Читать книгу DiGA VADEMECUM - Jörg F. Debatin - Страница 34

The German healthcare system is characterised by the coexistence of statutory health insurance (GKV) and private health insurance (PKV). Approximately 73 million people are statutorily insured. In the statutory health insurance system, all insured persons are treated equally with respect to benefits and contributions, taking into account their ability to pay and their needs (the so-called “solidarity principle”). In the private health insurance system, an insured person decides which benefits he or she wishes to take advantage of and which premiums/ fees he or she is willing to pay accordingly. In addition, individual risk, e.g., pre-existing conditions, and the resulting (expected) demand are taken into account. These and other factors result in an individual premium (the so-called “equivalence principle”). In the private health insurance system, individuals pay for services received and are subsequently reimbursed. In the statutory health insurance system this is not the case; insured persons receive benefits directly (both in-kind and services). From a legal perspective, insured persons are entitled to certain services from their respective insurer, however the insurer (a so-called “sickness fund”), does not provide these services itself but rather uses the services of healthcare providers. Billing for services takes place between health insurers and healthcare provider directly. There are only a few exceptions to this principle. As a result, prices are regularly agreed upon with health insurers and in many cases, there are uniform prices for all health insurers, which are agreed upon through the umbrella association of statutory health insurance funds, the The National Association of Statutory Health Insurance Funds (or GKV-Spitzenverband in German). This is also the case for DiGA reimbursement, where the respective DiGA manufacturer negotiates the reimbursed price with the National Association of Statutory Health Insurance Funds. If such negotiations fail, reimbursed prices shall be determined by an arbitration body.

This all sounds very elaborate. However, Germany is one of the few countries in which every citizen is free to choose his or her statutory health insurance plan as well as his or her doctors, hospital, or pharmacy, in any combination, and an individual can also change his or her mind at any time without giving reasons. Despite these many degrees of freedom, health insurance covers all essential costs.