Читать книгу DiGA VADEMECUM - Jörg F. Debatin - Страница 35

The duality of the insurance system in the German healthcare system is only one example of its complex structures. The healthcare system is also based on three pillars, which differ from one another in terms of their mandate, governance, and financing (see fig. 1).

Since the COVID-19 pandemic, at the latest, many have become aware that there are public health departments at the level of administrative districts or independent cities. They are part of the German public health service. When the country is not affected by a pandemic or other public health crisis, the focus of the public health service is on population health and the preventionof diseases, e.g., through general health promotion and infection prevention initiatives. The public health service is not relevant for the DiGA Fast-Track because DiGA can only prescribed in the event of illness and only by physicians at the expense of statutory health insurance payers. However, digital health tools, e.g., to trace infection chains or to monitor the health of individuals in quarantine, have great potential. There is also a considerable need to catch up in this respect, and these opportunities will certainly have to be considered and addressed in the coming years.

Fig. 1 The three pillars of the German public healthcare system

In addition to the public health service, there are the two “curative” pillars of the German healthcare system. Outpatient and inpatient care are concerned with care of the individual in the event of illness. Outpatient care is provided by doctors, dentists, psychotherapists, and other healthcare professions, such as physiotherapists or occupational therapists. Not every healthcare professional can provide care to patients that is covered bz statutory health insurance. For certain products and services, authorisation according to the social code is required. (“statutory health insurance authorisation”).

Physicians in private practice are often organised as individual small business owners. In the context of inpatient care, healthcare professionals are usually employed by the hospital. The two sectors also differ in their remuneration systems. In the inpatient care setting, billing is based on per-case flat rates, so-called Diagnosis Related Groups (DRGs). Patients are assigned to groups based on their diagnoses, the procedures performed in the hospital, and other factors.

The uniform evaluation standard is decisive for billing in outpatient care. This defines what kinds of services can be billed by statutory health insurance-accredited physicians and determines the so-called “point value” for a given service as well as the value of that service. The value of a “point” is regularly adjusted, so that the effective billing amount changes just as regularly. Physician services in standard care are reimbursed by an overall budget of the health insurers who release funds to the Association of Statutory Health Insurance Physicians, who, in turn, take over the distribution of the funds in the context of billing. In outpatient care, flat rates are also billed, in particular by general practitioners. In addition, and especially in specialist care, individual services or special flat rates may be billed. The uniform evaluation standard is negotiated by the National Association of Statutory Health Insurance Funds and the Association of Statutory Health Insurance Physicians in the evaluation committee. For hospitals, the National Association of Statutory Health Insurance Funds negotiates with the German Hospital Federation.

There are also considerable differences between the outpatient and inpatient sectors with regard to the services provided, especially those involving the use of technology: medical procedures in the outpatient sector, whether involving medical devices or not, are subject to authorisation, i.e., they may not be performed until the Federal Joint Committee has made a positive determinion that such procedures may be provided at the expense of statutory health insurance payers. Hospitals, on the other hand, may provide new services, including the use of new medical devices, without further permission. Hospitals are subject to a prohibition proviso, i.e., they may in principle provide all services as long as the Federal Joint Committee has not decided to exclude them from care.

In essence, the goal in both sectors is to guarantee high-quality and efficient care. However, as both systems are very complex, misaligned incentives are difficult to rule out. In addition, there are always considerable difficulties in designing patient transitions between the sectors.

These pillars of care are completed by the following further elements of patient care:

Pharmaceutical supply,

care in the form of outpatient services or care facilities as well as

therapyservices, e.g., in the form of physiotherapy or speech therapy.