Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.

Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their health-care providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer-provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany's neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.

[Evidence-based health policy or scientifically cloaked lobbyism--the utilization of research findings in health politics]. / Evidence Based Health Policy oder wissenschaftlich verbrämter Lobbyismus-- Die Verwertung wissenschaftlicher Erkenntnisse in der Gesundheitspolitik.

Like no other political field health politics has become the target of well-connected lobbyists. On the other hand, there is hardly any other area with so many different methodological and institutional consulting approaches. Since the emergence of concepts like evidence-based medicine and evidence-based healthcare now evidence-based policy seems to be cropping up at conferences and in publications. The author has been working at the various interfaces of research and politics. In this article he takes health politics as an example to look at the actual utilisation of scientific knowledge in politics. Following a brief introduction to the particularities of the healthcare sector the tense relationship between research and politics will be highlighted and specific examples will be given using both the genesis of the SHI Competition Act and the competencies and responsibilities of the Federal Joint Committee.

[Competition in healthcare--political intentions]. / Wettbewerb im Gesundheitswesen--politische Intentionen.

Over the last 20 years strategies introducing regulated competition have gradually been implemented in the corporatistically structured German healthcare system. In particular, this applies to the structure of health insurance organisation where the corporatively organised allocation system has deliberately been transformed to ensure health insurance choice. Accordingly, the laws governing membership, health insurance premiums and health benefits have been adapted and new rules for public finance including a risk structure compensation scheme encompassing the different kinds of health insurances have been established. The options for competition arising in the area of health service provision do not only affect the health insurance companies themselves, but also the relations to the providers of healthcare as well as their relationship with each other. This holds especially true of the role and function of the (regional) physicians' associations. The relation between collective agreements and individual contracts is still unclear. With the further development of strategies introducing regulated competition the possibilities and limitations of competition will have to be explored and many details--such as, for example, the implementation of the responsibility for ensuring the provision of healthcare services--need to be resolved.

[After one year of German Health System Modernization Act--current position and perspectives of the German healthcare reform from a political point of view]. / 1 Jahr GMG--Stand und Perspektiven der Gesundheitsreform in Deutschland aus politischer Sicht.

One year after the introduction of the German Health System Modernisation Act (GMG) it is still too early to take stock of its effects in a comprehensive way. Nevertheless trends may be observed and assessed. The targeted financial consolidation of the Statutory Health Insurance has been achieved (prematurely). Many players involved in healthcare make use of the new opportunities provided by the regulations of the benefits, contribution and contractual law. For example, this applies to establishing ambulatory healthcare centres or integrated care. The development of drug prices still remains a problem. This is why more healthcare reforms will be inevitable. The next reform will focus on ensuring that the funding of healthcare expenditures be sustainable and socially equitable.