Le financement des soins infirmiers à domicile en Belgique - KCE

92 Financing of Home Nursing KCE reports 122
GERMANY
Introduction
A special feature of the German Bismarck inspired health care system is the important
role played by self-governing bodies of service providers (professions and health care
organisations) and health insurance funds. Within a legal framework, the medical selfgoverning
bodies (the national associations of doctors and dentists, the German
Hospital Federation and the federal associations of health insurance funds) formulate
and implement in detail which services will be provided and under which conditions.
Only rather recently nurse associations (and other allied professionals) received formal
rights to be consulted in the health care decision-making bodies.
Besides a delegation to nongovernmental corporatist bodies, the health care system is
characterized by a decentralized federal organisation with actors organised on the
federal as well as the state (Land) level.
The health care system is based on social health insurance and characterized by three
co-existing schemes.
• The statutory health insurance covers a vast majority of the population (with
mandatory and voluntary membership);
• A smaller part of the population has private health insurance. A smaller group
of people are insured through private health insurance to fully cover health
expenditure. Premiums vary with age, sex and medical history. Separate
premiums have to be paid for spouses and children.
• A very small part of the population is covered by governmental sectorspecific
governmental schemes (military, persons on substitution service,
police, social welfare and assistance for immigrants seeking asylum).
Since the 1980s, Germany implemented many health care reforms, mainly aiming at
providing more efficient and cost-effective health care services. The most distinct
changes over the last 10 years are the control of freedom of choice in health care use,
improving choice in health insurance, the introduction of long term care insurance and
the increase in out-of-pocket payments. Policy makers have recently introduced
measures to restrict utilization of services and to provide stronger guidance for
patients. Contrary to many countries, German health policy makers are promoting
forms of care that reduce choice for patients. The Statutory Health Insurance (SHI)
Modernization Act (GMG) of 2004 and the Statutory Health Insurance Competition
Strengthening Act (GKV-WSG) of 2007 constitute important turning points. The total
number of sickness funds has decreased steadily after the introduction of the Health
Care Structure Act of 1993 by merging into single general regional funds per Land.
In 2004, the Federal Joint Committee (G-BA) x (laid down in Volume Five of the Social
Code Book) was established. All medical professional groups and patients are
represented in the governing bodies of the G-BA. The G-BA determines the benefit
package of the statutory health insurance and issues legally binding directives for health
care sectors. The G-BA has also been assigned with a range of responsibilities with
respect to quality assurance in the health care system. The G-BA issues directives
governing quality assurance in the ambulatory, inpatient and inter-sectoral spheres. All
directives issued by the G-BA are submitted for approval to the Federal Ministry of
Health (BMG).
The G-BA plays a very important role in ambulatory (outpatient) care too as for
reimbursement matters, any new provision of care must obtain a positive assessment
(based on evidence-based procedures) in terms of benefit and efficiency before it can be
reimbursed by the statutory health insurance funds. The G-BA also issues the directives
to safeguard medical service provision within statutory health insurance.
x http://www.g-ba.de/institution/sys/english/