[The Evaluation of the German Federal Law of Equal Treatment of Disabled Persons]. / Die Evaluation des Behindertengleichstellungsgesetzes Rechtliche Aussagen und empirische Ergebnisse zur Barrierefreiheit im Bereich der gesetzlichen Krankenkassen.

The German federal law of equal treatment of disabled persons (Behindertengleichstellungsgesetz des Bundes, BGG) came into effect in 2002. An evaluation of this law was required by the national plan of action for the implementation of the United Nations Convention on the Rights of Persons with Disabilities (CRPD). Project evaluation objectives were to estimate whether the needs of disabled persons were being met and whether the instruments proved to be adequate for fulfilling the aims of the law. Jurisprudential analyses in combination with surveys were used for this research. It was found that the BGG still lacks adequate publicity. Its impact, however, was assessed as positive. Results also indicate that there might be some shortcomings with regard to accessibility. For a closer examination, however, more data focusing on accessibility in the context of health care and rehabilitation is.

[Patient Participation in Development of Quality Indicators using the Example of National Disease Management Guidelines for Chronic Heart Failure - A Qualitative Analysis of Collective Perspectives]. / Patientenbeteiligung bei der Entwicklung von Qualitätsindikatoren am Beispiel der Nationalen VersorgungsLeitlinie Chronische Herzinsuffizienz - Eine qualitative Analyse kollektiver Sichtweisen.

PURPOSE: In this qualitative study it was investigated by group discussions with patients suffering from chronic heart failure, how relevant the existing quality indicators of the National Disease Management Guidelines for Chronic Heart Failure are being estimated. METHODS: 6 group discussions were performed. The sample was formed from 4 mixed-gender groups, a male group and a female group. Participants were recruited from local heart sports groups. For the interpretation a method similar to the grounded theory was used. RESULTS: The main conclusion is that in principle quality indicators are accepted. However, many of these indicators neglect the everyday aspects of patients' life. Participants show a disposition of "yes - but" regarding the quality indicators. This phenomenon could be theoretically grasped using the concept of order of knowledge. While participants keep referring to an order of everyday knowledge, quality indicators make recourse to a medical order of knowledge. Both orders of knowledge may compete with each other. CONCLUSIONS: The professional knowledge order of medicine needs to open up to a patients' knowledge order. Patient representatives in health care bodies need to be trained to develop a reflexive point of view to different knowledge orders enabling them to represent patients' everyday knowledge more confidently. Otherwise there is danger of conformation to the professional knowledge order of medicine only for reasons of being recognised as equal partners.

[The "Wunsch- und Wahlrecht" from §9 SGB IX in case of the application for the medical rehabilitation: findings of a regional survey among insurees of a federal pension fund and a compulsory health insurance fund]. / Das Wunsch- und Wahlrecht des §9 SGB IX bei der Beantragung einer medizinischen Rehabilitation: Ergebnisse eines regionalen Surveys unter Versicherten der Gesetzlichen Renten- und Krankenversicherung.

OBJECTIVES: The Social Code Book Nine (SGB IX), which was implemented in 2001, contains the "Wunsch- und Wahlrecht" for medical rehabilitation services in para. 9. This describes a right to participate and choose in the process of rehabilitation. The aim of the study was to collect representative data about the implementation of the para. 9 SGB IX during application for medical rehabilitation services from the applicants' point of view. METHODS: A total of 2 000 applicants for rehabilitation services (all somatic and psychosomatic indications) of a federal pension fund and a compulsory health insurance fund were invited to take part in a postal survey about the "Wunsch- und Wahlrecht". RESULTS: The response rate was 66%. Most respondents reported that their application for rehabilitation services was approved immediately. People who supported respondents during application and gave information about the "Wunsch- und Wahlrecht" differed according to the kind of rehabilitation services the respondent applied for. Half of the respondents reported to have known about their "Wunsch- und Wahlrecht". The percentage was considerably higher for patients applying for post-hospital rehabilitation. Approximately 2/3 of the respondents had wishes concerning the choice of rehabilitation clinic. Half of those respondents reported their wishes to the insurer. Most wishes concerned the choice of a specific clinic, a place/region or the clinic's distance from the applicant's home. Wishes reported to the insurer were often considered (89%). Most important selection criteria for rehabilitation clinics were aspects of accommodation, clinic facilities and location, followed by aspects of treatment and the respectful treatment of rehabilitation patients. Concerning the mode of information about rehabilitation clinics, applicants preferred brochures (vs. internet), comparative and impartial information about the clinic and subjective accounts of individual rehabilitation patients. CONCLUSIONS: This study is an evaluation of how the "Wunsch- und Wahlrecht" has been translated to reality of rehabilitation services provided by a federal pension fund and a compulsory health insurance fund. The findings show that many respondents know about their "Wunsch- und Wahlrecht" and make use of it to a certain degree. At the moment wishes still relate mainly to the place or region of rehabilitation. This shows the necessity of informing applicants about their "Wunsch- und Wahlrecht" on a regular basis. At the same time they must be enlightened about potentially important criteria for choosing a rehabilitation clinic.

[Legal context of prioritization in rehabilitation]. / Rechtliche Rahmenbedingungen von Priorisierung in der Rehabilitation.

Participation benefits (rehabilitation) in Germany are granted on the basis of public social security law. Allocation and prioritization, hence, are to be seen in a legal context. As far as they belong to subsistence level requirements, participation benefits have to be granted unconditionally in case persons are needy. As all kinds of participation benefits also are part of social assistance law it can be assumed that they are part of subsistence. In light of individual basic freedoms, members of an obligatory system of social security have to be granted essential benefits in case of major contingencies. Basic equality rights demand objective reasons for making distinctions. Discrimination on the basis especially of religion, race, gender and disability is forbidden. This has to be taken into account also in prioritization by benefit usefulness. Substantial criteria for prioritization have to be stipulated by law. The divided system of rehabilitation in Germany impedes a systematic prioritization because benefits continue to be granted according to different criteria. The social code book 9--SGB IX--demands common guidelines for the rehabilitation administration bodies, but these guidelines are not concrete enough so far. It remains to be seen whether prioritization criteria can be extracted from the various benefit prerequisites. Prioritization is subject to narrow limits as far as persons are basically entitled to a benefit. This holds true also in case of rehab budgets such as those in statutory pension insurance. Anyhow, research needs to be done on whether these lead to prioritization in practice and which criteria would be relevant. A highly prioritizing impact is exercised by decisions about the available infrastructure of rehabilitation services and facilities, but there is neither a clear legal basis nor research on this subject. Finally, not only prioritization within rehabilitation has to be discussed but also prioritization between rehabilitation and acute medicine.

[Company integration management in small and medium-sized companies. Legal requirements and prerequisites for successful implementation]. / Betriebliches Eingliederungsmanagement in Klein- und Mittelbetrieben. Rechtliche Anforderungen und Voraussetzungen einer erfolgreichen Umsetzung.

UNLABELLED: The article is based on the results of the project "Company integration management in small and medium-sized companies. Legal requirements and prerequisites for a successful implementation" (01 January 2009-31 August 2010). BACKGROUND: Since 2004 all employers have been legally bound to offer company integration management (BEM, Betriebliches Eingliederungsmanagement) for all employees who have been incapacitated for work for more than 6 weeks within a year (Section 84 SGB IX, Book 9 of the German Social Code). Objective of this law is to ensure ongoing employment. OBJECTIVE: The aim of the study was to investigate the requirements companies, rehabilitation centres and services as well as social insurance institutions are faced with according to Section 84 SGB IX. Prerequisites for an effective implementation of BEM in small and medium-sized enterprises were analyzed. METHOD: Protocol-based interviews with experts were adopted. A total of 38 interviews with experts were carried out. The experts interviewed were either willing to give information by interest (concernment) or were named by law as an initiator or co-operator in the process of integration. A substantial literature research was performed in advance of the interviews. RESULTS: The awareness level of BEM is still very low even 7 years after its introduction. Small and medium-sized enterprises do not have any significant experiential knowledge of long-term incapacity for work and, hence, about BEM. Due to a lack of workers representation in many small and medium companies, management does not receive initiatives or support in implementation of BEM from employees' side. Employers prefer a central contact point providing them with the information and help needed, the common service units, however, being widely unknown in this context. Cost comparisons suggest that a company integration management might be more cost-effective than dismissing employees who are incapacitated for some fields of work. These findings might even hold true for small and medium-sized companies. Social insurance institutions are aware of company integration management; however there is a substantial lack of experience. There is some evidence that incentives and bonuses according to Section 84, 3 SGB IX would not have any significant impact on the implementation of company integration management in small and medium-sized enterprises. POLICY RECOMMENDATION: All relevant actors in the field of company integration management should reassess their possibilities to advocate integration management. Not only employees but also employers and social security institutions will benefit from comprehensive implementation of company integration management.

[Relevance of the "Wunsch- und Wahlrecht" of § 9 social code book 9 in medical rehabilitation from the patients' perspective]. / Die Bedeutung des Wunsch- und Wahlrechts des § 9 SGB IX für die medizinische Rehabilitation aus Sicht der Rehabilitanden.

OBJECTIVES: Everyone applying for medical rehabilitation (and other benefits to support participation) has a "Wunsch- und Wahlrecht" (meaning the right to individual wishes and choice relative to assessments, services and institutions as well as to the various benefits) according to § 9 of Book 9 of the German Social Code (SGB 9) concerning every aspect of the implementation of these services. This study was aimed at exploring the wishes of rehabilitants, their attitudes towards and experiences with the various aspects of the "Wunsch- und Wahlrecht" as well as their criteria in choosing a rehabilitation centre. METHODS: A total of 10 open guided focus groups were conducted with 71 male and female participants from 5 different indications and aged between 26 and 80 years. Transcripts were analyzed by means of a summary content analysis. RESULTS: Persons applying for medical rehabilitation benefits did not as a rule get information about their "Wunsch- und Wahlrecht" during the application process. Applying for post-hospital rehabilitation often meant to be faced with an only allegedly existing choice ("pseudo Wunsch- und Wahlrecht"). The participants objected only rarely to this missing share in decision-making. Most of them did not care about their rights to choose a rehab centre if only the application for rehabilitation was allowed. Various arguments were brought forward against the "Wunsch- und Wahlrecht", especially insufficient information about and time for enforcement and implementation of the "Wunsch- und Wahlrecht". Despite an explicit stipulation in § 9 SGB 9, notices of approval rarely stated reasons for ignoring the wishes expressed by the applicants. Many participants had reflected only little about choosing a specific rehab centre when applying for rehabilitation. Accordingly, most of the participants had difficulties to mention possible selection criteria. DISCUSSION: On the whole, applicants have Only little knowledge about the "Wunsch- und Wahlrecht". This complicates its implementation considerably. The preconditions for making informed and valid choices between different clinics are not given under these circumstances. Most interviewees do not attach much value to the "Wunsch- und Wahlrecht". CONCLUSIONS: From a social law perspective, it should be demanded that rehab applicants have to get better information about their "Wunsch- und Wahlrecht" and that they must be empowered to decide on their choice based on objective and valid information. The active role in the rehabilitation process that should generally be demanded from rehabilitants, should also be encouraged and fostered in choosing a rehabilitation centre.

[Legal questions concerning needs assessment for participation benefits]. / Rechtsfragen der Bedarfsfeststellung für Leistungen zur Teilhabe.

Needs Assessment for participation benefits (rehabilitation) in Germany is part of the administrative proceedings. It is condition for the decision of the responsible administrative bodies. It is underlying the principles of public inquiry, which can be carried out by experts of social medicine. It has to be carried out within a 3-week period and within a maximum of 7 weeks if a certificate has to be given. Following the principle of cooperation the need has to be assessed for all administrative bodies possibly involved as responsible for a participation benefit to be provided. In practice, however, needs assessment is still focussed on issues within the specific domain of the various administrative bodies. There is hardly any research on the implementation of needs assessment under a legal point of view. It could be started by carrying out an analysis of official files and by expert interviews.

[Technical AIDS to compensate for disability: legal framework and need for reform]. / Hilfsmittel zum Behinderungsausgleich: Rechtlicher Rahmen und Reformbedarf1.

The supply with rehabilitative technical aids in Germany is regulated in a complex way. Technical aids can be granted by different social security agencies for purposes of medical treatment, for long term care, for compensation of disabilities in the context of medical rehabilitation, for workplace participation and for participation in society. At present, the most relevant carriers of technical aids for compensation of disabilities are the statutory health insurance funds. In practice and jurisprudence there are several problems. A distinction is made between direct and indirect compensation of disability, and the obligation to provide cover is restricted to the compensation of basic needs. Both are questionable in the light of the German disability law and the ICF. The needs assessment cannot be carried out by physicians alone but has to be multifactorial. Fixed prices for technical aids are not always sufficient. In that case they are unlawful according to the latest jurisprudence of the Federal Social Court. The technical aids register of the statutory health insurance funds cannot restrict the rights of the insured. Further problems of legislation and practice are the responsibility for the supply with technical aids in homes for elderly or disabled persons and the tendering procedures of the statutory health insurance funds. A new codification is needed to simplify and clarify the law.

[Coordination in medical rehabilitation: demands on professions and institutions]. / Koordination in der medizinischen Rehabilitation: Anforderungen an Berufsgruppen und Institutionen.

Coordination of medical treatment, rehabilitation and long-term care is an important demand on the social and health care system. For rehabilitation in Germany, coordination and needs assessment have to be carried out across the responsible administrative bodies (section 10 SGB IX), and common service units (section 22 SGB IX) are to help. For long-term care, a new entitlement for Care counselling (section 7a SGB XI) in Care bases has been established recently in several German Länder (section 92c SGB XI). Hospital social services are obligatory according to the laws of most of the German Länder. Controversially discussed is the question whether responsibility for case management should be placed with the administrative bodies, the health care and social institutions like hospitals, or with third parties like self-help groups. This is regulated differently in the various sectors of the health care system. The professional law of the nursing professions allows to transfer coordination responsibilities to them, but social security law does not. Interprofessionally elaborated and accepted guidelines are an approach to establishing comprehensive standards of responsibility. Needs assessment to be carried out across the sectors should be regulated in social security law.

[Legal aspects of "patient orientation" in rehabilitation]. / Rechtliche Aspekte einer "Patientenorientierung" in der Rehabilitation.

Social Security Law und especially Book Nine of the Social Security Code, SGB 9 follow the guideline of self-determination and equal participation of disabled people. With this background it has to be criticized to regard disabled people as patients. Rehabilitation Administration has to be oriented on individual needs. The right to individual wishes and choice of assessment, services and institutions and of the benefits has to be respected. Also the services and institutions have to respect self-determination and to enable to exercise it. On an institutional level the organisations of disabled people have to participate in designing the benefits, the planning of the infrastructure and the counselling of people with disabilities. In practice, the SGB 9 still has to be implemented consequently.

[The SGB IX, book 9 of the German social code, in the development of social security law]. / Das SGB IX in der Entwicklung des Sozialrechts1.

The SGB IX is the legal basis of rehabilitation in Germany since 2001. It is embedded in the codification of the German social code, the Sozialgesetzbuch (SGB). There it has an intermediate function between the general social law and the special laws of the social insurance and social security institutions. Rehabilitation in Germany is working in a system of several different institutions with different legal roots. In special these are compensation of damages caused by employment accident and war and the avoidance of disability benefits by rehabilitation and activation. Inequality of treatment of disabled people according to the cause of their disability and to their employment status are accepted less; common principles of rehabilitation are being searched. Important reforms of rehabilitation law have taken place in 1974 and 1975. Since then problems have become visible in implementation and in the coordination of the complex system. SGB IX is a new effort for a general rehabilitation law. Open questions remain in handling the relations between rehabilitation and sickness treatment, long term care and prevention. Important are the newly defined terms for participation (Teilhabe) and disability (Behinderung), which build the linkage of SGB IX with constitutional law and with the health sciences. A weak point is still the relation of disability and age. Political attempts for unequal benefits in health insurance endanger the now reached level of rehabilitation law.