Since the Sickness Funds are for-profit entities, I asked if the Funds compete with each other. Thorsten said that all Sickness Funds are about "95% identical" to each other, but that they do compete on the other 5% by "making your Fund as attractive as possible." That takes the form of, for example, special contracts with psychotherapists and hospitals which go beyond - or offer something different - than is offered by other Funds. Due to the German concept of Solidarity that emerges from the German social code, it is understood and accepted by most Germans that the overall package of benefits is made possible by young healthy people paying premiums that largely pay for those who are sick. I say "most Germans" because about 10% of the population chooses private insurance instead of the Sickness Funds (you must earn more than 50,000 euros per year to be eligible). On the plus side, with private insurance you are not bound by what the Sickness Funds have decided are covered treatments and your premiums are significantly lower. However, these premiums increase with age and only cover the individual (each family member must be covered separately). And should you become severely and/or chronically ill, your premiums can skyrocket.
Cost containment for the Sickness Funds is primarily achieved by annual negotiations around reimbursement rates for any and every treatment and service. Such a situation would be anathema in America, but as Thorsten said, "Social good, that is our Bible." And by having a set rate for all treatments, it creates certainty for stakeholders and makes a realistic budget possible.
I asked Thorsten and Jorn specifically about hospital stays and reimbursements, since in the U.S. this is a major driver of costs. They said that until 2003, hospital reimbursement payments were based on the number of days the patient stayed. The result was that patients who, for example, could have been discharged on a Friday were kept hospitalized until Monday. The new system now bases reimbursements on "diagnosis groups." For example, Thorsten said, if someone breaks her leg it will be reimbursed at a set amount regardless of the number of days the patient stays in the hospital.
Unfortunately, a byproduct of this change has been what Jorn called "the bloody discharge," where a patient has not been fully cured or healed but is nevertheless discharged and referred to their primary care physician for follow up. "This is an ongoing discussion for us," Jorn said.
I went on to ask about the German dichotomy between the system that AOK is part of (the Statutory Health Insurance, or Sickness Funds) and the private insurance system. I understood that the premiums for the private system were considerably lower than for the Sickness Funds, but given that premiums for the private system were subject to substantial increases with age and illness, why, I inquired, would people opt for private insurance?
"We have been having this discussion for ages," Jorn responded. "It is often a financial decision," he said, because the premiums are much lower. But there are other factors. Civil servants, he said, get their premiums paid by their employer, and certain trade groups have their own dedicated private insurance. Also, Jorn said, private insurance "pays for everything, and we don't."
Does this mean, I asked, that the private system is potentially subject to unnecessary care? Yes, Thorsten said. One indication they have seen is that while most doctors' patient mix includes only 10% from private insurance, they are deriving 20-30% of their income from those patients.
What about Germany's aging population, I asked? Like the U.S., Germany has a high average age and a birthrate that is below replacement. Is there a concern about exploding medical costs relate to this demographic reality?
"I personally don't think [out of control costs] will happen," Jorn said. He referenced the concept of Solidarity that I discussed in an earlier post. "Our Solidarity system is designed for the sick," Jorn said. Thorsten added that Germany is also focusing much more now on disease prevention through public awareness and programs about nutrition and exercise that will hopefully help produce healthy aging. And in fact, Jorn interjected, "A new law is being adopted that stipulates we have to make a certain amount available for prevention." It doubles the amount spent on exercise and nutrition, including cooperation with gyms where Fund members get special rates, as well as providing medical and dental checkups in schools for children. "We want to be known as a health fund, rather than a Sickness Fund," Jorn stated.
Earlier in the Fellowship I had some private conversations regarding the sharing of personal medical information. I had been told that there was very little sharing, making each patient a "black box" anytime they went to see a physician other than their primary care provider. Thorsten said this was largely the case.
"We have had this discussion for many many years now" to create ways to privately share information, he said. "But this idea has remained an idea only."
So this is a part of the German system that is not working that well, I said. But you are still clearly proud of what has overall been achieved. What works best in German healthcare?
Solidarity, both Jorn and Thorsten answered. Also, Thorsten added, by statute the government "can't tell us how to cover care, they can't take money out of the system. And we have easy and fast access" to care.
Thorsten and Jorn were very generous with their time, which permitted an extensive discussion. I'll have much more to say about it as I process the information and integrate it with other interviews in Germany. For now I have just a few impressions.
One thing that struck me is how right Sigrid Becker-Wirth of MediNetz was: if you are undocumented, you have very few options for care that don't make you highly likely to be deported. The gentlemen from AOK both said several times that the undocumented are "not part of the system." My interpretation is that the Germans leave the undocumented out in the cold for healthcare not due to animus regarding their race or country of origin but because of the German regard for adherence to the system (this interpretation has been reinforced by private conversations with others during my trip). As noted earlier, this regimentation carries excellent benefits in many respects, but makes it very difficult indeed for those who are outside the system. I'd go so far as to say that the undocumented may be better off in the United States because, although the undocumented face severe challenges in America, there is no "duty to denounce," which I've learned not only makes life difficult for the undocumented but also for asylum seekers who fear the required registration by which they can be tracked if their request for asylum is denied.
Many U.S. hospitals are not very fond of the readmission penalty that they can incur under the Affordable Care Act when a patient is hospitalized again within 30 days. And they have a point, to a certain extent. But the results speak for themselves, and I wonder if the "bloody discharge" phenomenon in Germany would not fade if they adopted the same policy.
I think it's pretty clear that the U.S. will not be adopting a Sickness Fund model anytime soon. But one aspect we could and should follow is the public release of data. As Thorsten mentioned, there is a degree of competition between the Sickness Funds, one aspect of which is a ratings guide that provides data on multiple categories. And since 2007, all hospitals have been required to publish results on 27 selected indicators defined by the Federal Office for Quality Assurance. Germans can review this data and use it to change Sickness Funds if the ratings indicate, for example, that your Fund is not well managed or is charging higher premiums for services, and they can readily compare hospitals. Granted, this is not a perfect analogy when it comes to insurance since Americans cannot cross state lines when purchasing insurance, but the idea of greater transparency in performance data about insurers - and providers - is long overdue in the United States.
No comments:
Post a Comment