Pharmaceutical Budget Replacement Act
| Basic data | |
|---|---|
| Title: | Law on the replacement of the pharmaceutical and therapeutic budget |
| Short title: | Pharmaceutical Budget Replacement Act |
| Abbreviation: | ABAG |
| Type: | Federal law |
| Scope: | Federal Republic of Germany |
| Legal matter: | Social law |
| References : | 860-5-21 |
| Issued on: | December 19, 2001 ( BGBl. I p. 3773 ) |
| Entry into force on: | December 31, 2001 |
| Please note the note on the applicable legal version. | |
The law to replace the drugs and medicines budget (abbreviated drug budget Redemption Law - ABAG) 2001 abolished the budget for healing and medicines from.
It was passed on December 19, 2001. It was promulgated in Federal Law Gazette I 2001 No. 71 of December 21, 2001. The law came into effect on December 31, 2001.
This law changed some paragraphs in the fifth book of the Social Security Code (SGB V) and thus replaced the regulations on the drug and therapeutic budget of the Health Structure Act of 1992.
Here are the main changes:
- Section 73 SGB V: The Association of Statutory Health Insurance Physicians (KVen) can also provide comparative information on inexpensive, prescribable services, including the respective prices and fees, and provide information on indications and therapeutic benefits based on the generally recognized state of medical knowledge.
- § 84 SGB V: KVen and Kassen agree on a volume of expenditure for medication and bandages for one calendar year in advance (for 2002 by March 31, 2002 at the latest) on the basis of a federal recommendation. A target agreement should ensure that the expenditure volume is adhered to. Overruns, undercuts can become the subject of the overall contracts and thus affect the fee negotiations. Independently of this, the health insurers can grant the KVen a bonus. The data situation is to be improved by monthly reports from the health insurances on the development of the expenditure of drugs and bandages to the KVen. This enables quick information relating to the individual doctor. If this has not yet been done, benchmarks for 2002 must be agreed by March 31, 2002 at the latest and also broken down according to patient groups and types of illness. A framework at federal level ensures a uniform procedure and must be agreed for the year 2002 by January 31, 2002 between the National Association of Statutory Health Insurance Physicians and the central associations of the health insurance funds. Health insurance companies and doctors agreed on almost 38 billion marks (around 19.5 billion euros) as the volume of pharmaceutical expenditure for 2002. This corresponds to an increase of 4.5 percent compared to the actual expenditure in 2000. At the same time, the expenditure volume is around 4.75 percent below Actual expenditures from 2001. These regulations for the area of drugs and bandages also apply analogously to expenditures for medicinal products.
- Section 106 SGB V: A benchmark test will take place as before if the doctor exceeds his so-called test volume and cannot justify this with special features in the practice (e.g. a particularly large number of chronically ill patients).
In the future, the examination volume will consist of:
- the benchmark volume (results from multiplying the benchmark by the number of cases)
- plus a percentage of 15% for the audit and 25% for the recourse . These percentages can be agreed differently by the contractual partners at the national level.
If the limit is exceeded slightly, the examination board must also arrange for specific advice from the doctor.
If a doctor is more than 25 percent above the reference value, he must reimburse the health insurance companies for the additional expenses, if they cannot also be explained by special practice features. However, the existence of a practice must not be jeopardized by the reimbursement to the health insurers.
The Association of Statutory Health Insurance Physicians and the health insurances can advise the contract physicians on questions of the profitability of prescribed or initiated services. The cash registers provide the KVs with the data required for this.
Explanation
The law abolished the budgets for medicines and medicinal products that were in effect until the end of 2001. Until then, there was an upper limit for the expenses incurred for drugs, bandages and therapeutic products for all contract doctors of an Association of Statutory Health Insurance Physicians (KV). This budgeting was introduced by the Health Structure Act in order to stabilize health insurance contributions.
If the upper limit of expenditure agreed between the health insurance companies and the KVen was exceeded, collective liability of the KVs took effect - a reduction in the total remuneration of the doctors in a KV in relation to the excess of the budget. Since collective recourse was difficult to implement and legally problematic, a new solution had to be found.
The drug budget replacement law replaces the budget with drug target agreements that relate to expenditure volumes.
These target agreements are made between the health insurance companies and the 23 associations of statutory health insurance physicians and must be implemented by the KVs. For this purpose, the KV determines an individual benchmark for the prescription volume for each individual statutory health insurance practice.
Specific benchmarks also apply to individual specialist groups. In order for doctors to be able to adhere to their guideline values, health insurers and health insurance companies must inform them about inexpensive medicines that can be prescribed and advise them on their therapeutic benefits.
If the health insurance doctor exceeds this benchmark , the KV will initially advise him in terms of an economic prescription. However, individual recourse is also possible as part of the performance audits.
Statutory health insurance physicians who do not exceed their target volume can receive bonus payments.
The law aims to control (limit) drug expenditure and improve the quality and economic efficiency of drug supply.
