Gp in Europe



Social healthcare in Germany is organised on the basis of sickness funds and is legally based on the Sozialgesetzbuch V which specifies the following:

the population covered by social security;

population groups which can join the social security system on a voluntary basis;

services covered by the sickness funds;

type and organisation of the sickness funds; contributions to the sickness funds (paid half by the employers and half by the employees or workers); relations between sickness funds and doctors, dentists, hospitals and other service providers.

In 1997 DM230,900 million was spent on social healthcare services in total as compared to 1 69,900 million in 1 993.A doctor who wants to provide outpatient care for social security patients has to register with the Regional Panel Doctors' Association (KassenarztlicheVereinigung). One of the conditions is the successful completion of a postgraduate specialist education either in general practice or in another specialty. Furthermore, the doctor has to apply to a joint committee of doctors and sickness funds representatives (Zulassungsausschu}. It is possible that a region is closed for a given specialty since there is a planning system (Bediirfsplanung) for outpatient care. Once the doctor has his or her accreditation (Zulassung) he or she has to become member of the regional Panel Doctors' Association from which he or she gets paid on the basis of a mixed tariff with certain lump sums and fees for service payment. Furthermore, the Panel Doctors' Association scrutinises the carrying out of the panel doctors' duties and by monitoring their activities establishes a profile for economic control.More than 90 per cent of the population are covered by the social healthcare scheme. This means for the social security patient in January 1999:

free choice of doctor in outpatient care;

direct access to general practitioners and to specialists;

doctors services free of charge and with only small charges for certain other services, eg:

I) DM 8-10 as the patient's share for each item on a medical prescription depending on the size of the package;

II) ten per cent for a physiotherapist's service;

III) DM1 7 per day for the first 14 days in hospital;

IV) DM20 for cost of transport to a hospital when unfit. The patient has to prove his or her membership of a given sickness fund by a chip card. If a second medical opinion is necessary or another specialist has to be called upon, the patient




34.4 %

hospital services

34.6 %

18.1 %


17.4 %




9.2 %




6.2 %

dental prosthesis

10.1 %

6.7 %

physiotherapy, orthopaedic





prosthesis, glasses, etc

7.5 %

7.3 %

sick pay

6.2 %

11.0 %

other services


should get a referral from his or her general practitioner (GP) but he or she may also present his or her chip card to the specialisi without consulting his or her GP beforehand.As Germany has a fairly even population distribution, all area' are well-served with doctors and hospitals. For economic reason1 it is felt by a number of politicians, sickness fund representative' and professionals that there are too many hospital beds and toe many doctors for an economic and efficient health system. Others think that there are still needs to be catered for.Self-employed professionals, merchants and employees with an income above that which requires enrolment with the social sickness funds, and who are not voluntary members, have private-health insurance contracts. Furthermore, some of the higher earning employees with voluntary cover who wish a private room in hospital and free choice of a senior hospital doctor ir case of illness, take out a private insurance contract in addition to their social cover.


Primary healthcare
Primary healthcare is shared by GPs, paediatricians, specialist' in internal medicine and other specialists, depending on the choice of the patient and their prevailing health condition.The professional organisations of doctors consider that the relationship between the number of GPs and specialists ii out of balance so that young doctors should be encouraged tc go into general practice and undergo the necessary coinpk'nu'ntary vocational training.From 282,737 physicans in activity end of December 1997, 69,257 specialists and 46,062 GPs were in outpatient care.An integral part of primary healthcare is preventive medicine with programmes for defined conditions, such as special examinations for children up to the fourth year, early cancel detection and the like. Furthermore, GPs have fought successfully for their part in social medicine, emergency care, occupationa health and health counselling.The surgeries of some GPs are of a comparable standard with the well equipped offices of specialists in internal medicine Nevertheless, there will be a limit to the technical services c primary care doctor may perform.


The remuneration of the GP
Since January 1996 the traditional fee for service system has been changed and is still under construction. To get hold of  the quantity of services, the payment system now contain' basic fees (lump sums) and quantity limits, where service;are paid less once the limit is exceeded. Furthermore, indi vidual budgets are built to ensure that doctors cut ou unnecessary services. Since there are budgets for oulpatien medical care, pharmaceutical products and the referral tc non-medical professionals for physiotherapy, ergotherapy speech therapy, the value of the payment is not a fixed one but floats with the number of services of all doctors within c region, a situation which causes great discontent amongst the profession.


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