Medical care centre
The aim of the 2003 health reform was to permanently reduce the contributions to statutory health insurance and thus the ancillary wage costs. Since 2004, in addition to registered contract doctors in individual practices or joint practices, medical supply centers (MVZ) have also been able to take part in contract medical or contract psychotherapeutic (statutory health insurance) care. Initially, the law was not aimed at the hospital sector, but it did mean that hospitals were increasingly given the option of providing outpatient treatment.
Similar to the polyclinics of the GDR , any number of licensed doctors or psychotherapists can work there as an employee, which is only permitted to a very limited extent in conventional practices. Medical care centers can employ interdisciplinary specialists from different disciplines and psychological psychotherapists, or consist only of doctors of one specialty or only of psychotherapists. In the GDR, general practitioners and specialists worked almost exclusively in the polyclinics. These polyclinics were almost completely abolished in the course of the reunification of Germany . Only facilities according to § 311 SGB V a. F. ( Dispensaries ) may have grandfathered. In contrast to the polyclinics of the GDR, the structural conditions of today's medical care centers are rarely clinically-like.
The legal basis is Social Security Code (SGB V). As a rule, only the authorized founders named below can be shareholders in an MVZ. For the "medical management" of the MVZ, the provisions of hospital law apply in principle. The head does not need to be a member of the Association of Statutory Health Insurance Physicians (KV) or a contract doctor. For patients, a medical care center has similarities with a group practice with the difference that there is no direct treatment contract with the treating doctor, but with the MVZ.of Book V of the
Changes regarding investor Z-MVZs through the Appointment Service and Supply Act
As a result of the Appointment Service and Supply Act , which came into force on May 11, 2019 , the founding authority of hospitals for dental MVZs (Z-MVZ) will in future depend on the maintenance of certain supply components, which the MVZs founded or operated by a hospital can only achieve at a maximum may be. These proportions are graded as a percentage according to the degree of coverage of the respective planning area.
Establishment and approval
With the GKV Supply Structure Act (GKV-VStG), since January 1, 2012, medical care centers (MVZ) can only be operated by licensed doctors, psychotherapists, licensed hospitals, providers of non-medical dialysis services or non-profit organizations involved in the medical care of the statutory health insurance (GKV) on the basis of approval, authorization or contract, can be established (new ) SGB V). In addition, only partnerships , registered cooperatives (eG) and limited liability companies (GmbH) are permitted for MVZ start-ups . Stock corporations (AG) are not permitted .
Until December 31, 2011, an MVZ could also be established by any service provider approved under SGB V (in addition to doctors and psychotherapists, pharmacists, hospitals, preventive and rehabilitation facilities as well as medical and aids providers) who, based on authorization, approval or contract participated in the medical care of patients with statutory health insurance. Private hospitals, pharmaceutical companies, health insurance companies or their associations, (dental) medical associations, hospital companies, owners of management companies, dental technicians, etc. were not permitted. Details on this were laid down in the law on amendments to the law on contract doctors. In practice, this meant that MVZs were founded more and more frequently by investors who, as investors, for example by purchasing a care service, meet the requirements for establishing an MVZ. In order to counter the risk that medical decisions are influenced by capital interests , the Statutory Health Insurance Supply Structure Act, which came into force on January 1, 2012, stipulates that only contract doctors, hospitals, certain providers of non-medical dialysis services and certain non-profit organizations are entitled to found an MVZ are.
With the Statutory Health Insurance Supply Strengthening Act, which came into force on July 23, 2015, the legal framework for establishing an MVZ was changed again. Since then, it has also been possible to set up medical care centers that are identical to the medical group. This means that pure general practitioner medical care centers as well as specialized medical group medical care centers are also possible. In addition, the municipalities were given the opportunity to set up MVZs.
Admission is granted via the admissions committee at the Association of Statutory Health Insurance Physicians (KV) for the location of the branch as a doctor or the location of the permanent establishment. The health insurance companies can also conclude direct contracts with MVZ as part of integrated care . Requirements for admission are:
- At least two half-approvals by contracted doctors.
- Submission of a partnership agreement and appointment of a medical or psychotherapeutic director. The medical director is not subject to any instructions in medical matters. The medical management does not need to have management powers. Purely psychotherapeutic MVZs can also be managed by a psychologist.
- Assumption of a guarantee by all shareholders (founders) for the claims of the responsible Association of Statutory Health Insurance Physicians for the MVZ (for start-ups since 2007).
The quarterly billing of an MVZ is similar to an interdisciplinary group practice for the Association of Statutory Health Insurance Physicians. The MVZ carries out the billing for the KV. The contractual relationship exists here between MVZ and KV. In the private medical billing, the MVZ sends the claim (invoice) directly to the patient, as the private treatment contract exists between the patient and the MVZ. In the event of liability, the patient and cost bearer are approached directly to the MVZ, similar to hospitals.
The circle of possible MVZ founders has been significantly reduced since January 1, 2012 compared to the previous situation. The objective is to save costs (shared use of resources such as medical technology, rooms, personnel), close cooperation between several disciplines with short distances, and to relieve the medical profession of administrative tasks.
As of March 31, 2010 there were 1,503 medical care centers with 7,526 doctors, 6,206 of whom were employed. As of September 30, 2011 there were 1,750 MVZs with 9,571 contract doctors, 8,257 of whom were employed. As of December 31, 2011, there were 1,814 medical care centers with 10,020 doctors, of which 8,662 were employed. At the end of 2015, the number increased to 2,156 medical care centers, which employ 12,976 salaried and 1,341 freelance doctors.
It is noticeable that the proportion of employed doctors has increased, while the proportion of freelance workers is stagnating. With around 18% of all MVZs, most have so far been founded in Bavaria.
Taxation in the start-up phase depends on the legal form chosen and the method of start-up. When converting an interdisciplinary joint practice in the legal form of a company under civil law (GbR, also called BGB-Gesellschaft) into an MVZ-GbR, there are no special tax features, as the tax co-entrepreneurship (under changed medical law conditions) is continued.
If doctors contribute their practices or their shares in the business assets of group practices when establishing or expanding an MVZ-GbR, this can be done in a tax-neutral manner under certain conditions in accordance with the Transformation Tax Act (UmwStG) without revealing hidden reserves . In addition to the continued book value , u. a. mandatory requirement that a company, partial company or a co-entrepreneur share with the essential operating principles is brought into the MVZ-GbR.
If an MVZ capital company (exclusively GmbH) is created by bringing in a practice or a portion of a joint practice against the granting of company rights, UmwStG is applicable. The book value approach is also possible here under certain conditions. It should be noted, however, that the contributor, provided that he has determined his profit to date in accordance with (3) EStG, must prepare a contribution balance and thus switch to the determination of profits in accordance with Section 4 (1) EStG, revealing a transitional profit . Furthermore, if the book value is continued, the hidden reserves are transferred from the person of the contributor to all shareholders without differentiation. As a result, this can lead to deferred tax liabilities being transferred from one shareholder to the other at the expense of their assets. Insofar as § 20 UmwStG is applicable, the granted shares in the corporation represent so-called "blocking period subject (previously brought in)" shares with continuation of book value. If these shares are sold within seven years after contribution, special taxation of the capital gains according to UmwStG occurs.
For the choice of legal form from a tax point of view, the total tax burden is decisive.
The partners of a partnership earn income from self-employed work . Each partner has to pay direct tax on his share of the profits. If it is a commercial partnership, there is commercial income. In the case of commercial income, the partnership is subject to trade tax , but the trade tax is offset against the shareholders' income tax.
In the case of corporations, corporation tax and trade tax arise on the taxable profit at the company level . If the shareholders are employed by the corporation, the salary payments represent operating expenses that reduce profits . At the shareholder level, income tax is payable on the salary payments. Distributions by the company are currently taxed at a flat rate of 25% plus solidarity surcharge and, if applicable, church tax within the framework of the withholding tax.
The Scientific Services of the German Bundestag point out the following points of public criticism of MVZs: “MVZs are repeatedly subject to public criticism, especially from the medical profession, which is hardly surprising in view of the increasing competition in the outpatient sector. The main criticism is that the 'penetration' of management companies, private clinic owners and hospitals into the outpatient care market restricts the patients' free choice of doctor, jeopardizes the professionalism of medical practice and displaces established specialist practices. In fact, the MVZ in absolute numbers (2,821 MVZ vs. 88,722 approved practices) still lead a niche existence. ”In the discussion, no experience reports or practical examples regarding the points of criticism have been cited so far.
After the dissolution of the GDR health system and its polyclinics in the early 1990s, there is now a U-turn on this point. With a continuous development with the preservation of the polyclinics, a number of undesirable developments (shortage of doctors, long distances) in the area of the new federal states could possibly have been avoided or alleviated.
In 2018, the President of the German Dental Association, Peter Engel, warned that more and more dental care centers were falling into the hands of non-care capital investors. “The cornerstones of our free professional practice are independence from instructions, ethical obligations and public service mandate. These are foreign words for these investors - what counts for them is profit maximization and the highest possible return on capital. Our patients must be protected from this ”.
According to Wolfgang Eßer , chairman of the board of directors of the National Association of Statutory Health Insurance Dentists , dental medical care centers are set up by financial investors primarily in large cities and metropolitan areas, i.e. usually in high-income regions. This leads to an undersupply in rural and structurally weak areas and jeopardizes the guarantee of comprehensive and local care and the patients' right to a free choice of doctor.
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- dropped in 2015 with the Statutory Health Insurance Care Strengthening Act
- , wording and changes
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