JANUARY

GERMANY
have their own premises. In 2014, of the roughly 109,600 self-employed SHI-accredited physicians in
ambulatory care, 52,800 (48%) were practicing as family physicians (including GPs, internists, and pediatricians)
and 56,800 (52%) as specialists. There were about 2,000 multispecialty clinics with more than 13,000 physicians
(10% of ambulatory care physicians) in 2014. Around 11,000 physicians working in multispecialty clinics are
salaried employees, while 12,000 are employed in practices of self-employed physicians. The total number
of ambulatory care physicians is more than 130,000 (Federal Association of SHI Physicians, 2015). Some
specialized outpatient care is provided by hospital specialists, including treatment of rare diseases and of severe
progressive forms of disease, as well as highly specialized procedures.
Individuals have free choice among GPs, specialists, and, if referred to inpatient care, hospitals. Registration
with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds
are required to offer their members the option to enroll in a “family physician care model,” which has been
shown to provide better services and also often provides incentives for complying with gatekeeping rules.
SHI-accredited physicians in ambulatory care (GPs and specialists) are generally reimbursed on a fee-for-service
(FFS) basis according to a uniform fee schedule negotiated between sickness funds and physicians (see below).
Payments are limited to predefined maximum numbers of patients per practice and reimbursement points per
patient, setting thresholds on the number of patients and treatments per patient for which a physician can be
reimbursed. For the treatment of private patients, GPs and specialists also get an FFS, but the private tariffs
are usually higher than the tariffs in the SHI uniform fee schedule. Pay-for-performance has not been established
yet. The average reimbursement of a family physician is above EUR200,000 (USD254,000) per year, covering
costs for personnel, etc., but excluding income from private patients, which varies substantially (Federal
Association of SHI Physicians, 2015).
Financial incentives for care coordination can be part of integrated care contracts, but are not routinely
implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD152,
in 2015) for patients enrolled in a Disease Management Program (DMP), in which physicians provide patient
training and document patient data. Bundled payments are not common in primary care, but a regional
initiative, “Healthy Kinzigtal” (Kinzigtal is a valley in southeast Germany), provides an example of a shared
savings model offering primary care doctors and other providers financial incentives for integrating care across
providers and services.
Administrative mechanisms for direct patient payments to providers: SHI physicians in ambulatory care
bill their regional associations according to a uniform fee schedule; the associations are in turn reimbursed by
sickness funds. Copayments or payments for services not included in the benefit catalogue are paid directly
to the provider. In cases of private health insurance, patients pay up front and submit claims to the insurance
company for reimbursement.
After-hours care: After-hours care is organized by the regional associations of SHI-accredited physicians to
ensure access to ambulatory care around the clock. Physicians are obliged to provide after-hours care in their
practice, with differing regional regulations. In some areas (e.g., Berlin), after-hours care has been delegated
to hospitals. The patient is given a report of the visit afterwards to hand to his or her GP. There is also a tight
network of emergency care providers (the responsibility of the municipalities). After-hours care assistance is also
available via a nationwide telephone hotline (116 117-Ärztlicher Bereitschaftsdienst). Payment for ambulatory
after-hours care is based on the above-mentioned fee schedules, again with differences in the amount of
reimbursement for SHI and PHI.
Hospitals: Public hospitals make up about half of all beds, while private not-for-profits account for about a third.
The number of private, for-profit hospitals has been growing in recent years (now around one-sixth of all beds).
All hospitals are staffed principally by salaried doctors. Doctors in hospitals are typically not allowed to treat
outpatients (similar to hospitalists in the U.S.), but exceptions are made if necessary care cannot be provided by
office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also
provide certain highly specialized services on an outpatient basis.
International Profiles of Health Care Systems, 2015 71