Health fund
As a health fund to international standards, a system referred to in public health insurance systems with multiple insurers (health insurance), where the financial flows are organized so that the contributors (members, but also, employer social security authority), pay contributions to a central location from which the Funds are distributed to the individual insurance carriers (e.g. practiced in the Netherlands , Belgium and Israel).
The concept of the health fund contrasts with a model in which the contributors (members, but also employers, social benefit providers) pay the contributions directly to the individual insurance providers (e.g. practiced in Switzerland ).
With the introduction of the health fund to finance statutory health insurance in Germany on January 1, 2009, the legislature switched from the second model to the first variant.
Germany
history
On February 2, 2007, the German Bundestag passed the law to strengthen competition in statutory health insurance (GKV-WSG), which the Federal Council approved on February 16, 2007; this law provides for the introduction of the health fund (through amendment of the fifth book of the social code ).
Key points and regulations upon introduction
The idea for the health fund goes back to the Dortmund finance scientist Wolfram F. Richter . His concept was taken up by the Scientific Advisory Board at the Federal Ministry of Finance and brought into politics. The advisory board saw the approach as a possible compromise between the politically rival models of citizens' insurance and the health premium at the time . The coalition of Union parties and the SPD agreed on July 4, 2006 within the framework of a "key issues paper" on the introduction of the health fund, whereby the originally planned inclusion of private health insurance was canceled and the tax financing of tasks for society as a whole (such as contributions for children in statutory health insurance with a requirement of around € 16 billion per year) is only to start in 2008 with € 1.5 billion and in 2009 with € 3 billion.
With the introduction of the health fund, the contribution and tax monies intended for statutory health insurance will be collected centrally; The health insurance funds then receive allocations from the health fund , from which they are supposed to finance the expenses for health services and their administrative costs. The health insurance companies first collect the social security contributions and transfer them to the health fund, which is administered by the Federal Social Security Office. The previously different contribution rates of the health insurance funds have been replaced by a uniform contribution rate that is set by the federal government.
In 2010, allocations from the health fund amounted to € 170.3 billion.
Uniform contribution rate
For 2009, the federal government has standardized the general contribution rate for employees and initially set it at 15.5 percent of income (7.3% employer contribution + insured person 7.3% + 0.9% special contribution that only the insured person pays). In the case of pensioners who are subject to compulsory insurance, the Deutsche Rentenversicherung, like the employers, has borne 7.3% since 2009, the remaining 8.2% are borne by the pensioner themselves and by the employees.
The employer's health insurance contributions are frozen insofar as the contribution rate to the health fund is only to be increased if the fund no longer covers 95% of the expenses of the statutory health insurance funds (at least 5% must be financed by additional contributions to be made by the insured person alone ) .
The allocation of funds to the health insurance companies takes into account the probability of illness of an individual in relation to a certain population ( morbidity ), whereby the risk structure compensation is restructured . As a result, each fund should receive approximately the financial resources it needs to supply its insured persons. When Bundesversicherungsamt a Scientific Advisory Board has been established to prepare the morbidity-based allocation of resources; On January 9, 2008, the latter presented an opinion on the selection of 80 diseases which were taken into account in this allocation of funds. At the end of March 2008, the Federal Insurance Office presented the final list, which deviates considerably from the list of the Scientific Advisory Board due to greater consideration of the prevalence .
Exception for agricultural health insurance
The agricultural health insurance is not involved in the health fund due to its special social and financial policy tasks; there the contributions are still regulated by autonomous law (statute) with the participation of self-administration . The only exceptions to this are the contributions from pensions to the statutory pension insurance and from pension payments as well as additional income from non-agricultural self-employment: The regulations of general health insurance apply here, the contributions are calculated according to the relevant contribution rates, withheld by the paying agents including the pensioner's share and paid to the agricultural health insurance.
The exception to the exception are the pensions from the old-age insurance of the farmers , here only the insured part is paid, since the benefit expenses themselves are largely offset by the federal government through subsidies from the federal budget and thus a contribution by the old-age fund, which is also subsidized by tax revenues would represent an internal transfer .
Additional contribution for the individual cash register
Statutory health insurance companies that cannot refinance their expenses with the funds allocated from the health fund must, according to Section 242 I 1 SGB V a. F. request an additional contribution from their members. This additional contribution, which is specific to the health insurance fund, must naturally also cover the administrative costs associated with collecting it directly from the insured person. This has led to the fact that individual health insurances offer discounts if the insured person pays the additional premium in advance for the calendar year instead of monthly . In 2010, 13 direct federal health insurances demanded an additional contribution from their members. Only one health insurance company charged a percentage additional contribution of 1.00% of the income subject to contributions, the other required flat-rate contributions.
criticism
The former economist Bert Rürup criticized “that the labor factor should be burdened with € 5 billion in the next year, and then gradually return € 4.5 billion in 2008 and 2009. From an economic point of view, that is not particularly convincing ”. ( Non-wage costs )
The effects of the transition to morbidity orientation in the risk structure compensation associated with the introduction of the fund are controversial . According to the law, 50 to 80 serious chronic illnesses should lead to special payments. A further requirement is that the insured persons who suffer from these diseases have at least 50 percent above-average expenses. The thesis is put forward that the fixation of a morbidity-oriented risk structure compensation would extinguish competition between health insurers. In this way, monopolistically acting consumers protected by the Social Security Code (benefit-in-kind principle) would, qua law, confront atomistically oriented service providers. This automatically leads to a deterioration in supply via price and quality dumping.
However, the opposite thesis is also advocated, according to which only a sufficiently precise mapping of the morbidity in the risk structure compensation creates the conditions for the health insurers to compete for patient care and not primarily aim to attract healthy insured persons because they could offer cheaper contributions with them.
Andreas Köhler , former chairman of the National Association of Statutory Health Insurance Physicians (KBV) confirmed on January 22nd, 2009 that some health insurance companies apparently tried to influence doctors in their diagnosis in order to receive higher compensation payments from the risk structure compensation for more chronically ill patients. In order to limit the manipulation of medical documentation, coding guidelines are currently being drawn up by the National Association of Statutory Health Insurance Physicians and the health insurance companies.
Also Heinz Grossekettler , considered the co-inventor of the health fund, in 2006 criticized the implementation of the grand coalition . The original intention was clearly restricted and, above all, the limitation of the additional contribution was problematic.
According to the calculations of the health insurance associations , at least eight health insurance companies would allegedly have to close immediately due to bankruptcy , since they cannot survive financially with an assumed contribution rate of 15.5% and neither can the income from the additional contributions from their insured persons (due to the restriction to 1 percent of income ) would be sufficient.
The additional contribution is only to be paid by the insured and not by the employer. In addition to the special contribution (0.9 percent of income), the additional contribution (up to 1 percent of income) will contribute to a further softening of the parity principle and could also be interpreted as a 1.9 percent statutory reduction in income for the insured in favor of the employer .
The proposal of the Scientific Advisory Board to the Federal Insurance Office for the further development of the risk structure compensation has been criticized because, due to the selected statistical method, it focuses more on diseases that are very expenditure-intensive per patient and less often on diseases that are more frequent but not so expenditure-intensive per patient.
Since the doctors can directly influence the funds that the health insurers receive from the health fund through their diagnoses, the fund has strengthened the doctors' negotiating position with the insurers. For example, the Bavarian General Practitioner Association has agreed a significant fee increase with the AOK .
Convergence clause (additional clause)
In spring 2008, the public discussion about the introduction of the health fund focused on the so-called “convergence clause”, also known as the “Bavaria regulation”. The Bavarian Prime Minister Stoiber had enforced this regulation (§ 272 SGB V) in the negotiations in October 2006. According to this, the premium income in 2008 in a federal state, adjusted for the claims and payment obligations from the risk structure compensation and increased by the rate of change in the income subject to contributions, should be compared with the allocations from the health fund. If the difference between the two sizes is greater than 100 million euros, the allocations to the health insurance companies for the insured in the country should be increased or reduced accordingly. In mid-April 2008, an expert report commissioned by the federal government was presented. In contrast to the regulation originally envisaged in the law that the funding of allocations for countries with a "loss" greater than € 100 million should be provided by health insurance companies in countries with a "profit" greater than € 100 million, the legislator of the Law on the further development of the organizational reform of the statutory health insurance (GKV-OrgWG) decided in November 2008 that financing should come from the liquidity reserve of the health fund; Since the liquidity reserve has not yet been built up at the beginning, this in fact means that the federal government makes the payments to the health fund via liquidity aid.
Further development: Black and Red Federal Government 2009
The black and red federal government still agreed on January 12, 2009 as part of the economic stimulus package II to increase the tax subsidies in the health fund by 6.3 billion euros per year. As a result, the general contribution rate could be reduced equally for employers and employees by 0.3 percentage points from July 1, 2009 (cf. Art. 13 ZuInvG ).
Further development: Black and yellow federal government 2009–2013
As part of the GKV financial reform of the black and yellow federal government , the legislature decided with the GKV Financing Act (resolution in the Bundestag on November 12, 2010, in the Bundesrat on December 17, 2010) to increase the contribution rate by 0.6 percentage points to 15.5 % increase. The contribution rate should remain fixed at this level; a mechanism to adapt it is no longer provided. The intention is rather that the health insurances should continue to charge additional contributions if the allocations from the health fund fall short of the expenditure. The regulations for this additional contribution to the individual health insurance fund have been adjusted accordingly. A social equalization scheme was introduced for the additional contributions, which takes effect when the members' income is charged by two percent. The insured person pays the full additional contribution in each case; the social equalization is carried out by a corresponding reduction in the income-related contribution to the health fund. The benchmark for social compensation is not the actual additional contribution to the respective health insurance company, but the expected average additional contribution, which the Federal Social Security Office determines in advance by comparing the allocations from the fund and the forecast expenditure of the health insurance companies. For the years 2011 to 2013 it was determined that there was no average additional contribution, as the total expenditure of the health insurance funds was covered by the allocations. Therefore, from 2011 to 2014 there was no social compensation for insured persons who are insured with health insurance companies with an additional contribution.
Further development: Grand coalition since 2013
In the coalition agreement for the 18th electoral term of the Bundestag from November 2013, it was agreed to lower the general contribution rate from 15.5% to 14.6% by eliminating the special contribution rate of 0.9% to be paid by the insured. The funds to be paid out by the health fund to the health insurance funds will decrease accordingly. At the same time the coalition agreement specifies that the Convention inde pendent cash Individual additional contribution by an income from pending additional contribution is replaced. This eliminates the need for social compensation to avoid excessive demands on insured persons with low incomes. With the law on the further development of the financial structure and quality in statutory health insurance (GKV-FQWG), which the Bundestag passed on June 5, 2014 in its third reading, these agreements were implemented with effect from January 1, 2015.
Liquidity reserve, liquidity support
The statutory regulation stipulates that the health fund builds up a liquidity reserve with which, above all, fluctuations in income during the year are to be compensated. The liquidity reserve should amount to at least 20% of the monthly expenses of the health fund (Section 271 (2) SGB V).
Until the liquidity reserve was built up, it was planned that the federal government would give the health fund an interest-free liquidity loan if the health fund's own income was insufficient (Section 271 (3) SGB V). This became virulent in the build-up phase in the event of loss of premiums due to increased short-time work and rising unemployment in the current economic crisis. The then Federal Minister of Health, Ulla Schmidt , spoke of a protective umbrella for the health fund in order to create the impression that the recession had no impact on the financing of the health fund.
However, the loan had to be repaid in the following years. How this repayment should be financed was initially unclear. If the law and the risk structure compensation ordinance implementing the law remained unchanged, the allocations from the health fund to the health insurance funds would be reduced accordingly, so that the health insurance companies would have to levy additional contributions to a large extent. It was also conceivable, however, that the government would increase the contribution rate for the insured's contributions to the fund and thereby repay the loan to the finance minister. Ultimately, it was conceivable that politics would reduce the expenses of the health insurance companies within the framework of a cost-containment law, so that with the same contribution rate to the fund, only lower allocations to the health insurance companies from the health fund would need to be made and the health fund would receive financial leeway to repay the loan. The estimates routinely made by the statutory appraisers at the Federal Social Security Office on April 30th predicted a recession-related revenue deficit of just under € 3 billion in 2009, which would require a liquidity aid / loan from the federal government in this amount. In November 2010, the Bundestag decided to increase the contribution rate by 0.6 percentage points to 15.5 percent.
The liquidity reserve has risen sharply in recent years. As of December 31, 2011, it was € 9.5 billion. In the first quarter of 2014, the reserve amounted to 11.2 billion euros. Since no statutory upper limit has been set for the liquidity reserve, the health fund can theoretically create unlimited reserves. The missing upper limit is seen as a loophole in the law. For this reason, some economists are calling for a regulation similar to that for the sustainability reserve of the statutory pension insurance , according to which the liquidity reserve is limited upwards and surpluses are to be used automatically to reduce contributions. At the turn of the year 2015/2016, the liquidity reserve was 10 billion euros.
On November 10, 2016, the Bundestag passed the PsychVVG law, according to which 1.5 billion euros were withdrawn from the liquidity reserve in 2017 for the supply of asylum seekers and the expansion of telematics.
"Whatever it takes" - he will pay the clinics, promised Federal Health Minister Jens Spahn at the beginning of the Corona crisis. With the Covid 19 hospital relief package adopted on March 28, 2020, several measures to support hospitals in the corona crisis were approved in order to ensure health care for the population. The hospitals received financial compensation for postponed, predictable operations and treatments from the health fund's liquidity reserve. The same applied to the non-occupancy of beds in preventive and rehabilitation facilities. For each additional intensive care bed that the hospitals created, there was a grant of 50,000 euros, also financed from the liquidity reserve of the health fund.
For these payments from the liquidity reserve of the health fund, a total of over 7 billion euros have already flowed, including 530 million euros for intensive care beds. Based on research by the ARD politics magazine "Kontraste", it became known on July 16, 2020 that there is, however, a large discrepancy between the money paid out and the registered intensive care beds, as the so-called DIVI register shows. It is unclear where around 7,300 beds have remained. The intensive care beds would have to exist purely arithmetically due to the funding amounts paid out, wrote the Federal Ministry of Health. In fact, they are currently not found. In total, this corresponds to an unexplained funding amount of around 360 million euros.
Health fund in an international context
The health fund introduced into the German system with the health reform of 2007 is not an isolated case internationally. In the Netherlands , Belgium and Israel, for example, where several health insurances also compete with each other, the insured do not pay their income-related contribution to the individual health insurer, but to a health fund that distributes the funds to the insurances according to the risk of the insured. In contrast, the insured in Switzerland - as in Germany until the end of 2008 - pay their contributions to the respective health insurance company. But even there there is a risk structure compensation, which ensures that the funds are allocated to the respective health insurance companies taking into account the risk structures of their insured persons.
See also
literature
- The Health Fund: Functionality, Expectations and Criticism (Gerhard Deter, Alice Rensmann), in: German Bundestag, Scientific Services, Current Concept 2009 (No. 9/09)
- T. Drabinski: Health Fund ante portas . Volume 12. Series of publications, Institute for Microdata Analysis, Kiel. January 2008.
- D. Göpffarth, S. Greß, K. Jacobs, J. Wasem : Yearbook Risk Structure Adjustment 2007: Health Fund . Asgard-Verlag, St. Augustin 2007, ISBN 978-3-537-74307-7
- H. Pressel: The health fund: emergence - introduction - further development - consequences . Springer VS, Wiesbaden 2012, ISBN 978-3-531-19350-2
Individual evidence
- ↑ Wolfram F. Richter: Health Premium or Citizen Insurance? A compromise proposal. In: Wirtschaftsdienst , 2005, 693-697.
- ↑ Holger Pressel: The Health Fund: Origin - Introduction - Further Development - Consequences , Wiesbaden 2012.
- ↑ Archive link ( Memento of the original from February 15, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Breakthrough in health reform. Contributions rise - entry into tax financing. ( Memento of the original from July 4, 2006 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: heute.de , July 3, 2006.
- ↑ (cf. for example expert opinion by Cassel, Jacobs, Reschke and Wasem from 2001 for the Federal Ministry of Health: [1] → Chair → Downloads → Research reports)
- ↑ Archive link ( Memento of the original from January 29, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Archive link ( Memento of the original from January 29, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. .
- ↑ Archive link ( Memento of the original dated November 29, 2006 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ What Ulla Schmidt has kept secret. In: Focus online , November 10, 2008
- ↑ abkassieren such as doctors and cash after the reform - Health Fund. In: Panorama
- ↑ http://www.mm.wiwi.uni-due.de/ → Current information on research and policy advice → Entry from April 12, 2008
- ↑ Announcement of the average additional contribution 2014. Federal Ministry of Health
- ↑ Health insurance companies need almost three billion from the federal government. In: Der Spiegel , April 30, 2009
- ^ Dpa, Reuters, AFP: Health policy: Bundestag resolves black and yellow health reform . In: The time . ISSN 0044-2070 ( zeit.de [accessed February 4, 2016]).
- ↑ Federal Ministry of Health: GKV-Finanzentwicklung in 2011
- ^ GKV finances: Thick cushion despite losses. In: Pharmaceutical newspaper
- ↑ M. Hüther: Health insurance surpluses should not remain in the fund ( page no longer available , search in web archives ) Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.
- ↑ D. Fichte: Statutory health insurance: need to change specifications for the formation of reserves. (PDF; 243 kB)
- ↑ BMG: GKV financial results 2015. In: bmg.bund.de. Retrieved June 19, 2016 .
- ↑ FAZ.net: http://www.faz.net/aktuell/wirtschaft/wirtschaftsppolitik/1-5-millionen-euro-regierung-zapft-gesundheitsfonds-fuer-asylbewerber-an-14370438.html , August 3, 2016
- ↑ Hartmannbund: http://www.hartmannbund.de/detailansichten/aktuelle-meldung/meldung/psychvvg-beschlossen-15-millionen-euro-finanzspritze-fuer-die-kassen
- ↑ First payments: financial aid for clinics, prevention and rehabilitation facilities. Retrieved July 18, 2020 .
- ↑ Federal government puzzles over the whereabouts of more than 7,000 intensive care beds. Retrieved July 18, 2020 .
- ↑ Archive link ( Memento of the original from January 31, 2012 in the Internet Archive ) Info: The archive link was inserted automatically and not yet checked. Please check the original and archive link according to the instructions and then remove this notice.
