists and paediatricians practising as SHI-accredited physicians had to decide whether to work as family physicians (Hausärzte) or as specialists (Fachärzte) (§ 73 SGB V), the ratio of specialist physicians to SHI-accredited family physicians has increased in recent years. This also applies to internists or paediatricians starting a new practice. Family physicians and specialists have differing reimbursable service profiles, differing reimbursement pools and, since 2005, separate representation on the assemblies of delegates and the executive boards of the regional associations of SHI physicians (see section 3.7.2). Since 2005, political representation in assemblies and many boards of the regional associations of SHI physicians is determined separately according to the share of family physicians and specialists.
Table5.1 shows that, in 2012, of the 121 189 practising SHI-accredited physicians in Germany, 55 916 (46%) were practising as family physicians and 65 273 (54%) as specialists. Of the physicians practising as family physicians:
- 32 462 were qualified in general practice (physicians holding a specialist qualification in general practice);
- 5840 worked as practitioners (physicians without any specialist qualification practising family medicine);
- 11 994 were family internists (specialists in internal medicine); and
- the remainder were paediatricians.
The data do not provide any information on the number of paediatricians working as family physicians. Data from previous years, however, indicated that more than 90% of all SHI-accredited paediatricians (5730) were doing so (Busse & Riesberg, 2004). The share of all SHI-accredited internists working as family physicians was 60%. While GPs and practitioners accounted for only 36% of all SHI-accredited physicians in 2012, the total percentage of family physicians was 46% because of the inclusion of family internists and paediatricians. This percentage is expected to decrease as family physicians are on average older (i.e. more of them will leave the profession in coming years) while younger physicians are most often specialists.
Table5.1 also provides information on two aspects linking the ambulatory and the hospital sector. First, around 4.8% of all office-based physicians have the right to treat patients inside the hospital. This is mainly the case for small surgical specialties in areas where the hospital has so few patients with this need that a physician operating once or twice a week is sufficient. All other physicians transfer their patients to hospital physicians for inpatient treatment and receive them back after discharge (e.g. postsurgical care is usually done by office-based physicians). Second, in 2012, in addition to the office-based physicians, around 9899 hospital physicians were accredited to treat ambulatory SHI-covered patients. These accredited physicians are mainly heads of hospital departments who are allowed to offer certain services or to treat patients during particular times (when practices are closed). On average, more than one internist and nearly one surgeon per general hospital had an ambulatory accreditation (Kassenärztliche Bundesvereinigung, 2014).
From 1993, sickness funds were allowed to initiate pilot projects for gatekeeping systems and to offer those they insured a bonus. However, few pilot projects were introduced and sustained because of various legal barriers, resistance of the regional associations of SHI physicians and extra costs in the gatekeeping pilots. Since 2004, sickness funds are obliged to offer the option to enrol in a “family physician care model”, potentially with a bonus for complying with the gatekeeping rules. The first nationwide “family physician care model” contract was established by the AOK Baden-Wurttemberg, the German Association of Family Physicians and MEDI Baden-Wurttemberg, a parallel organization to the Regional Association of SHI Physicians of Baden-Wurttemberg. All 3700 family physicians in the state take part, and all regional fund-insured people above the age of 18 may take part. By spring 2011, around 1 million patients were enrolled. The enrolled patients paid 50% of the normal co-payment for physician visits (until they were generally abolished at the end of 2012) and could expect shorter waiting times to see their doctor and support in arranging appointments with specialists. The enrolled insured members can make use of evening office hours, expect shorter waiting times at their GP and are exempt from co-payments on some pharmaceuticals.
In January 2007, about 24.6 million SHI-covered people had the option (through statutes of their fund) to subscribe to a family physician care model and about 4.6 million had actually subscribed. About 1.8 million insured took part in the nationwide model of the Barmer Ersatzkasse (a substitute sickness fund), which allows for exemptions from co-payments for prescriptions if prescribed by their family physician.
The number of visits to ambulatory physicians has increased according to various surveys: between 1999 and 2002, the average rate of visits to private-practice physicians was reported to be 9.5–11.5 per year (Andersen & Schwarze, 2003). A survey of the Gmünder substitute fund identified as many as 16.3 visits in ambulant care per SHI-covered person in 2004 (Gmünder Ersatzkasse, 2006) and calculations from the Central Institute for SHI Physician Care (Zentral-Institut für die kassenärztliche Versorgung) even resulted in 17.1 visits per SHI-covered person for 2007 (Riens, Erhart & Mangiapane, 2012). Judging from this information, the WHO data presented in Fig5.1 may rather underestimate actual outpatient utilization in Germany. This may reflect the definition of a “case” (i.e. a treatment case is registered only once per quarter) where a patient may contact the doctor several times per quarter and yet be a single treatment case.
According to an international comparison based on data from the Commonwealth Fund, family physicians in Germany work on average 50.8 hours per week. With 250 patient contacts during the same time, their workload is twice as high as in other European countries (except Italy), the United States, Canada, Australia and New Zealand. According to the same survey, family physicians in Germany spent 70% of the weekly work time in contact with patients– resulting in a median time per patient contact of 9.1 minutes in Germany, followed by Italy with 10.3 minutes. This value is low compared with the remaining countries where the time per patient contact had a median ranging from 13.3 (United Kingdom) to 28.8 (Sweden) minutes (Koch et al., 2011).
An aspect with relevance for the coordination of services provided by family physicians and specialists was the introduction of structured treatment programmes, so-called DMPs in 2003. These were intended to organize the treatment and care of chronically ill patients across the boundaries of the individual service providers, thus providing care more in line with requirements and in a more efficient manner. Health care services for patients registered with one or several DMPs are provided using evidence-based guidelines and across the boundaries of the individual service providers. In contrast to integrated care (see section 5.4.3), which is aimed at cross-sector patient care, DMPs primarily aim at coordinating services at the ambulatory care level.
In February 2003, the Federal Insurance Authority accredited the first DMP, for breast cancer, in North Rhine. DMPs are based on a uniform contract between all sickness funds of a region and the regional association of SHI physicians as well as a number of hospitals. Measures for quality assurance include standardized documentation, feedback reports to physicians, patient information and reminder systems (Busse, 2004). By December 2012, 10 385 DMPs had been accredited by the Federal Insurance Authority, with a total of 7.164 million enrolled (partly in more than one programme, so that the total number was only 6.228 million) (Bundesversicherungsamt, 2013). Table5.2 shows the development of the number of accredited DMPs as well as participants since 2006. The decrease in the number of programmes since 2007 can be explained by the decreasing number of sickness funds as mergers and takeovers have also led to merged DMPs. The number of participants is, however, still increasing.
Up until the introduction of the Central Reallocation Pool and the associated morbidity-based risk structure compensation in 2009 (see section 3.3.3), DMPs were integrated into the risk structure compensation, which created an important incentive for the sickness funds to introduce structured treatment programmes. Insured individuals registered with one of the programmes were a separate group within the morbidity-based risk-adjustment scheme, which for them resulted in higher standardized health care expenditure in almost all age groups. Furthermore, the regulation did not lead to any additional costs for the health care system, but merely to a distribution in accordance with the associated risks for financial resources between the requirements for the group of average insured individuals and the requirements of the chronically ill, because the higher values for the DMP participants were compensated for by the reduction of the compensation rate for the group of “normal” insured individuals.
In 2009, this financial incentive for the sickness funds to introduce DMPs was abolished, as all indications of the existing DMPs are among the 80 diseases eligible to be taken into consideration under the morbidity-based risk-adjustment scheme (see section 3.3.3). However, for the continued support of DMPs, the sickness funds receive a lump sum for each DMP participant in order to cover the programme costs. In 2009 and 2010, this sum amounted to €180, and was reduced to €145.68 for 2014.
Background: Access to primary and ambulatory specialist care for people insured in the statutory health system is generally good in Germany. The proportion of people reporting an unmet medical need due to financial reasons, distance or waiting times is close to zero. However, especially in rural areas, perceived waiting times for an appointment with GPs or specialists, e.g. with pediatricians, are much longer. In addition, privately insured patients are financially more attractive for ambulatory care physicians than those with statutory health insurance (SHI), which leads to equity concerns related to longer waiting times.
In May 2019, the German parliament passed a law in order to increase service availability in the SHI system. The “Act to Strengthen Appointment Service Centers and Care Delivery” (Terminservice- und Versorgungsgesetz) bundles several measures that predominantly aim to improve accessibility of primary and outpatient care providers and to expand the benefit basket within the statutory health insurance system.
Appointment service centers
The Regional Associations of SHI Physicians will be required to further strengthen already existing appointment service centers. From January 2020, these service centers will be available 24/7 using the nationwide telephone number 116117. Prior to this reform, opening hours and telephone numbers varied across the regions. Service centers will be obliged to secure an appointment with a GP, pediatrician or specialist within a week, and an appointment with a psychotherapist within two weeks. Furthermore, the appointment service centers will be required to direct patients in need of acute care to an appropriate provider, which can be a nearby medical practice or hospital.
Extended opening hours of primary care providers
To increase service availability even more, SHI-affiliated physicians will be expected to notify the appointment service center about free time slots for appointments. Additionally, they will be required to provide consultations for at least 25 hours a week (up from the previous legislative minimum of 20 hours).At least five hours a week, the practice must be open to acute patients without an appointment.
Monetary incentives for medical doctors
The reform also offers many monetary incentives for medical doctors to settle down in rural areas or to provide care to new patients. In underserved areas, medical doctors will receive additional compensation if they settle down in these areas on top of their income. This is additional to the already existing tools and budgets to attract medical doctors to underserved areas (e.g. to operate medical care centers or to subsidize costs to refurbish medical practices). Furthermore, rheumatologists, psychiatrists and pediatricians will be exempt from the needs-based planning tool of the regional association of SHI physicians and thus free to settle down in any area of interest.
Expansion of SHI benefit basket
The reform also added several new services to the benefit basket, including "PrEP"(Pre-exposure prophylaxis) for patients with increased risk of HIV exposure, increased coverage of medical aids and cryopreservation for potentially damaging therapies.Furthermore, the fixed subsidy for dentures will be increased from 50% to 60% in 2021, which is expected to lead to additional spending of €570 million over the first year.
Enhanced digitalization in the German health care system The reform also explicitly rules on digital patient records by 2021. Furthermore, notifications on the absence of work due to illness can be handled online and will replace the paper-based notification by January 2021. As of today, Germany is the only EU member state that still handles these notifications using paper forms.