status quo of quo vadis? - KCE

KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 25
2.4.1.5 Learning points and suggestions for Belgium
The French experience illustrates some pitfalls in the implementation of a quality system
at national level. First, the lack of conceptual framework underlying the initiatives entails
difficulties for setting up a coherent system. Secondly, the scattered initiatives rely on
the willingness of many actors with conflicting interests. The lack of an integrated quality
system leads to an insufficient implementation in the practice. Finally, implementing
quality initiatives is difficult when they did not involve the profession within their
development.
The freedom of choice for the patients, the absence of gatekeeping system and the
weak structure of ‘liberal medicine’ are often identified as factors hampering the quality
of care whilst increasing the financial burden for the health care system. The ‘quality
steps’ in the ‘liberal’ sector remain very limited, and exclusively relies on voluntary
work.
Three last points are important for the French system:
• The balance between the obligation (recertification process for all
practitioners; responsibility of complex pathologies by health networks) and
the incitation towards voluntary investment in quality (e.g., creation of a label
‘médecin engagé dans l'entretien régulier de ses connaissances’, incentive to
create flexible networks of prevention or duty to assume the responsibility of
specific populations);
• The need for clarifying the role of each actor in quality improvement
initiatives e.g. URML, Ordre des Médecins, sickness insurance funds (with a
controlling section - to sanction frauds and dangerous behaviours and a
counselling section - to promote quality in the practices);
• The willpower of the system to empower the patient to act as a lever for
promoting health care quality: practice recommendations for the patients,
perspective of a ‘regional guide of he professionals of health’ listing the
labelled 'liberal' experts.
2.4.2 Germany
2.4.2.1 Organisation of the health care system, with focus on family medicine/general
practice
AMBULATORY MEDICINE AND GENERAL PRACTICE
Ambulatory health care is mainly provided by private for-profit providers. GPs/Family
physicians represent 55% of the physicians working in primary care. Nowadays, most
GPs work in single-handed practices also in the eastern part, which is remarkable as
until 1989 public polyclinics delivered most ambulatory services. 81 About one out of
three family physicians do not have any specialist qualification. With a 1,1 GP density for
a thousand inhabitants Germany is in the middle of the European group. 2 Today an
academic curriculum for GP exists in almost half of all (34) medical faculties.
SELECTION OF A FAMILY DOCTOR BY THE PATIENT
Sickness fund members are free to choose a family physician who cannot change during
the quarter relevant for reimbursement of services for that patient. 92 Patients frequently
choose office-based specialists directly. However, one of the experts consulted in this
project (J. Stock) notices today a reverse tendency: many elderly and ill people ask for a
gatekeeping system, to help them going through the jungle of the health system.
REIMBURSEMENT SYSTEM
Germany has a fee for service system. The statutory health insurance (SHI) is the major
source financing health care, covering 88% of the population (2003). The payment of
physicians involves two major steps.
First, the sickness funds make global payments to the physicians’ associations for the
remuneration of all SHI-affiliated doctors, instead of paying the doctors directly. The