Selective contract
Selective contract is a term from the statutory health insurance in Germany . Individual health insurance companies and individual service providers conclude a selective contract . The legislator speaks of an individual contract. The counterpart to the individual contract is the collective contract (overall contract), which all health insurances conclude, for example in outpatient medical care, via the respective Association of Statutory Health Insurance Physicians or Association of Statutory Health Insurance Dentists for all resident doctors or psychotherapists in a federal state or nationwide. In the case of a selective contract, the contract partner (s) are selected on both sides. In contrast to collective agreements, which health insurance companies are legally obliged to conclude, the conclusion of a selective agreement is voluntary. An exception are contracts for family doctor-centered care (HzV), which health insurance companies are obliged to conclude.
In outpatient medical, psychotherapeutic and dental care, selective contracts are concluded outside of the so-called standard care organized by the statutory health insurance associations (KV) or statutory health insurance associations , which is regulated in the collective agreement. In these selective contracts, parts of outpatient medical, psychotherapeutic and dental care for statutory health insurance can be agreed outside of the so-called standard care. Selective contract and standard care are complementary parts of contractual (dental) medical care. If the contract doctor , contract psychotherapist or contract dentist and statutory health insurance patient have both signed up to the relevant selective contract , the provisions of the selective contract apply. Otherwise, the standard care applies, in which every patient with the electronic health card can visit any contract doctor in Germany.
Contract types
The standard outpatient medical care is provided by contracts between the National Association of Statutory Health Insurance Physicians (KBV) or the Association of Statutory Health Insurance Physicians (KV) of the district or the Federal Association of Statutory Health Insurance Physicians (KZBV) or the Association of Statutory Health Insurance Physicians (KZV) of the respective federal state and the associations of statutory health insurances (GKV) ) regulated. For the agreement of selective contracts (without participation of the KV or KZV) the legislator has created the following contract types in Book V of the Social Code (SGB V):
Model project according to § 63 SGB V
Health insurance companies can agree on model projects for the further development of procedural, organizational, financing and remuneration forms for the provision of services "to improve the quality and economic efficiency of care" ( Section 63 (1) SGB V). According to paragraph 5, model projects are to be limited to a maximum of eight years and To evaluate § 65 SGB V scientifically with regard to their goals. After the evaluation, a nationwide model project on acupuncture led to the introduction of acupuncture for certain medical indications in the service catalog of the statutory health insurance.
Family doctor-centered care (HZV) acc. Section 73b SGB V
The family doctor care is acc. Section 73 (1a) of the Social Code Book V is performed by general practitioners, paediatricians and general practitioners in internal medicine. All health insurances must offer their insured persons a HZV ( § 73b Abs. 1 SGB V). A health policy conflict has flared up since 2008 about this obligation of the health insurance companies and the way in which this obligation is implemented and is still ongoing (see below).
Special outpatient medical care according to Section 73c SGB V (deleted)
With contracts according to § 73c SGB V, any number of services of contract medical, contract psychotherapeutic or contract dental care could be regulated in a selective contract. The § 73c SGB V was within the statutory health care law to strengthen deleted and its content is largely in the revised § 140a risen SGB V.
Special care acc. § 140a SGB V
Special care contracts can regulate preventive, outpatient and inpatient care deviating from the collective agreement. Condition is according to According to Section 140a, Paragraph 1 of Book V of the Social Code, it must be a matter of "care across different service sectors or interdisciplinary and cross-disciplinary care" or special outpatient medical care.
Section 140a SGB V was re-regulated in the course of the GKV-VSG. The contract paragraph, which was previously called “Integrated Care”, only permitted interdisciplinary and interdisciplinary services (i.e. “service combinations” such as outpatient-inpatient or outpatient rehab or general practitioner-specialist) in addition to cross-sectoral services. Between 2004 and 2008 there was § 140d SGB V-old a so-called start-up financing of up to 1 percent of the volume of the contract doctor and inpatient service expenses. The legislature wanted to encourage the conclusion of such contracts. A conflict had developed between the service providers (mainly general practitioners, specialists, hospitals, rehabilitation facilities and pharmacies) over the distribution of this start-up financing, which has subsided since the end of the start-up financing in 2009.
Other contract types
There are numerous other selective contracts in addition to outpatient medical or psychotherapeutic care. Large parts of the supply of medical aids are agreed in selective contracts ( Section 127 SGB V). The discount agreements for pharmaceuticals are also concluded selectively between individual health insurance companies and pharmaceutical companies ( Section 130a SGB V). The contracts with rehabilitation facilities are also made selectively for each facility and fund ( § 111 SGB V).
A new attempt to give the cross-sectoral and multi-disciplinary-interdisciplinary upwards momentum, the Innovation Fund . For this will be provided for innovative new forms of care and health services research available from 2016 300 million € annually.
Similarities and differences between the contract types
The model projects no longer play a major role in the reality of care and the political discussion. Contract doctors and insured persons have freedom of contract in selective contracts: They can, but do not have to, sign up for a selective contract, provided they meet the participation requirements. Only if the contract doctor and the statutory health insurance patient are both enrolled in the same selective contract will care no longer take place via the standard care. Insofar as contractual medical services from the standard care are included in contracts according to Sections 73b or 140a SGB V, the health insurance company must adjust its total remuneration to the KV - unless the expenditure for this is estimated to be higher than the adjustment volume (Section 140a, Paragraph 6 SGB V). The total remuneration is reduced by that part that is no longer provided and billed via the standard supply, but via the selective contract. The adjustment is made on a personal basis for the insured persons registered on the basis of so-called historical accounting data, i.e. for all services from the selective contract that were provided for these insured persons via the standard care in certain previous quarters. The amount of the adjustment amounts is mostly disputed between the health insurance and KV.
There is no such adjustment for services that go beyond standard care. The benefits according to selective contracts are subject - like the entire supply in the GKV - the economic efficiency requirement according to § 12 SGB V. For integration contracts also applies according to Section 71 (1) SGB V the principle of stable contribution rates .
Contractual partners of the health insurance companies can under the selective contracts u. a. Be contract doctors, contract psychotherapists and communities of contract doctors or psychotherapists. In the special care contracts, providers of hospitals, rehabilitation and care facilities, pharmaceutical companies and medical device manufacturers, long-term care funds, management companies and associations of statutory health insurance physicians are also possible (Section 140a (3) SGB V).
Which of the contract types is chosen when regulating a certain part of the supply to achieve the goals is v. a. a matter of expediency. With Section 73b SGB V, only general practitioner topics can be regulated. The combination of outpatient and inpatient services is only possible with an integration contract.
Care goals for selective contracts in outpatient medical care
The German health care system is leading in an international comparison, but still has numerous potential for optimization. With selective contracts, the contractual partners (mostly smaller parts) pick out the supply and redefine it. From the point of view of the statutory health insurance, legitimate goals can only be an improvement in the quality and cost-effectiveness of care. The concept of quality is broadly defined and includes u. a. the following goals:
- better communication between service providers, health insurers and patients
- better coordination of service provision
- faster healing success
- Avoidance of recurrence (“revolving door effect”) and chronification
- fewer side effects
The aim is to achieve a higher quality compared to standard care or the same qualitative result as in standard care, but more economically, i.e. more cost-effectively.
Recent conflict over family doctor contracts
The legislator had specified the obligation of the health insurance companies to offer HZV models as of January 1, 2009 in Section 73b (4) SGB V with the following wording and tightened it from the health insurance perspective: "To ensure the comprehensive range of services according to paragraph 1, health insurance companies have alone or in cooperation to conclude contracts with other health insurance companies by June 30, 2009 at the latest with communities that represent at least half of the general practitioners of the district of the Association of Statutory Health Insurance Physicians participating in primary care. If the contracting parties cannot reach an agreement, the community may request the initiation of arbitration proceedings in accordance with paragraph 4a. "
To such communities acc. 4, the German Association of General Practitioners then carried out a corresponding mandate procedure for general practitioners in most federal states (in cooperation with its own management company HÄVG and in some cases with other medical associations). With this mandate, the regional associations of the German Association of General Practitioners have offered all health insurance companies in Germany negotiations about CO contracts. The General Practitioner Association has initiated the arbitration procedure mentioned in Paragraph 4 against the health insurance companies who did not want to accept the offer to negotiate or the contract offered . The supervisory authorities of the health insurance companies had appointed four arbitrators nationwide, who to date have divorced HZV contracts for the insured of certain health insurance companies in different federal states. In Bavaria and Baden-Württemberg in particular, contracts were divorced, the content of which is largely based on the BKK contract from Baden-Württemberg, which in turn is based on the contract of the AOK Baden-Württemberg. Some health insurance companies consider the fees in the contracts based on this model to be significantly higher than in the standard care and therefore do not see profitability. As a result of the arbitration proceedings, health insurance companies are forced to enter into such contracts and some health insurance companies see the risk of having to raise additional contributions and then losing many members, given the current underfunding from the health fund.
On November 12, 2010 the Bundestag passed an amendment to Section 73b of the Social Code Book V, which the Bundesrat passed on December 17, 2010. It came into effect retrospectively on September 22, 2010 and brought the following significant changes:
- The medical fee in HZV contracts must not be higher than in the standard care via the KV. A higher remuneration must be refinanced through savings from the contract.
- Each fund must submit new CO contracts to their supervisor, who can object to the contract.
- Contracts existing before September 22, 2010 - in particular their remuneration regulations - are protected until June 30, 2014.
These regulations also apply to contracts that are concluded in the context of arbitration proceedings.
swell
- Social Code 5 (SGB V)
- Special report 2012 by the German Advisory Council on the assessment of developments in the healthcare system: competition at the interface between outpatient and inpatient health care
Individual evidence
- ^ Report on the development of integrated care 2004 - 2008. BQS, accessed on June 16, 2016 .
- ↑ Innovation Fund . Bundesverband Managed Care eV, accessed on June 16, 2016 .
