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24 APPENDICES Physiotherapy KCE reports vol. 40 4.2.2. Number of physiotherapists The number of practising physiotherapists was around 100.000 in 2004. Approximately 31.000 physiotherapists were registered as private practitioners in that same year. They are responsible for the foremost part of outpatient services. Around 5.500 students graduated as physiotherapists in 2005. Unemployment among physiotherapists is estimated at around 5.000. 4.2.3. Practice Physiotherapists work in solo or group practices (including multidisciplinary practices) as well as in hospital settings, prevention centres or rehabilitation centres ( Vorsorge- oder Rehaeinrichtungen ). Health professionals working in hospitals or institutions for nursing care or rehabilitation centres receive salaried pay. Services in ambulatory SHI-care are subject to fee-for-service payment ( Einzelleistungsvergütung ). 4.3. CONDITIONS FOR COVERED SERVICES In order for patients to be reimbursed under SHI, a referral prescription by a specialist physician or general practitioner is mandatory. Patient co-payments are limited to a lump sum payment of 10 per prescription in addition to 10% of overall treatment costs. The German reimbursement scheme characterizes anatomically grouped disorders by type of diagnosis, indication/symptoms, treatment objectives, duration and number of sessions per typical patient case (see example in the appendices). A single prescription usually comprises 6 up to 10 treatment sessions, as defined by the Heilmittel-Richtlinien (cf. infra). In principle, patients can receive further care following ensuing prescriptions. However, in practice, prescribing physicians act as gatekeepers, curtailing reimbursed expenditures. This is clearly demonstrated in the figures for the observed mean number of sessions (see included appendix 5) per treatment type as these hardly exceed the standard prescription numbers. In all, some 5 billion euros worth of outpatient physiotherapy care were reimbursed in 2005. This amount includes charges covered by complementary insurance. 4.4. QUALITY ASSURANCE AND EVALUATION SYSTEM 4.1.1. Agreements between professional associations and insurance funds In accordance to the social welfare law, national health insurance providers and professional associations agree to uniform definitions of provided physiotherapy services as a safeguard for standard quality of care. These agreements include: Required staff, practice space, equipment and other organisational prerequisites. Specifications regarding administered therapies: definition, prescription, indication, objectives, duration, etc. These elements are listed in the so-called Richtlinientekst and Heilmittel-Katalog An inspection committee composed by representatives of insurance funds and professional associations is entitled to verify practitioners compliance to the above agreements. 4.4.2. Voluntary quality schemes 4.4.2.1. Quality schemes for individual practitioners Physiotherapists are offered the possibility to further enhance their professional expertise through continuing learning programs organised by the professional associations These programs encompass
KCE reports vol.40 APPENDICES Physiotherapy 25 training courses, workshops, conferences and literature studies. Several certification programs have been developed by professional associations in collaboration with health insurance companies. These programs deal with specialty fields such as manual therapy techniques, lymph drainage therapy, orthoses/protheses patient instruction, etc. Certified physiotherapists are entitled to various financial advantages ( erhöhten Abrechnungsposition ) for the delivery of reimbursed outpatient care. Furthermore, physiotherapists contribute, through the professional associations, to the development of guidelines ( Leitlinien ). Certain certified training programs lead to specialisations that are formally recognized by insurance funds. At present, there is an ongoing debate on the voluntary status of continuing learning. It is very likely that from 2007 onwards, continuing learning will become mandatory ( Fortbildungsflicht ). 4.4.2.2. Quality schemes for practices The Institut für Qualitätssicherung in der Heilmittelversorgung (IQH e.V.) aims at improving practice standards through a comprehensive quality program. Self-assessment surveys, workshop cycles and external auditing are means applied to screen and raise physiotherapist s practices general working standards. The IQT is a private organisation and participation as a practice is voluntary. 4.5. HEALTH INFORMATION SYSTEMS Centralized data for the whole of Germany on expenditures by type of intervention, sex and age are collected through the Heilimittel-Informations-System (HIS), a common project by national health insurers. At set intervals utilisation data, both country-wide and per region, are published through the HIS-website. Moreover, certain large sickness funds periodically publish specific analyses based on these data (1,2). In all, the purpose of the collected data is to allow for follow-up of budgetary evolutions. 4.6. KEY POINTS The German Health System is grass-root based at the provincial level (Länder). Substantial regulatory powers are granted to professional associations in a spirit of consulted self-administration. Reimbursed physiotherapy care has been defined in a nation-wide uniform and detailed manner. Cost containment is achieved through gatekeeping (mandatory referral prescriptions). Continuing education will probably become mandatory for physiotherapists practicing under the SHI.
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