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German health reform likely to raise costs for patients

BMJ 2004; 328 doi: (Published 09 January 2004) Cite this as: BMJ 2004;328:70
  1. Annette Tuffs
  1. Heidelberg

    Germany's healthcare reforms that took effect at the beginning of this month look set to drive up the cost of annual health insurance for the average family by several hundred euros, instead of substantially cutting the fees as intended.

    Health insurance fees, half of which are paid for by employers, currently range from 12.6% to 14.9% of annual income, but health economist Rolf Rosenbrock, professor of social sciences and public health at the Technical University in Berlin and member of the Advisory Council for the Concerted Action in Health Care at the German health ministry, predicts in the latest issue of the weekly Focus magazine that these will fall by only a small margin or stay the same.

    Health insurance companies have announced that they have to pay off their collective debts of €3bn (£2m; $3.8m) and will wait for the rest of the health reforms to take effect before lowering their costs by the anticipated sum of about €10bn.

    From 1 January, Germans covered by the state health insurance scheme will have to pay a quarterly €10 (£7; $13) every time they visit a family doctor or a specialist. But although most are willing to pay, patients have been dismayed by the complicated fee structure.

    A spokesperson from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung),said that only a few non-urgent patients had been sent home because they did not have the cash or other means to pay. Hospital emergency rooms, where each visit now costs €10, asked patients to pay up later if they could not pay on the day.

    But the situation is trickier for pharmacies, where patients now have to pay 10% of the drug price—a minimum of €5 to a maximum of €10. Drugs costing less than €5, which patients used to pay for themselves, now fall within this new pricing structure.

    Nevertheless, health minister Ulla Schmidt still hopes that patients will quickly become familiar with the new system and that in due course health insurance fees will fall substantially, easing the financial burden of patients and employers. But she said that she has no intention of forcing the health insurance companies to slash their fees.

    But the health minister was less sanguine about a decision taken by the joint committee of doctors and health insurance companies to redefine the status of chronically ill patients.

    In future, patients will be classified as chronically ill if they visit their doctor at least twice a month, have been treated in hospital over the past two years, and require care because of a disability. But this could exclude many patients with heart failure or diabetes.

    Chronically ill patients have to pay a maximum of 1% of their income on health insurance, whereas all other patients pay a maximum of 2%. Ulla Schmidt said that this new definition would not be accepted by her ministry, which makes the final decision on payment levels. She also fears that patients might seek advice or treatment unnecessarily, in order to fit the “chronically ill” definition, thereby reducing their healthcare bill.

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