Statutory health insurance supply strengthening law

Basic data
Title:	Law to strengthen supply in the statutory health insurance
Short title:	Statutory health insurance supply strengthening law
Abbreviation:	GKV-VSG
Type:	Federal law
Scope:	Federal Republic of Germany
Legal matter:	Social law
Issued on:	July 16, 2015 ; ( BGBl. 2015 I p. 1211 )
Entry into force on:	predominantly 23rd July 2015
Weblink:	Text of the law
	Please note the note on the applicable legal version.

The law to strengthen the supply in the statutory health insurance (GKV supply strengthening law - GKV-VSG) was passed by the German Bundestag on June 11, 2015 and its main parts came into force on July 23, 2015. The main goals of the law are to ensure nationwide outpatient medical care, to improve patient access to medical services and to promote innovative forms of care that were prepared by the Statutory Health Insurance Care Structure Act.

Legislative process

The Statutory Health Insurance Care Strengthening Act essentially implements the decisions on outpatient health care of the coalition agreement of the 18th legislative period of the German Bundestag . The draft law was introduced by the Federal Ministry of Health on February 25, 2015 and adopted by the German Bundestag on June 11, 2015 with the consent of the government parliamentary groups, the abstention of the left-wing parliamentary group and the rejection of the green parliamentary group. The law did not require the approval of the Bundesrat.

Content

Ensuring outpatient medical care

Numerous measures of the Health Care Strengthening Act were aimed at ensuring outpatient medical care, especially in rural areas . The background to these measures is the partially existing and, to a much greater extent, threatened undersupply in primary care. While there is an oversupply of general practitioners in many metropolitan areas, around a third of all planning areas have a coverage rate of less than 100 percent. In some areas an existing or at least an imminent undersupply has already been officially established. Rural areas in particular are affected by this development. There is also an undersupply in some regions for individual specialist groups in specialist care.

Purchase regulation

The statutory health insurance associations are responsible for ensuring medical care in the outpatient area . With the Statutory Health Insurance Supply Structure Act from 2012, they were given the opportunity to refuse to fill a vacant doctor's seat in areas with oversupply and to buy the doctor's practice instead. It was at the discretion of the admission committees to make use of this measure. Overall, only a single doctor's seat was bought nationwide. The Council of Economic Experts described the lack of use of this instrument to assess the development in the health care system in view of the massive maldistribution in outpatient care as “incomprehensible”.

The governing coalition saw this lack of activity as a failure of medical self-administration. In the coalition agreement, the parties therefore agreed to make the purchase regulation more binding and thus to limit the scope of action of the admissions committees. Accordingly, with the Statutory Health Insurance Supply Structure Act, it was decided to convert the previous optional provision into a target provision. Medical offices that become vacant in areas with arithmetical oversupply must from now on be bought up by the Association of Statutory Health Insurance Physicians, unless supply reasons speak against it in individual cases. With the new regulation, the admissions committees have the opportunity to fill necessary doctor's offices in areas with a mathematical oversupply. The draft law originally provided that the purchase obligation should apply from a supply level of 110 percent. In the legislative process, this limit was increased to 140 percent.

The stricter purchase regulation met with strong resistance from the medical profession. She sees the reform as a threat to the professional profession of doctors. She also doubts whether the measure is suitable for redistributing doctor's offices from metropolitan areas to rural areas. It is an illusion to believe that doctors who are not allowed to practice in the city would move to the country. In addition, the demand planning is too imprecise and ignores the supply of urban areas for the neighboring regions. It does not reflect the population's real need for care, but is "arbitrary and accidental". The National Association of Statutory Health Insurance Physicians drew attention to its position with a nationwide poster campaign . This approach was sharply criticized by the ruling coalition.

The protests of the medical profession could not prevent the change of the purchase regulation. However, individual points of criticism were taken up. On the one hand, the limit for buying up doctor's seats has been increased from 110 percent to 140 percent. On the other hand, the requirements planning is to be reformed. With smaller planning areas and the consideration of other criteria such as social factors, the morbidity and the accessibility of the doctor's office, the requirements planning should be more targeted. The Federal Joint Committee was commissioned to revise the requirements planning guideline by December 31, 2016.

Financial incentives to settle

In order to finance the funding measures to ensure statutory medical care, the statutory health insurance associations were given the opportunity to set up a structural fund with the Supply Structure Act. The resources of the Structural Fund are to be used in particular for subsidies for the investment costs for setting up a new branch or for setting up branch practices, for supplements for remuneration and training as well as for the award of scholarships. To finance this, the Association of Statutory Health Insurance Physicians pays 0.1 percent of the total morbidity-related remuneration, which is supplemented by contributions from the regional associations of the health insurance companies and the replacement funds. Up until now, the financing of support measures from structural funds was tied to the state committee's determination of the existence or threat of undersupply or local supply needs. This condition was deleted with the Supply Strengthening Act so that funding can also be preventive in the future.

There will be no registration fees for a branch in underserved areas. The admissions committee can also decide to forego charging fees in areas that are not underserved or to reduce them if this appears necessary for reasons of supply.

With the Statutory Health Insurance Supply Structure Act, the statutory health insurance associations have been given more flexibility in the distribution of the total remuneration through the fee distribution scale (HVM) in order to better meet the special regional care needs and care structures. By increasing transparency, the Pension Strengthening Act intends to strengthen the distribution of fees in its function as a fee policy instrument. In the future, the principles and supply goals of the fee distribution standards are to be presented transparently. Possible health care goals could include, in particular, a stronger focus on the needs of patients with severe chronic illnesses, multimorbidity and age-related illnesses as well as the elimination of supply bottlenecks in structurally weak areas.

Strengthening cooperative forms of care

The approval of medical care centers (MVZ) is made easier. In the future, the condition that medical care centers must be interdisciplinary will no longer apply. This means that MVZ can also be used solely for general practitioners or specialized medical specialist groups. Municipalities were also given the opportunity to set up their own MVZ as a public institution and thus actively influence and improve care in the region. The establishment of a municipal MVZ is, however, still linked to the respective requirements planning.

The law is also intended to improve the promotion of practice networks . In future, the statutory health insurance associations will have to promote practice networks, provided they have recognized this. The National Association of Statutory Health Insurance Physicians determine the criteria and quality requirements for recognition in agreement with the National Association of Health Insurance Funds .

Participation of hospitals and university outpatient departments in outpatient care

Even before the Health Care Strengthening Act, the admissions committees had the option of allowing hospitals to participate in outpatient medical care upon their application. However, this option was "used rather cautiously in practice." The regulation is therefore becoming more binding. In cases in which there has been an undersupply, the admissions committee will in future be obliged to approve the application by the hospitals to participate in statutory health care.

University outpatient departments must in future not only be authorized by the admissions committees for medical treatment for the purposes of research and teaching, but also for care "for those people who, due to the nature, severity or complexity of their illness, require examination or treatment by the university outpatient department ". Which patients this affects is determined by the National Association of Statutory Health Insurance Funds, the National Association of Statutory Health Insurance Physicians or the National Association of Statutory Health Insurance Dentists and the German Hospital Society in a joint contract. You can also agree on exceptions to the generally applicable transfer reservation by a specialist.

Strengthening the family doctor profession

With the Care Strengthening Act, the federal legislature obliges the associations of statutory health insurance physicians to ensure a clear and permanent separation of general practitioner and specialist doctor remuneration in their fee distribution standards. This prevents the services provided from one service area from reducing the other part of the total remuneration.

To strengthen the family doctor profession , the number of at least further training positions to be funded in general medicine will be increased from 5,000 to 7,500. The subsidy is to be raised to the level of the collective wage agreement in the hospital.

In addition, in the future, only general practitioners will be entitled to vote in the general assembly of the National Association of Statutory Health Insurance Physicians. The same applies in reverse to the group of specialists. The originally planned application of this procedure to the regional associations of statutory health insurance physicians was not implemented. When voting on common topics, the votes are weighted in such a way that the votes of representatives of general practitioners and specialists are par.

Improving access to medical services

Appointment service points

With the Statutory Health Insurance Care Strengthening Act, the federal legislature also reacted to the complaint of patients with statutory health insurance that sometimes long waiting times for a specialist appointment were made. To shorten waiting times, the Association of Statutory Health Insurance Physicians must set up appointment service centers by January 23, 2016 . These offices have the task of offering insured persons an appointment with a specialist within one week if a referral is available. The appointments can also be arranged with a specialist at a distance of around 30 to 60 minutes driving time. Desired appointments are not taken into account and appointments are not made with psychotherapists, dentists or orthodontists. In the case of ophthalmologists and gynecologists, the transfer reservation does not apply. The arranged appointment must not be more than four weeks in the future. If the appointment service point is unable to offer an appointment during this period, it must grant an outpatient treatment appointment in a hospital. The appointment service points are to be subjected to an evaluation by June 30, 2017.

Proponents of the appointment service points refer to the positive experience of the Association of Statutory Health Insurance Physicians in Saxony, which was previously the only KV to operate a comparable service telephone. On the other hand, critics, who are mainly found in the associations of statutory health insurance physicians, are of the opinion that this procedure restricts the free choice of doctor and causes unnecessary costs and bureaucracy. The National Association of Statutory Health Insurance Physicians (KBV) described the appointment service centers as a "purely populist instrument of politics [...] for tapping votes".

Revision of the psychotherapy guideline

The Federal Joint Committee is instructed to revise the Psychotherapy Guideline by June 30, 2016. The introduction of psychotherapeutic consultation hours and the increased promotion of group therapies are intended to reduce waiting times and ensure prompt care. In the consultation hours, the need for treatment should be clarified at short notice and individual advice given about various care offers.

Improve hospital discharge management

In order to achieve closer links between the outpatient and inpatient sectors, discharge management after hospital treatment is improved. From now on, hospitals must define the immediately necessary follow-up services in a discharge plan. In doing so, they are given the right to prescribe medicines in small quantities and services such as home nursing and prescription for medicinal products for a period of up to seven days. In future, they can also issue certificates of incapacity for work for a maximum of seven days. The health insurance companies have to participate in the implementation of the discharge plan. Together with the hospital, the health insurers must contact the necessary service providers in good time before discharge. The insured persons have a direct legal claim against the health insurance company for this additional support of the discharge management.

Expansion of benefit entitlements

Second opinion

With the Supply Strengthening Act, insured persons have a legal right to an independent second medical opinion for certain quantity-sensitive, plannable interventions. Which interventions are involved is determined by the Federal Joint Committee. The aim is to prevent unnecessary operations. To obtain a second opinion, patients can freely choose between all doctors and facilities participating in statutory health care and among the approved hospitals that meet the intervention-related requirements of the Federal Joint Committee. Only the doctor or the facility that is supposed to carry out the procedure cannot be called upon for a second opinion.

Changed entitlement to sick pay

Until now, the entitlement to sickness benefit has been valid from the day after the medical diagnosis of incapacity for work. Insured persons whose entitlement to continued remuneration has been exhausted and who are regularly unable to work for just one day due to the same illness (e.g. due to chemotherapy or a certain form of dialysis) have not received any sick pay. In contrast, the benefit for hospital treatment or treatment in a preventive or rehabilitation facility was paid from the start. This unequal treatment will be abolished with the Supply Strengthening Act. From now on, the entitlement to sickness benefit exists from the day it is determined.

Promotion of innovative forms of care

Innovation fund

An innovation fund is being set up at the Federal Joint Committee to finance projects that aim to improve cross-sector care . These innovations must have sufficient potential to be permanently included in standard care . The Federal Ministry of Health names possible funding priorities: telemedicine, care models in structurally weak areas, models with delegation of medical services, development and expansion of geriatric care and model projects for drug therapy safety in multimorbid patients.

Between 2016 and 2019, 300 million euros will be made available annually, of which 225 million euros will be used to fund innovative cross-sector care projects and 75 million euros for health services research. Financing is provided by the statutory health insurance, half from the liquidity reserve of the health fund and half from the health insurance companies. A ten-person innovation committee at the Federal Joint Committee decides on the allocation of funding. It consists of three members of the health insurance funds, one member each from the National Association of Statutory Health Insurance Physicians, the National Association of Statutory Health Insurance Dentists and the German Hospital Society, the chairman of the G-BA as well as two representatives of the Federal Ministry of Health and one representative of the Federal Ministry of Education and Research .

Flexibility of the regulations on selective contracts

Making the regulations on selective contracts more flexible is also intended to help promote new forms of care. The possibilities of the health insurance companies to conclude good contracts in competition are expanded. From now on, there is no longer any obligation to submit selective contracts to the responsible supervisory authorities for review before they take effect, as this administrative-intensive procedure delayed selective-contract forms of supply. Instead, the supervisory authority can now request and review the contracts if necessary. Innovative services that are not part of the standard health insurance coverage can also be included in the contracts.

Overall rating

The Law on Strengthening Care was met with strong opposition, particularly from general practitioners and their representatives. The two biggest points of contention were the tightening of the rules for buying doctors' seats and the establishment of appointment service centers. Behind these debates lies a fundamental conflict over the organization of the German health care system. This is traditionally characterized by a high degree of self-administration. Decisions are made by the associations within the framework of the law and under state supervision, but without the direct involvement of the state. With the Health Care Strengthening Act, the legal requirements are made more binding and thus the scope of action of self-administration partners, especially the associations of statutory health insurance physicians, is restricted. The latter complain about the grand coalition's self-image of “being able to regulate everything better itself”. The Hartmannbund also criticizes the "continued policy of state interference in the freedom to exercise the medical profession" and the "political involvement in the area of medical self-administration." The resident doctors and their representatives see the Law on Strengthening Care as a further step towards a state-controlled health system .

Proponents of the law, on the other hand, consider stronger state intervention to be inevitable, as the self-government would not have been able to independently regulate existing problems such as insufficient medical care and waiting times for specialist appointments. In their eyes, the Supply Strengthening Act is a “political self-defense reaction” to the failure of self-administration. The chairman of the Expert Council for the Assessment of Developments in the Health Care System, Ferdinand Gerlach , is satisfied with the law: “Waiting is no longer an option. Some things are already going in the right direction. "