Prospects of gatekeeping in German social health insurance

Abstract

From 2004, German social health insurers are bound by law to offer their insured a gatekeeping option. In return for renouncing direct access to specialist care, the insured can be granted bonus payments by their social health insurer. So far, experience with gatekeeping is very limited in Germany. In social health insurance, sickness funds are very reluctant to offer gatekeeping, although this was already legally possible before 2004. In the private health insurance sector, cost savings in gatekeeping tariffs are probably the result of self-selection of the insured rather than more cost-efficient provision of health care services. International experience does not prove that gatekeeping results in cost savings or a better patient-physician relationship. Although in countries with a strong primary care system there is a higher life expectancy, gatekeeping is not the only factor to bring about this effect. It is not to be expected that the new legislation will result in a major proliferation of gatekeeping options in German social health insurance. Either the gatekeeping options will not be attractive for the insured or sickness funds will use gatekeeping options as an instrument for risk selection.

The New Public Management theory and European health‐care reforms

“…But experiments were short‐lived: in France only five per cent of French citizens adopted a gate‐keeper, and two years later the system was dropped. In Germany, gate‐keeping experiments were limited to a small number of voluntary programs (Greß et al 2004). Health‐care networks increased organizational efficiency in Switzerland, in Germany, where physician networks (e.g., das Deutsche Gesundheitsnetz ) were close to the gate‐keeping experiments in Switzerland (Himmel 2000; Ratajcak 1998), in France (e.g., réseaux de soins ), and in Italian urban areas.…”

Design and Delivery of a Tailored Intervention to Implement Recommendations for Multimorbid Patients Receiving Polypharmacy into Primary Care Practices

“…Patients in Germany have free choice of doctors and do not have to be registered at any primary care practice. Therefore different care providers are able to alter medication regimens without communication with the general practitioner (GP) [ 6 ]. To date there is no established patient tracking system in Germany and physicians' awareness of the impact of such interface problems seems to be low [ 7 ].…”

Wer wählt den Hausarzt zum „Gatekeeper“?

“…Da die Patienten ohne Umwege an die richtigen Fachärzte weitergeleitet werden, sollen Schnittstellenprobleme minimiert und eine effiziente Leistungserbringung gewährleistet werden. Durch die intensivierte Betreuung, insbesondere von Patienten mit hohem Versorgungsbedarf, soll der Hausarzt in seiner Koordinierungs-, Betreuungs-, Dokumentations-und Integrationsfunktion gestärkt werden, was im Idealfall zu einem verbesserten Behandlungsverlauf führen kann [3,4].…”

“…Es ist daher anzunehmen, dass besonders gesundheitsbewusste und jüngere Versicherte den Tarif wählen[4]. Aus Sicht der Gatekeeper-Funktion wäre damit aber die falsche Zielgruppe angesprochen, da insbesondere Ältere und chronische Kranke mit hohem Versorgungsbedarf von der Koordinierungs-und Betreuungsfunktion des Hausarztes profitieren können.Der vorliegende Beitrag möchte daher der Frage nachgehen, welche Bevöl-kerungsgruppen besonders häufig in ein Hausarztmodell eingeschrieben sind und einer intensiveren Betreuung durch den Hausarzt zugestimmt haben.…”