Priority-setting, rationing and cost-effectiveness in the German health care system.
Germany has just started a public debate on priority-setting, rationing and cost-effectiveness due to the cost explosion within the German health care system. To date, the costs for German health care run at 11,6% of its Gross Domestic Product (GDP, 278,3 billion €) that represents a significant increase from the 5,9 % levels present in 1970. In response, the German Parliament has enacted several major and minor legal reforms over the last three decades for the sake of cost containment and maintaining stability of the health care system. The Statutory Health Insurance--SHI (Gesetzliche Krankenversicherung--GKV) is based on the fundamental principle of solidarity and provides an ethical and legal framework for implementing equity, comprehensiveness and setting the principles and rules for financing and providing health care services and benefits. Within the SHI system, several major actors can be identified: the Federal Ministry of Health, the 16 state ministries of health, the Federal Joint Committee (G-BA), the physicians (with their associations) and the hospitals (with their organizations) on the provider side, and the sickness funds with their associations on the purchasers' side. This article reviews the structure and complexities of the German health care system with its major players and participants. The focus will be put on relevant ethical, legal and economic aspects for prioritization, rationalization, rationing and cost-effectiveness of medical benefits and services. In conclusion, this article pleads for open discussion on the challenging subject of priority-setting instead of accepting the implicit and non-transparent rationing of medical services that currently occurs at many different levels within the health care system, as it stands today.
Division of Hematology and Oncology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ziemssenstrasse 1, 80336 Munich, Germany. fuat.oduncu@med.uni-muenchen.de
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D001294:Attitude to Health; D003363:Cost Control / Q000191:economics / Q000379:methods / Q000458:organization & administration; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics* / Q000458:organization & administration; D005858:Germany; D006077:Government Agencies / Q000458:organization & administration; D017048:Health Care Costs / Q000706:statistics & numerical data; D015276:Health Care Rationing / Q000191:economics* / Q000458:organization & administration; D018166:Health Care Reform / Q000191:economics / Q000458:organization & administration; D006292:Health Priorities / Q000191:economics* / Q000458:organization & administration; D006801:Humans; D009313:National Health Programs / Q000191:economics / Q000458:organization & administration; D011787:Quality of Health Care / Q000191:economics / Q000458:organization & administration