sou · H0B333 · 2012-05-15 00:00:00 — The national health priorities first adopted for the period 2005 to 2009, and succeeded with priorities for the period from 2010 to 2014, and the new provisions for the governance and surveillance of social health insurance at national level have reemphasised the central level governance model that is based on the central government leading and setting directions for the health care system. But on-going reforms at the regional and the national levels may challenge its traditional role in future. Especially the 2009 Hospitals, Patients, Health and Territories Act empowered the regions for a more integrated approach towards health financing and the delivery care. The regional health autho- rities have now become a more important actor in governing ambu- latory care, hospital care, and their so-called third sector, the health and social sector (Chevreul et al. The number of admini- strative stakeholders at national and local level remains very high and it is yet to see what effect the new arrangements will have on the traditional challenges of the French health care system such as how to effectively coordinate care between the different health care sectors and numerous players, and how to sustain the level of care given the high level of expenditures. The big question is how the regional health authorities will interpret their new role. they prevent innovation by trying to cut costs? Much will depend on the leader of the health care region. Governance model and recent changes has a division of responsibility between central govern- ment, the federal states and the so-called self governing bodies. These corporatist health care providers and social health insurers are usually legitimated through social elections. The subnational players have traditionally a powerful policy making role. The cen- tral government however has gradually enhanced central level con- trol over social health insurance financing and the provision of ser- vices: A national social health insurance fund, the so-called soli- darity fund, was established in 2009 and has centralized the collection of all social health insurance contributions. At the same time, the level of social health insurance contributions became nationally fixed and uniformly applied to all social health insurers for the first time. And a new law on health care provision will take some planning of highly specialized ambulatory health care services out of the hands of the association of ambulatory care physicians working under social health insurance conditions and shift it to the regional ministries of health to influence the of prac- tices towards geographically remote areas (in essence rural areas, and the eastern Länder). Public health emergency planning is another field that experiences a gradual shift of traditional responsibilities from regional to central level. Within the corporatist actors, the trend is towards progressive merging and centralizing administrative units. Overall, policy priorities of the German social health insurance system are determined by a balance between the objective to allow choice of the insured on their insurers and health care pro- viders and macroeconomic concerns over social health insurance expenditures. The objective to ensure consumer choice has contributed to the promotion of market competition between insurers in the past and has also provided the basis – although less explicitly – for the modest promotion of competition amongst providers in both hos- pital and ambulatory care. The coalition government of the democrats and the Liberals intended to reinforce competition of funds in 2009 by setting contribution rates centrally but intro- ducing the option for funds to levy and collect a surcharge to health insurance contributions in order to cover their excess expenses. Between 2009 and 2011 this surcharge was limited to but from 2011 onwards, these surcharges are no longer limited. In addi- tion, a special exit condition was granted for members wishing to change their funds so that the additional surcharge has not become subject to price competition between funds. Individuals whose ave- rage surcharges exceed of their gross income are granted lower contribution rates, these are covered by general taxes. Additional surcharges levied by sickness funds were expected to promote efficiency of the funds since it was expected that surcharges would become an important criterion for members choices towards the more efficiently operating funds. In addition, the Health Financing Act aimed to separate labor costs from health expenditures by capping health insurance contributions at , and increasing the share of the employees (Bäumler et al. The introduction of the solidarity fund in 2009 was motivated by the intention to potentially increase the governments influence on health insurance finance, by enabling tax subsidies. The progressive merger of health insurance funds, and the creation of a single peak organization of sickness funds is motivated by the objective to increase transparency, reduce fragmentation in decision making, and make collective contracting more efficient. Improving the coordination of care has been another key objec- tive that drove the introduction of disease management programs in 2002. The creation of the in 2009 has been one of the most fundamental financing reforms of the German social health insurance system in the past decade. has centralized the pooling of social health insurance contributions of all socially health insured members (of the population), which were previously collected and pooled by health insurance funds individually. The social health insurers continue to collect contributions from their members and pass these on to the Fund. Funds are reallocated to the social health insurers based on a standard average cost (per month per insured), age, gender, employment status and mor- bidity patterns of the insured. The risk compensation scheme for the morbidity structure relates to 80 well-defined chronic cost intensive diseases and is identified through hospital discharge data and diagnostic data of ambulatory care physicians. A standard con- tribution rate (of gross income, up to an income ceiling) had been set initially. The second economic stimulus plan con- tained a further tax-based injection of funding, to lower the contri- bution rate to in 2009. In 2010, the contribution rate was increased again to . The share of the insured amounts to , the employer share is and fixed. The government loan subsidy to the social health insurance scheme is gradually increased up to 14 billion in 2012. of the new central fund facilitates more centralized monitoring of social health insurance revenues and increases the opportunities to effect transfers from taxed sources. The majority of self-governing actors have moved towards more concentrated governance structures over the past decade. One of the nationally most prominent decision-making institutions for the social health insurance scheme is that was established in 2004 (et al., 2011). is composed of an equal number of providers and insurers. Patient representatives participate with- out voting rights. is responsible for defining the benefit package of the social health insurance on the basis of syste- matic reviews – partly provided by – on the costs, benefits and cost effectiveness ratios of pharmaceuticals and interventions. There have been a num- ber of recent considerations to increase the democratic legitimacy of . One current parliamentary debate focuses on the proposal for political nominations of representatives in . There has also been a notable merger of sickness funds from more than 960 in 1995 to 153 in 2011 – a development, which was explicitly intended by the government. The majority of sickness funds are organized at national level with central decision-making processes, whereas sub-national units have mostly administrative roles. One single peak organization of sickness funds was created through a merger of several peak organizations of sickness funds in 2007 and now operates as the central governance institution repre- senting all 153 sickness funds and thereby the interests of close to 70 million German people under social health insurance. The peak organization of sickness funds has advisory functions for the fede- ral and state parliaments and federal governments, is a member with voting rights of , and is a key negotiator for collective and for individual contracts under social health insurance. Mergers of funds are ongoing to date. For instance, a major merger is prepared between the DAK (the German Sick- ness Fund for Employees; Deutsche Angestellte Krankenkasse) and the BKK Gesundheit (a company based sickness fund; Betriebs- krankenkasse Gesundheit) as of January 2012. The new DAK Health will insure 6.6 million people, 5.1 members and their dependents making the fund the third largest following the (8.5 million insured) and the TK (7.7 million insured). The DAK has recently launched plans to eliminate the surcharges of in order to retain existing members and to attract new members. The Health Financing Act has liberalized the per capita sur- charge to cover health insurers additional expenses as mentioned above. In addition, the Act eased the switching to private supple- mentary health insurance by allowing individuals earning above per year to opt out social health insurance. Previously, individuals had to earn more than in three con- secutive years to be eligible for opting out. Disease management programmes were enforced in 2002 on the basis of selective contracting initially for Diabetes type II, breast cancer, coronary heart disease, and chronic obstructive lung disease and later extended to Diabetes I, asthma and heart failure. Health insurance funds can contract providers selectively for the integrated management of the diseases following a protocol of minimum requirements on treatment guidelines and referrals to specialists, quality , documentation, training and information of pro- vider and patients, and evaluation three years following accredi- tation. DMP contracts are conducted selectively between sickness funds and general practitioners, and in order to enroll into DMP, patients have to sign up for a specific provider. Until 2008, sickness funds received a higher share from the risk structure compensation scheme for patients enrolled in the DMP, a scheme introduced in 1994 to redistribute sickness funds incomes based on average spending of insurers by age and sex. At the time the risk structure compensation mechanism did not take into account patients with chronic diseases so that insurers concentrated on attracting the healthy. Upon introduction of the DPM, insured people received a higher pay under the risk structure compensation scheme that then provided a strong incentives for insurers to roll out DMP to their patients. As of , 5.9 million patients – around of the members of the social health insurance scheme – were en- rolled in DMP and more than 60.000 providers participated Debates and expected impact The introduction of the solidarity fund has been one of the most important changes in the governance structure for social health insurance. The fund turned out as a compromise between two different fundamental reform models for health insurance in the national election campaign of 2005. The concept of the is a capitation based uniform scheme for all socially health insured citizens. It includes a tax-funded insurance scheme for children, and tax subsidies for low-income individuals. The substitutionary private health insurance would remain in place. The Social Democrats favor an income-based model of the whole popu- lation (see section on outlook). Some experts have criticized that the fund worked against transpa- rency by making it more difficult to chase the flow of funds from sickness funds to the fund and the redistribution of funds from the national fund to the individual insurers. In addition, some claimed that the morbidity structure compensation mechanism might lead to a positive selection of sickness funds towards health risks eligible for compensation payments. There was also concern about an addi- tional administrative layer due to the solidarity fund, which would lead to higher administrative expenditures and more bureaucracy. The introduction of the fund coincided with the financial crisis of 2009 and two consecutive economic stimulus plans of the German government. The first stimulus package contained a lowering of the contribution rate to to lighten employers social insurance costs and to stipulate consumer consumption. The financial crisis became thus a first successful test case of the solidarity fund. Following this experience, the governmental authority to interfere in funding social health insurance contributions became better accepted amongst those that had been critical (mostly represen- tatives of the health insurance funds). A relatively small number of health insurance funds claims sur- charges from patients or reimbursed part of the paid contributions but this has led to a substantial shift of insurance membership. For instance, the DAK that had introduced a surcharge of lost 460.000 insured during 2010. Winners were those funds without surcharges such as for instance the GEK, TK, and the IKK. Since the introduction of the solidarity fund in 2009, one sick- ness fund – the City BKK – was closed. The city BKK recorded ongoing financial difficulties since several years. The elevation of the surcharge of per month resulted in substantial mem- bership exits. has announced the closure of a second fund, the BKK for health professions by the end of 2011. The Health Financing Act has been highly controversial. Oppo- nents such as the opposition parties and unions, social associations and the media have raised concern that the surcharges in social health insurance and the strengthening of private health insurance may inequalities in financing, access to care and the pro- vision of services. The latter is an anticipated effect of strengthening the private insurance sector which might provide incentives for providers to prioritize their services on the privately insured, as these are subject to higher reimbursement rates compared to ser- vices provided under social health insurance conditions. The poli- tical opposition has argued that the Health Financing Act will place some emphasis on competition by price, rather than by quality as had been intended with the introduction of equalized contribution rates in 2009. Defenders of the reform claim that the new compen- sation scheme that applies to individuals paying more than of their gross wages or salaries is more equitable since the tax subsidy to compensate their lower contribution rates is funded out of gene- ral taxation and not only out of social health insurance contribu- Some health economists have pointed out that the combina- tion of income dependent and flat rate fees will promote fragmen- tation in the sources of funds and pooling and will make health insurance funding more regressive. Overall, most commentators agree that the Health Financing Act is not likely to influence sustainability of health insurance financing in the longer run. The German social health insurance system has gradually moved towards more central governance approaches, deploying two main strategies. One strategy is to centralize and further empower cor- poratist governance arrangements of the self-governing actors. The increase of decision-making power for coverage decisions in the social health insurance benefit basket through the Standing Com- mittee, the centralization of peak organizations of health insurance funds and the progressive merger of insurers to create more powerful negotiators vis-à-vis providers are prominent examples of this strategy. A second strategy is to strengthen national-level regu- lation of certain aspects of health insurance funding such as through the solidarity fund and the standardization of the contribution rate. Notably the objective to sustain choice of consumers for their insurer and on their providers has so far accompanied most re- forms and will likely continue to do so since choice has been a con- sistent privilege of the German citizen on their health insurance and health care throughout different governments that seems poli- tically difficult to remote. It is likely that the debate around a more form of statutory insurance will be revitalized in the near future. The Social Democrats are currently maturing their plans for a citizen insu- rance that would apply to the whole of the population, bring back the equally shared contribution rate between employers and em- ployees, and would effectively lead to an exodus of substitutionary private health insurance since well paid Germans earning above per year, civil servants and or self employed (except those already enrolled in private health insurance) would no longer have the choice between the private and the statutory scheme. In addition, private health insurers would be obliged to offer a basic scheme with regulated premiums. In this model, contributions would continue to be income related but all income of employees, salaries and any extra incomes, would contribute to the scheme, with the exception of capital incomes and rents. The model would also re- inforce the competitiveness of the social health insurance market, by removing the uniform contribution rate. The morbidity-related risk structure compensation mechanism would be extended to cover many more diagnoses. The continue to defend their more liberal model allowing the private health insurers to provide substitu- tionary insurance as before but introducing capitation-based contribution rates with state subsidies for low-income families. Governance model and recent reforms has a tax funded health system with a predominantly publicly owned and operated hospital system. In the early 1990s, the 19 regions and autonomous provinces assumed the most important role in funding and delivering health care in . The regional health departments are responsible for providing the delivery of a nationally set standard basic benefit package through a network of outpatient facilities (so called local health enterprises) and pri- vate and public hospitals. The national government sets out the objectives and basic principles of the system and is responsible for regulating the pharmaceutical market and monitoring the con- sumption of pharmaceutical. Reforms since the 1990s have aimed at enforcing balanced regional budgets, standardizing clinical prac- tice through a national clinical guidelines programme and electronic patient records, and delegating managerial autonomy to hospitals and local health enterprises (Lo Scalzo et al. Policy priorities and tools A major shift of responsibilities occurred in 1997 when regions were empowered to set their own reimbursement rates, allocate and withhold public funds, and set quality standards in addition to those spelled out at national level. The downward shift of fiscal and decision-making responsibility took place in a broader context of political devolution in most social policy domains. Within the sub- national level there has also been a concentration of powers in the regional health departments of the regions whilst the power of provinces and municipalities is negligible. At the same time, hospi- tals and local health enterprises have gained more decision-making autonomy in their management, finance and administration in the 1990s by creating NHS foundation trusts. This was motivated by the intention to introduce some market competition between public and private providers aimed at increasing efficiency in manage- ment and services quality, however these expectations were not fully achieved owing to the different pace of implementation by the different regions and fragmentation in the internal market (Lo Scalzo et al. This has recently somewhat reversed by creating single management and administrative boards of several providers. A was introduced by the national government with the idea to subsidize regions not able to cover the basic benefit package (the southern regions). It essentially contained an equalization scheme to redistribute financing to regions on the basis of geographic criteria and population size, health care needs of the population, and fiscal capacity to rectify the on-going diffe- rences in provision of services between the center-north regions and the south. However this was not implemented as planned owing to disagreement over the redistribution formula (Lo Scalzo et al. There is still a notable trend of an increasing steering role and control of the national government on regional financial perfor- mance on cost containment illustrated through two recent develop- ments. First, since 2009, the central government has the mandate to appoint an external commissioner who is responsible for working with regions that are overspending their budget targets or break the nationally defined financial rules. These regions will have to develop and adopt regional recovery plans that spell out the activi- ties planned to recover their regional budget deficits and improve their financial situation. The mandate of the commissioner is to monitor progress towards regions implementation of their recovery plans, to influence this process as needed and provide technical support. This process thus sets out a new collaborative agenda between the national government and the respective regions with disciplinary consequences for non-compliance. It has enabled in- creased governmental interference with the autonomy of the regions to fund and plan health care services. Since 2009, several of the regions have had to adopt recovery plans and collaborate with the commissioner. A second emerging, albeit not yet implemented, issue is a new scheme to set the prices of health services of hospital, community and public health services according to the best performing regions at national level. According to the scheme, standard costs will be set at the level of average services costs of the regions best per- forming in their health care expenditure targets. The introduction of this scheme is highly controversial not only because it will further dilute the powers of the regions in setting their prices but also because it will inevitably give fewer resources to the under-funded regions. The national health plan 2010 to 2012 agreed between the natio- nal and the regional governments in 2009 furthermore introduces a set of new standards to monitor regional performance on clinical costs, personnel, hospital admission rates etc. and puts forward a monitoring process. There is a strong role for pharmaceutical regulation and cove- rage decisions on pharmaceuticals at national scale but health tech- nology assessment and priority setting for interventions is not taking place at national scale. Some northern regions including Piedmont, , Lombardy and are more than others in using HTA to plan services and for reimbursement decisions. Only recently there has been a call for more inter-regional collaboration. Care for the elderly and the disabled population is a major issue for the ageing Italian population but coordination and integration is still underdeveloped partly owing to a backlog on policy commit- ment to provide a strategic frame to services provision by a wide range of providers for long-term care and palliative care with diffe- rent institutional arrangements including residential, partly resi- dential, and community home care. Health Plan 2010 to 2012 introduces commitment towards a programme to develop new regulations for elderly and home care. So far, interregional collaboration in services provision is very limited.