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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.