Germany (observer)

Germany (observer)

The situation of general practitioners in Germany

Ullrich Weigeldt, Head of the German UEMO Delegation

There are essentially two types of public legal entities in the field of medicine in Germany: General Medical Council, which are concerned primarily with aspects of specific training and occupational law, and the “Kassenärztliche Vereinigungen” (Associations of Statutory Health Insurance Physicians), which all family doctors and specialists admitted to practice in Germany are required to join. These “Kassenärztliche Vereinigungen” negotiate a total fee for all services rendered by physicians in private practice with health insurers and distribute funds from this amount.
In the past, this distribution process has led to a relative increase in the proportion of fees paid to specialists in comparison to those paid to family doctors. Even the committed efforts of family doctors within these organizations have failed to reverse this trend.
German family doctors are organized within a strong association, the “Deutscher Hausärzteverband” (German Association of Family Doctors), composed of some 33,000 members out of a total of roughly 50,000 physicians registered as family doctors. According to information available to us, not all of these individuals actually work as family doctors, as a number of them provide services in such fields as psychotherapy, homeopathy, and other niche specialties.
Political activity in recent years has focused to an increasing degree on the implementation of competitive elements in the health care sector. During the same period, the number of statutory health insurance providers (public legal entities covering 90% of all insured individuals, in addition to private health insurance providers, which account for about 10%) has fallen from over 1000 to approximately 160.
Through lobbying and public relations activities, the Deutscher Hausärzteverband has taken advantage of this orientation toward competition to achieve autonomy for family doctors with respect to fee rates. A law was passed providing for direct agreements between the Hausärzteverband and health insurance providers. The legal entities are explicitly excluded from this process.
Through these contracts, which have now been concluded with all health insurance providers in Baden-Württemberg and Bavaria, and to which family doctors and insured may subscribe voluntarily, we have achieved significantly higher fees for family doctors, a reduction of red tape and an independent advanced training programme oriented towards the problems faced by family doctors. The insured bind themselfes to contact first a general practitioner.
The fee system consists of a flat-rate annual fee which does not depend on the number of contacts, a flat-rate fee for extended treatments and, in particular, a flat-rate fee for the treatment of chronically ill patients. The objective of this system is to reduce the frequency of patient-physician contacts in Germany (currently the highest in the world at 17.9 contacts per capita per year) while increasing the amount of time available for consultation with each patient.
On the basis of these contracts, participating physicians also accept certain requirements regarding the prescription of medications in accordance with contracts between health insurers and pharmaceuticals. They take part in quality forums and advanced education programmes for general practitioners, which are required by law to focus on such matters as physician-patient dialogue, psychosomatic disorders, pain and palliative treatment and geriatric medicine. The development of an independent IT structure which can be integrated into existing systems will facilitate billing and cost-effective prescription.

End of the merging family medicine and general internal medicine
Since May 2010, family medicine has once again become an autonomous field of medicine in Germany following the failed attempt to merge the fields of family medicine and general internal medicine since 2002. The Association of Internists was unwilling to relinquish the autonomous field of general internal medicine and withdraw from the field of general medical practice. The resulting advantage is that family medicine now  – as it was before 2002 – has the status of an independent field of medicine, which has a favourable impact on education and research and promotes the development of a strong presence in university education. Specific training in family medicine lasts 5 years and includes at least 2 years of work in general practice . Exact requirements are established by the General Medical Councils in each state. Ideally, minimum periods of training in surgery and paediatrics will be required in addition to the mandatory period of training in internal medicine.
The purpose of funding support for specific training in general medicine provided by health insurers and the “Kassenärztliche Vereinigungen” is to halt the decline in the number of general practitioners working as family doctors. Consequently, only a small portion of compensation for physicians undergoing specific training as general practitioners will have to be paid by practice owners.
In spite of this increased funding support (which has not always been provided at consistent levels in the past, however), the number of physicians undergoing advanced training is significantly lower than that of retiring physicians. From 2000 to 2008, 1560 fewer general practitioners entered the field of family medicine than left it. The discrepancy amounted to 590 general practitioners in 2008 alone.

Cologne, 20th of July, 2010

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