JANUARY

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GERMANY management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. However, there is no revalidation requirement for physicians. Hospital accreditation is voluntary. All new diagnostic and therapeutic procedures applied in ambulatory care must be positively evaluated in terms of benefits and efficiency before they can be reimbursed by sickness funds. Volume thresholds have been introduced for a number of complex procedures (e.g., transplantations), requiring a minimum number of such procedures for hospitals to be reimbursed. Process and (partly) outcome quality are addressed through the mandatory quality reporting system for the roughly 2,000 acute-care hospitals. The recently passed Hospital Care Structure Reform Act will provide a focus on quality-related hospital accreditation and payment, beginning in 2016 (see section on reforms). Disease management programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance. Nonbinding clinical guidelines are produced by the Physicians’ Agency for Quality in Medicine and by professional societies. All hospitals are required to publish results on selected indicators defined by the Federal Office for Quality Assurance and, until 2015, the AQUA Institute, allowing for hospital comparisons. Many institutions and health service providers include complaint management systems as part of their quality management programs; in 2013, such systems were made obligatory for hospitals. At the state level, professional providers’ organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims. To strengthen quality by law, in addition to the above, government commissioned the Federal Joint Committee in 2015 to establish the Institute for Quality and Transparency in Health Care, replacing the AQUA Institute. The institute is operational from January 2016, with the task of developing further indicators for quality assurance, which might provide an additional criterion for decisions on hospital planning and payment. The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. In August 2013, as part of the National Cancer Plan, the federal government passed a bill that proposes the implementation of a nationwide standardized cancer registry in 2018 to improve the quality of cancer care. What is being done to reduce disparities? Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ between states. Health disparities are implicitly mentioned in the national health targets. A network of 53 health-related institutions (e.g., sickness funds and their associations) promotes the health of the socially deprived (Cooperative Alliance National Health Targets, 2015). Primary prevention is mandatory by law for sickness funds; detailed regulations are delegated to the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds support 22,000 health-related programs, e.g., in nurseries and schools (Federal Association of Sickness Funds, 2015). With the Act to Strengthen Health Promotion and Prevention, these programs will be further developed and financially supported (see below). The Health Monitor (Gesundheitsmonitor) is a national association of nonprofit organizations and sickness funds. To assess access to health care, it regularly conducts studies from the patient perspective, for example, on the level of information, experiences with health care, or evaluation of health system reforms. 74 The Commonwealth Fund
What is being done to promote delivery system integration and care coordination? GERMANY Many efforts to improve care coordination have been implemented, e.g., sickness funds offer integrated-care contracts and disease management programs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2014, 9,917 registered disease management programs for six indications had enrolled about 6.5 million patients (more than 8% of all the SHIinsured). There is no pooling of funding streams between the health and social care sectors. From 2016, the Innovation Fund will promote new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD381 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds will be awarded through an application process overseen by an Innovation Committee based at the Federal Joint Committee. What is the status of electronic health records? About 90 percent of physicians in private practice use electronic health records (EHRs) to help with billing, documentation, tracking of laboratory data, and quality assurance. The use of online services to transmit billing information and documentation from disease management programs is obligatory. Hospitals have implemented EHRs to varying degrees. Unique patient identifiers do not exist and interoperability is limited, as data safety concerns represent a significant obstacle. As of 2015, electronic medical chip cards are used nationwide by all the SHI-insured; they encode information as to the person’s name, address, date of birth, and sickness fund, along with details of insurance coverage and the person’s status regarding supplementary charges (Company for Telematics Applications for the Electronic Health Card, 2015). In 2015, the Federal Cabinet proposed a bill for secure digital communication and health care applications (E-Health Act), which provides concrete deadlines for implementing infrastructure and electronic applications, and introduces incentives and sanctions if schedules are not adhered to. SHI physicians will receive additional fees for transmitting electronic medical reports (2016–17), collecting and documenting emergency records (from 2018), and managing and reviewing basic insurance claims data online. From July 2018, SHI physicians who do not participate in the online review of the basic insurance claims data will receive reduced remuneration. Furthermore, in order to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan, starting in October 2016. In the medium term, this medication plan will be included in the electronic medical record (Federal Ministry of Health, 2015). How are costs contained? All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added medical benefit. Drug companies are required to produce scientific dossiers for all new drugs demonstrating added medical benefit, which is then evaluated by IQWiG, followed by a Federal Joint Committee decision within a six-month period. For drugs with added benefit, the Federal Association of Sickness Funds negotiates a rebate on the manufacturer’s price that is applied to all patients. In addition, rebates are negotiated between individual sickness funds and pharmaceutical manufacturers to lower prices below the reference price. Recently, reliance on overall budgets for ambulatory physicians and hospitals and on collective regional prescription caps for physicians has been replaced by an emphasis on quality and efficiency. The Hospital Care Structure Reform Act aims not only to link hospital payments to good service quality, but also to reduce payments in the case of “low value.” To extend competition, some purchasing powers have been handed over to the sickness funds, e.g., to contract providers selectively within an integrated care contract or to negotiate rebates with pharmaceutical companies. International Profiles of Health Care Systems, 2015 75
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
Page 24 and 25: CANADA funding to 145 not-for-profi
Page 26 and 27: CANADA Organization of the Health S
Page 28 and 29: CANADA provides recommendations to
Page 30 and 31: CANADA Health Council of Canada (20
Page 32 and 33: CHINA Private health insurance: Com
Page 34 and 35: CHINA is not substantially more exp
Page 36 and 37: CHINA Organization of the Health Sy
Page 38 and 39: CHINA References Chen, X. (2014).
Page 40 and 41: DENMARK In addition, nearly 1.5 mil
Page 42 and 43: DENMARK Social psychiatry and care
Page 44 and 45: DENMARK Quality data for a number o
Page 46 and 47: DENMARK portion is small, it makes
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Page 50 and 51: ENGLAND immunization, and vaccinati
Page 52 and 53: ENGLAND Hospitals: Publicly owned h
Page 54 and 55: ENGLAND Organization of the Health
Page 56 and 57: ENGLAND How are costs contained? Ra
Page 58 and 59: ENGLAND Organisation for Economic C
Page 60 and 61: FRANCE VHI finances 13.8 percent of
Page 62 and 63: FRANCE The average income of primar
Page 64 and 65: FRANCE What are the key entities fo
Page 66 and 67: FRANCE inequities in prevention rel
Page 68 and 69: FRANCE Nolte, E., C. Knai, and M. M
Page 70 and 71: GERMANY There were 42 substitutive
Page 72 and 73: GERMANY The 16 state governments de
Page 76 and 77: GERMANY What major innovations and
Page 78 and 79: INDIA Private health insurance: The
Page 80 and 81: INDIA provide after-hour care, reim
Page 82 and 83: INDIA are provided by other ministr
Page 84 and 85: INDIA How are costs contained? Ther
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Page 88 and 89: ISRAEL Together, these two types of
Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
Page 114 and 115: JAPAN The author would like to ackn
Page 116 and 117: THE NETHERLANDS receive faster acce
Page 118 and 119: THE NETHERLANDS Hospital payment ra
Page 120 and 121: THE NETHERLANDS Organization of the
Page 122 and 123: THE NETHERLANDS References Organisa
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NEW ZEALAND provided in GP clinics.
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NEW ZEALAND management (e.g., clean
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NEW ZEALAND including such informat
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NEW ZEALAND largely through efficie
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132
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NORWAY Primary, preventive, and nur
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NORWAY Patients are free to choose
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NORWAY What are the major strategie
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NORWAY The National System for the
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SINGAPORE Medifund is the governmen
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SINGAPORE Public hospital funding i
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SINGAPORE Public consultation: The
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SINGAPORE To keep demand for servic
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152
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SWEDEN What is covered? Services: T
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SWEDEN Hospitals: There are seven u
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SWEDEN Care, which promotes use of
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SWEDEN What major innovations and r
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SWITZERLAND Insurers offer premiums
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SWITZERLAND Hospitals: About 70 per
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SWITZERLAND Organization of the Hea
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SWITZERLAND To control pharmaceutic
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UNITED STATES What is covered? Serv
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UNITED STATES Administrative mechan
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UNITED STATES The Institute of Medi
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UNITED STATES adopted at least a ba
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The COMMONWEALTH FUND Affordable, q
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