Professor Ferdinand M.

Gerlach, MD, MPH

Primary health care

and family medicine in Germany
Current status and recent policy developments

Washington, April 2010

 Professor Ferdinand M. Gerlach, MD, MPH

Overview:
German health care system
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Universal: for entire population

 Europe's oldest universal health care system

 Origins dating back to Otto von Bismarck's Social
legislation, which included the Health Insurance Bill of
1883, Accident Insurance Bill of 1884, and Old Age
and Disability Insurance Bill of 1889
 Mandatory health insurance
 These bills originally applied only to low-income workers
and certain government employees
 Their coverage, and that of subsequent legislation
gradually expanded to cover virtually the entire
population
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Two main types of health insurance

 Universal multi-payer system with two main types of

health insurance: statutory and private
 Germans are offered three mandatory health benefits,
which are co-financed by employer and employee: health
insurance, accident insurance, and long-term care
insurance
 Currently 90% of the population is covered by a basic
health insurance plan provided by statute, which provides
a standard level of coverage
 The remainder (10%) opt for private health insurance,
which frequently offers additional benefits (open for self-
employed and individuals with income above a relatively high threshold)
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Funding of health care systems in Europe

 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Some characteristics
 Number of sickness funds in 2010: approx. 160
(early 1990s: more than 1.000)

 General contribution rate: 14.9%

 Distribution employer/employee: 50/50
 All sickness funds: not-for-profit entities under public law
 Subject to control by government or entitled agency
 Classic example of enforced self-regulation
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Novel forms of care

 Integrated care programms

Designed to better coordinate:
• care between general practitioners (GP‘s) and specialists,
• across inpatient and outpatient sectors,
• rehabilitation and pharmacies (in some cases)
Insurers are allowed to contract directly and selectively since 2004 with
providers from different sectors and specialisations.

 General Practitioner centred models (HZV)

Promoted since the healthcare reform of 2004 which obliged insurers to offer
such programs to their patients:
• GPs will direct patients through treatments,
• avoiding costly multiple treatment or diagnosis,
• improving the flow of information between different healthcare providers,
• thus improving cost efficiency
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Novel forms of care (II.)

 Health care reform of 2007: aims at strengthening GP

centered models further

 It obliges social insurers to offer GP-centred models

 Members who wish to enrol in such a program (with

gatekeeping by GPs) would bind themselves to limit
their free choice of phycisians for one year
 Professor Ferdinand M. Gerlach, MD, MPH

Distinguishing features of the

German health system
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Doctor patient contacts

(Grobe et al. 2008, 1.6 mln insured persons at Gmünder ErsatzKasse)

 92.6% of the population consult an ambulatory doctor

in a single year
 Ø 17.9 doctor contacts/year/person
of which 7.1 contacts to a GP
 Utilization over the last four years:
up 7% (despite introduction of practice fee)
 Average Monday: almost 8%, on peak days
(e.g. 01.10.2007) 11.75% of the German population
(= 9.7 million persons)
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Diagnoses per patient

(Grobe et al. 2008, 1.6 mln insured persons at Gmünder ErsatzKasse)

 Population average per person/year (2007):

25.8 (ICD-)Billable diagnoses.
Adjusted for duplicate diagnoses etc.:
9.3 require further clarification/treatment
 Despite questionable validity of diagnosis that led to bill:
- Medical care appears to be fragmented
- Indications of lack of cooperation and of priority setting
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Short consultation times and long working days

 Doctor‘s consultation times: per patient, 30% lower in

Germany than the European average and thus the
shortest in Europe.
 Nevertheless, German doctors have longer working
days (IQWiG 2008).

 Facit: German doctors (and their patients) feel like

“a hamster on a treadmill“
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

International comparison
(Koch et al. 2007, 6088 GPs from 7 countries)
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main
Hausärztliche Versorgung Fachärztliche Versorgung

Allgemein-/Praktische Ärzte, Alle anderen Facharztgruppen

Jahr Internisten, Kinderärzte Primary care

Anzahl Anteil Anzahl Anteil
physicians versus
1991 44.521 60,1% 29.542 39,9%

1992 45.831 59,3% 31.445 40,7% specialist

1993 62.375 59,7% 42.181 40,3%

1994 62.340 58,7% 43.900 41,3%

1995 62.477 58,1% 45.020 41,9%

1993 to 2007:
1996 59.828 54,8% 49.290 45,2%

1997 60.244 54,6% 50.151 45,4%

Specialists: +43,6%
1998 59.120 52,5% 53.563 47,5%
PCP: -6,5%
1999 59.188 52,4% 53.746 47,6%

2000 59.601 52,3% 54.418 47,7%

2001 59.555 51,6% 55.890 48,4%

2002 58.844 50,7% 57.221 49,3%

2003 58.718 50,3% 57.977 49,7% since 1993: plus East Germany
2004 58.837 50,3% 58.153 49,7%
Kopetsch 2003, 44;
2005 58.698 49,9% 58.849 50,1% Gesundheitsberichterstattung des
Bundes 2008, SVR own calculations
2006 58.602 49,5% 59.675 50,5%

2007 58.304 49,1% 60.554 50,9%

 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Coordinating care: how are we doing?

 Services often poorly coordinated between

ambulatory and hospital, between acute and long-term
care
 Limited sharing of clinical information between
professionals at different sites
 No information system to oversee flow of patients
throughout the system
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Barriers to care coordination (Bodenheimer)

 Overstressed primary care physician

 Uninformed, passive patient
 Lack of computerized records that link different sites
of care
 Dysfunctional financing
 Lack of integrated systems of care
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Hamster Care

“Across the globe doctors are miserable because they feel like
hamsters on a treadmill. They must run faster just to stand still …
The result is a reduction in the quality of care and an increase in
burnout among doctors.”

Morrison and Smith, BMJ 2000;321:1541

 Professor Ferdinand M. Gerlach, MD, MPH

Future approach
towards coordinated medical care
on a regional basis
Recommendations
2009 report of the Advisory Council on the Assessment of
Developments in the Health Care System

Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen

 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Core aims

 Gear towards demographic change, shift in the

morbidity spectrum
 Strengthen sustainability and prevention
 Reduce unnecessary contacts/workload:
“Get off the hamster treadmill!“
 Overcome inefficient competition (between different
healthcare providers): better coordination
 Structure altered to take account of needs of care
providers
 Attractive working conditions for future doctors
 ...
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Selected strategies

 EU-concept on primary care

 Patient-Centered Medical Home
 Bellagio-Model of population-oriented primary care
 Roadmap by the Royal College of General Practitioners
 Chronic Care Model to provide comprehensive medical
care for the chronically ill
 Cooperation with other professions
(AGnES, MoPra, VERAH)
 Managed Care (using systematic review)
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

From sectoral to population-oriented medical care

 Professor Ferdinand M. Gerlach, MD, MPH

Future approach:
Implementation using example of
primary care practice
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Primary care practices

Features: launching pads for change

 “Developed organizations“
 Relatively large sizes: 4-6 doctors, specialized
healthcare assistants and nurses
 Registration model: Defined population
 Team approach: Involvement of non-physician personnel
 Liaison: with specialists from hospitals/practices
 GPs as coordinators/facilitators with ultimate
responsibility
 Longer surgery opening times, flexible working hours
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Primary care practices

characterized by multifaceted healthcare services

 Systematic analysis/stratification according to risk

factors in patient population (e.g. diabetes)
 Special healthcare services (e.g. vaccination reminders)
for various groups of patients
 Separate surgery hours assigned for structured,
interdisciplinary health services
 Case management, long-term monitoring, training of
chronically ill by healthcare assistants
 Involvement of chronically ill in their therapy
 Communication channels: eMail, telephone consultation
hours
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Primary care practices

Problem

Continuity in doctor-patient relationship!?

 Trial involving 284 general practices in 10 European
countries (including Germany): Patients feel themselves
to be significantly better looked after in small
practices than in larger-scale practices with several
contact persons and/or employees
(Wensing et al. 2008)

Teamlet-Model (Doctor plus healthcare assistant)

(Bodenheimer and Laing 2007)
 Institute of General Practice
Johann Wolfgang Goethe-University, Frankfurt am Main

Next health reform? Consider Cheng Sung Mei´s

cosmic law of health care
1. „At any time, anywhere in the world, people will
whine about their health care system“.

2. „The decibel level of whining is only weakly related

to how much a country spends on health care“.

3. „At any time, anywhere on the globe, there will be

calls for a major health reform“.

4. „At any time, anwhere on the globe, the last health

reform will be said to have failed“.
(Uwe Reinhard, Princeton University, 2006)