Germany
The situation of general practitioners in Germany in the run-up to
the year 2000
Dr
Thomas Lipp, Head
of the German UEMO Delegation
Structural
reform 2000
Following the change of government as a result of the Bundestag
elections in September 1998, a health policy dominated by the Social
Democratic Party and Alliance 90/Greens will now determine future
decisions in the Federal Republic of Germany. After the introduction
of a cost containment act, which already took effect on 1 January
1999, the debate now focuses on the introduction of a structural
reform, which is intended to enter into force on 1 January 2000.
According to both governing parties, one key feature of this
comprehensive reform will be to strengthen the position of general
practitioners and family doctors in Germany. The Federal Ministry of
Health has developed the idea of obliging all health insurance funds
to offer a tariff under which, in return for paying a lower
contribution, the insureds first have to go to their general
practitioner or family doctor, before being referred to specialists,
if necessary. This proposal made by the Federal Minister of Health
(Alliance 90/Greens) emphasises the voluntary nature of choosing a
tariff of this kind and is very similar to a model involving the
free choice of a general practitioner or family doctor which the
Professional Association of General Practitioners and Family Doctors
in Germany (BDA) has already been propagating for two
years.Problematic for the health system as a whole are the plans of
the coalition government to limit the expenditure of the statutory
health insurance system by way of a global budget. Such a strict
limitation of expenses would oblige all service providers in the
health system to provide medical care and services to an
increasingly old population with rising morbidity rates, while
incomes are stagnating on the whole. Another centra] aspect of the
Structural Reform 2000 is the growing signs of hospitals becoming
more involved in outpatient care. As the Federal Lander have a
strong influence on the legislative process, it will be almost
impossible to prevent the plan of allowing highly specialised
hospital doctors to become more active in the outpatient sector.
Restriction
of drug prescription by general practitioners
At the end of 1998, the Federal Committee of Physicians and Health
Insurance Funds adopted binding drug guidelines which list so-called
drugs of debatable efficacy, the costs of which are no longer
reimbursed by the statutory health insurance funds. Reimbursement
for other groups of drugs is also subject to restrictions under
certain conditions. These exclusion regulations will primarily
affect drug prescription and patient care by general practitioners
and family doctors, as no other professional group prescribes
mild-acting drugs to a comparable extent. There are also numerous
serious restrictions in the field of the topical application of
drugs for widespread diseases, such as venous complaints and
rheumatic diseases. Despite the protests of the BDA, the
Hartmannbund association, and also the Association of Doctors in
Ambulatory Care (NAV), against these guidelines, it must be stated
that the representatives of the specialists in the Federal Committee
of Physicians and Health Insurance Funds made very extensive
concessions to the health insurance funds in submitting these
guidelines.
Introduction
of five-year continuing education in general medicine
The medical profession decided to introduce five-year continuing
education in 1997. However, this system was not to be implemented
until satisfactory financing of the necessary continuing education
places could be guaranteed. Since that time, there have been
top-level negotiations between the medical organisations, the health
insurance funds, the hospital associations and representatives of
the Ministries of Health. The ultimate result was an immediate
programme which obliges the health insurance funds to promote
continuing education places in the inpatient and outpatient sector
with up to DM 2,000.00 per month. Consequently, the definitive
decision to prolong continuing education in general medicine to five
years was taken in 1998.Despite the extensive consensus of opinion
in the medical profession as regards the need to extend the period
of continuing education for future general practitioners and family
doctors, there were controversial debates as to the detailed form it
should take. After the German Medical Congress likewise resolved
that medical services provided by family doctors should in future be
assigned exclusively to the genera] practitioners, there were major
conflicts regarding the scope of the medical care to be provided by
family doctors, particularly in the technical sector. The
associations of doctors of internal medicine made vigorous efforts
to have technical and therapeutic services and methods, such as
long-term blood pressure measurements, Holier ECGs, sonography, etc,
excluded from the field of general medicine and assigned exclusively
to internal medicine. The technical downgrading of the surgeries of
general practitioners has been successfully prevented. Continuing
education now lasts a definitive five years and encompasses all the
aspects necessary for the medical care of the patients of family
doctors. As a result, general medicine has at last gained the
recognition and status it deserves in Germany. |
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