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Experience of German Health Care system application for Chinese health care reform

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The objective was to provide health insurance for wage-earners. The ... self employed, full coverage for civil servants (9% of work-population = 7,5 Mio. ... – PowerPoint PPT presentation

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Title: Experience of German Health Care system application for Chinese health care reform


1
Dong Hengjin, MA, MD, PhD Group leader Health
Economics Dept. of Tropical Hygiene and Public
Health Heidelberg University
Experience of German Health Care system ---
application for Chinese health care reform
2
Content
  • German healthcare system in general.
  • German healthcare financing.
  • Experience of German healthcare financing.
  • Can the experience be applied to China?

3
Healthcare system in general
4
Health care delivery
  • Outpatient care (since 1931)
  • GP, Specialists, Dentists
  • Optiker, etc.
  • Physiotherapists, etc.
  • Midwifes and Nurses,
  • Pharmacists
  • Inpatient care (hospitals) private and public
  • Cities and districts (public) (53.9)
  • Charity associations, churches (37.7)
  • Private clinics (8.3)

5
Main system of financing ()
Source Federal Statistical Office 2004
6
Some health statistics (2003)
  • Health expenditure 11.1 of GDP
  • Expenditure per capita US 3204
  • Physicians/1000 population 3.6
  • Hospital beds/1000 population 6.4
  • Average length of hospital staying 9.6 days

7
Healthcare financing History and development
  • Founded in 1883 by Bismarck under the Sickness
    Insurance Act
  • The objective was to provide health insurance for
    wage-earners
  • The principles were
  • Solidarity rich poor
  • healthy unhealthy
  • small family big family
  • young elder
  • State-welfare the state would provide for the
    welfare of its citizens who in turn shall be
    loyal to the state

8
History (cont.)
  • The insurance system was run by sickness funds
  • Wage-based contributions employers (1/3) and
    employees (2/3)
  • Benefits package represented employees interests
  • Providers were contracted competitively
  • After second world war in west Germany
  • Contributions by employers and employees were
    equalized
  • The payment of ambulatory physicians shifted from
    capitation to fee-for-service
  • The insurance coverage was expanded to ever
    larger segments of the population

9
Population coverage ()
Bärnighausen T, Sauerborn R. 117 years of the
German health insurance system are there any
lessons for middle- and low-income countries?
Social Science Medicine, 54 1559-1587, 2002.
10
Main stages of German Social Security
  • 1883 Social Health Insurance
  • 1884 Accident Insurance
  • 1889 Old Age and Disability Insurance
  • 1931 Unemployment Insurance
  • 1995 Long-term Care Insurance

11
Key Players
12
Distribution of German health insurance types
Social welfare
coverage
1,3
no
via state
Private
insurance
1,1
Health-
0,2
insurance
9,7
Statutory health insurance, 87.7
  • self employed, full coverage for civil servants
    (9 of work-population 7,5 Mio.), additional
    coverage
  • financial aid via state (Police, army,
    community service)

13
Benefits package
  • Ambulatory and hospital care
  • Dental care
  • Home care
  • Rehabilitation
  • Prevention program
  • Drugs
  • Medical aids
  • Transport costs
  • Direct payment (cash for sicker and maternal)

Plus co-payment
14
Contribution rate
15.5 in 2009
15
Healthcare financing Reform
  • Fund mergers
  • Risk structure equalization
  • Competition
  • Provider payment
  • Cost containment

16
Fund mergers
17
Risk structure equalization
  • Risk structure equalization scheme came into
    effect in 1993
  • The objective was to balance the risk and
    financial power among different sickness funds
  • Risks include age, gender, the number of family
    members covered by the policy of the family head,
    and the number of disabled

18
Competition
  • The objective is to increase administrative
    efficiency of sickness funds.
  • Free choice of sickness funds for all since 1996.
  • Competition among sickness funds via the
    contribution rates (catalogue of medical supply
    and service is fixed).
  • Free choice of health providers in order to
    improve quality of health care.

19
Provider payment
  • GP from fee-for-service to service points.
  • Hospital
  • full reimbursement (to 1994)
  • mixed payments (per case, per diem, to 2003)
  • DRG (after 2003)

20
Cost containment
  • From 1975 to 1997, the provider payment was
    through fee-for-service system. Under this
    system, cost containment measures included
    expenditure cap, global budget.
  • From 1997 to 2003, global budget was replaced by
    specialty-specific, flexible practice budget,
    which is targeted at a negotiable growth rate.
  • Since 2003, DRGs system, mainly for hospital.
  • Drug price cut
  • Reference price
  • Integrated care
  • HTA
  • Increase co-payment

21
(No Transcript)
22
New tariffs and types of bonuses
  • participation in preventive examinations
  • participation in prevention programs
  • participation in company health improvement
    programs (bonus for employer, too)
  • participation in special health providing models

free choice of type of bonus by sickness fund
liberation from co-payments possible retrospec
tive repayment of contribution rate (max. 1
month's amount) reduction of co-payment or
repayment of contribution rate possible
23
Experience Can the experience be applied to
China?
  • Small, voluntary and informal risk-sharing
    schemes as the starting point
  • Incremental legislative changes to achieve
    supra-regional compulsory insurance
  • Incremental expansion of coverage to achieve
    universal coverage
  • Incremental extension of the benefit package
    (originally income-loss, sick-pay) to attain
    comprehensive coverage including medical care

24
ExperienceCan the experience be applied to China?
  • Similar benefit package in all social health
    insurance schemes
  • Co-payment from less to more
  • Reference price
  • Drug price negotiated with pharmaceutical company
  • Balance risk and financial power among insurance
    companies
  • Free choice of insurance and providers

25
Experience Can the experience be applied to
China?
  • Merge schemes
  • Integrated care
  • Separate outpatient care and inpatient care GPs
    for outpatient care (private) and hospitals for
    inpatient care (most public)
  • Solidarity
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