The Reform of the German Health Sector: Integrated Service Delivery Systems - Cost Containment and Quality Enhancement - Attaining Diverging Ends by Similar Means

Contents

List of Figures

List of Tables

List of Abbreviations

1. Introduction

2. Managed Care
2.1. What is Managed Care?
2.2. Instruments of Managed Care
2.2.1. Gatekeeping and Specialists
2.2.2. Case and Disease Management
2.2.3. Compensation Schemes and Incentives
2.2.4. Quality Control
2.3. Evolution of Managed Care
2.4. The Three Pillars of Managed Care
2.5. Applicability of Managed Care from the US to the German System

3. Integrated Service Delivery Systems
3.1.1. Current Deficiencies and Goals to be achieved
3.2. Development and Concept
3.2.1. Legal Aspects
3.2.2. Contracting Partners
3.2.3. Compensation
3.2.4. Financing IV Structures
3.3. Factors for Success
3.4. Organization and Management

4. Quality Management in the System of
4.1. Results of Empirical Research
4.2. Is the IV Approach suitable for Quality Enhancements?
4.3. Quality of Provision – Contractual Means
4.4. Outlook

5. Conclusion

Bibliography

Appendix

List of Figures

Figure 1–1 A Layer Schema

Figure 2–1 Resource Efficiency and the Choice of Positive and Negative Incentives

Figure 3–1 Potential Partners in IV Structures

Figure 0–1 Contract between the KVSA and AOK Sachsen-Anhalt

Figure 0–2 Information Technology and Computer Applications in the Health Sector

Figure 0–3 Registered IV Contracts by Region

Figure 0–4 Actors in the Health Economy – Traditional System

Figure 0–5 Actors in the Health Economy – IV System

Figure 0–6 Care Providers in Currently Existing IV Contracts

Figure 0–7 Porter’s 5 Forces

Figure 0–8 Porter’s Value Chain

Figure 0–9 Physician’s Current and Prospective Use of Various Data Sources

Figure 0–10 Dementia Decision Tree by knowledgeTools

Figure 0–11 Quality Assurance in an IV contract by the GEK Brandenburg

Figure 0–12 Quality Assurance Documentation ASQ1

Figure 0–13 Quality Assurance Documentation for the Integra Network Magdeburg

Figure 0–14 Possible Variables for Future Research

List of Tables

Table 2–1 Managed Care Instruments – An Overview

Table 3–1 Advantages and Disadvantages for Main Actors in the IV System

Table 0–1 Advantages and Disadvantages of various Compensation Modes

Table 0–2 Checklist Regarding Quality Issues

Table 0–3 Quality Dimensions in IV contracts

List of Abbreviations

illustration not visible in this excerpt

1. Introduction

With reforms in the years 2000 and 2004, respectively, the German government created a new playground for actors in Germany’s health sector. In previous years, a cumulative number of events were said to seriously impair the efficiency of the health system as it was established. The recent policy can be characterized by a shift towards rationing and standardization, in short, a trend towards Managed Care (MC).

This paper is supposed to take up the part of the reforms which are aimed at introducing MC practices in the German health sector. This comes mainly in the form of Integrated Service Delivery Systems (ISDS), which overcome the burden of the traditional sectoral splitting of prevailing institutions in the health economy. The state’s priorities have been cost containment and quality enhancement. Yet these goals were perceived to be unattainable at the same time due to their state of being. The primary focus of this work is to show how government outlines the compatibility of these measures and which legal context has been established to put them into practice.

The first section deals with the evolution of Managed Care, outlines its instruments, and tries to figure out why this structure seems to be particularly useful in reacting to market failures in the health sector. Information asymmetries, moral hazard and public good character are problems that need to be overcome. Policy means of information, communication, technology, and networking are suitable approaches to address the above disturbances. An attempt to examine the transferability of Managed Care from the Anglo Saxon to the German system is to be undertaken.

The main part of this work attempts to outline the development of ISDSs in Germany, of which the predominant version is the ‘Integrierte Versorgung’ (IV). The legal framework, contractual means, payment schemes, and possible partners in the IV system are to be analyzed just as well as factors for success of this rather new model of care provision. It follows an introduction to the concept of network organizations which will lead directly to management areas that are particularly important when setting up networks. Eventually, advantages and disadvantages for the main actors in the system of IV are listed.

The last part of the paper analyzes whether ISDS are able to smooth out imponderabilities resulting from the traditional system of provision. Particularly, the mix between cost containment and quality enhancement is reconsidered. Outcomes of empirical research will be presented. Quality criteria, as they are suggested in the literature, will be discussed, and measures for continuous improvement collected. As shown in this subdivision, the problem of data collection severely limits current options to evaluate quality. Measurable, clearly defined parameters are required to do so and have to be developed, consequently. Suggestions are being made as to which variables could be selected for further research. Other distracting factors are legal matters concerning the disclosure of IV contacts which considerably complicate the issue.

Another approach towards describing the changes in the health sector is the consideration of Williamson’s governance mechanisms.^[1] He stresses the importance of institutions and their effects on organizational and individual behavior. This fact is illustrated in Figure 1-1. By changing the institutional ‘health’ environment, various governance parameters for care providers are changed, one of them being the newly established freedom to contract between insurance companies and a selection of care providers. As a result, strategic partnerships or networks are going to be formed. Furthermore, a selection of MC instruments will also affect individual attributes, changing the propensity to consume services, inter alia.

Figure 1–1 A Layer Schema

illustration not visible in this excerpt

Source: Williamson (1996), p. 326.

2. Managed Care

2.1. What is Managed Care?

“There is no single valid definition of Managed Care up to this point”.^[2] “The term encompasses a diverse array of institutional arrangements [and resembles] more complete contingent claim contracts”.^[3] “Generally, Managed Care is understood to be a market oriented system of provision of services and insurances in the health sector, the goal of which is the efficient allocation of scarce resources”.^[4] The development of the concept was driven by the desire to reconstruct the US health system in order to contain costs and ensure high quality standards of care provision.^[5]

The main feature of this theory is the guided or ‘managed’ provision of care through the insurer, which breaks up the traditional boundaries between units of medical care, administration and finances. The underlying incentive system works in two ways: Consumers sacrifice some of the freedom to choose care providers. This might be achieved through financial stimuli. Alternatively, a predefined range of providers might be offered and patients can select any of them from the given network. Co-payments to outsiders will be considerably higher.^[6] The suppliers of medical services are directly controlled in terms of quantity regulations or guidelines determining the methodological standards.^[7]

In short, Managed Care Organizations (MCOs) “may intervene in the relation between the provider and the insured individual, limit service in particular circumstances, and may selectively contract with a defined set of providers”.^[8] The contracts between insurers and individuals may be differentiated by their characteristics of the premium, the covered benefits, and the particular cost-sharing mechanisms. Mutual agreements between insurers and providers contain selection mechanisms, payment structures and methods to measure and monitor service utilization.^[9]

The most common form of a MCO is the Health Maintenance Organization (HMO), in which a given insurance premium allows for a predetermined spectrum of services to be used by the enrollee. Over time, different models have evolved, some of which are the Staff-Model, the Independent Practice Associations (IPAs), the Preferred Provider Organizations (PPOs), the Group Model or the Network Model.^[10]

2.2. Instruments of Managed Care

There are a variety of instruments available, which can be incorporated into MC contracts. This section aims at introducing the most important ones and concludes with an overview of all instruments. The particulars to be discussed are Gatekeeping/Specialists, Case Management, Compensation Schemes/Incentives, and Quality Control.

2.2.1. Gatekeeping and Specialists

Contrary to the traditional system of care, where general or specialized providers of services could be freely selected among the preferred population, there is a restricted access under MC. “Gatekeeper arrangements require enrollees to obtain a referral from a specified primary care physician before consulting a specialist”.^[11] The Gatekeeper is responsible for the coordination of processes and ensures a provision of services on the lowest possible level^[12], e.g. “less costly services are substituted for more costly ones”, where applicable.^[13] Gatekeepers are comparable to general practitioners in the traditional German system, yet, their duties increase under the system of MC as they also take the role of the case manager. Generally, Gatekeepers will treat patients according to their qualifications and transfer them to a specialist when additional abilities are required.^[14] For a practical illustration of a Gatekeeper clause, see Figure 0-1, i.e. the contract between the AOK Sachsen-Anhalt and the Association of Statutory Health Insurance Physicians Saxony-Anhalt (Kassenärztliche Vereinigung Sachsen-Anhalt, KVSA), in the Appendix.

2.2.2. Case and Disease Management

This management tool includes two distinct features, specifically Case and Disease Management. “Where Case Management describes the coordination processes of individuals (e.g. stroke of Mr. Miller), Disease Management is more about patient groups (e.g. all patients with leukemia)”.^[15] Both of them aim at the harmonization of prevention, diagnosis, therapy, rehabilitation, and care in order to cut costs and enhance quality. Similarly, they involve the integration of various care providers. With Case Management, the center of integration is the individual, whereas Disease Management Programs focus on specified diagnoses groups. To encourage all parties involved to cooperate, financial incentives are used. This is one of the reasons why MC should be attractive for insurers, providers, and users. Negotiations leave room for all potential partners to be better off; hence, Pareto improvements can be achieved.^[16]

The likelihood of their application increases with the cost-intensiveness of individual cases. Trends of outsourcing, or carving out, can be observed in this scenario as specialized knowledge is vital.^[17]

2.2.3. Compensation Schemes and Incentives

Incentives are the driving force behind service delivery in MC structures. They support the economically sound use of resources and help to achieve the desired levels of high quality given the appropriateness and the necessity of the treatment. Capitation, or fixed payments, are frequently applied in MC structures and replace traditional fee-for-service arrangements, which historically provided incentives for the overprovision of services.^[18] Capitation payments will result in per-head revenues for care providers independent of the actual amount of time spent on the case.^[19] Other alternatives are wages and case based lump-sum payments. For a complete study of advantages and disadvantages of potential compensation modes available in MC structures, consult Table 0-1 in the Appendix. “Plans may combine these mechanisms, as well as bonuses, withholds, and other incentives, into tailored incentive schemes”.^[20]

The primary goal of every scheme should be a mix of compensation elements that enhances the quality of the provision structure in the desired way. Thus, providing the right amount of positive and negative incentives to ensure a treatment that is medically necessary and appropriate, yet avoids the waste of resources. For the distinction of positive and negative incentives see Figure 2-1.

Figure 2–1 Resource Efficiency and the Choice of Positive and Negative Incentives

illustration not visible in this excerpt

Source: Augurzky et al. (2004), p. 34 (RWI Analyse).

2.2.4. Quality Control

“The qualification and reputation of care providers as well as the size of the corresponding panel are of utmost importance for the success of a HMO”.^[21] With the help of Utilization Reviews and Quality Management Committees, the provision of care can be evaluated, this holds for the quality of provision as well as for the appropriateness.^[22] Additionally, there are a variety of external management tools, such as feedback mechanisms, or continuous quality improvement programs that can be applied.^[23] Yet, institutional arrangements in Germany regarding quality measurement and evaluation are rather young, which can be proven by the establishment of the Agency for Quality in Medicine (Ärztliches Zentrum für Qualität in der Medizin, AEZQ) in 1995 or the Institute for Quality and Efficiency in the Health Sector (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWG) in 2004. As a comparison, the American Society for Quality has been in place for roughly 60 years now.^[24]

Within MC, quality is supposed to be a crucial competitive factor. Providers are likely to follow either a cost leadership or a differentiation strategy.^[25] In the former case, suppliers will aim at increasing service provision as much as possible and exploit economies of scale. In the latter, firms might prefer specialization on particular fields of indications and the development of a brand name.^[26] Differentiation efforts are likely to have a positive impact on quality. An integration of services can be expected to take place as providers of services are likely to join forces and offer a full array of benefits.^[27] A more detailed discussion on integration of services is provided in Chapter 3.

Many HMOs contain departments for the evaluation of new technologies. Due to the fact that technological innovation was one of the driving forces behind the recent cost increases in the health sector, these departments perform cost-benefit analyses for the adaptation of large scale projects.^[28] The increased use of technology can, generally, be associated with quality enhancements; however, they have to be compared to the resulting costs.

Insurance companies now take on a more active role in the provision of care which leads to an increase of authority or a relative improvement in the status-quo, whereas the providers of care will be worse off in terms of bargaining power. The insurance companies will be in the position to dictate treatment schemes and physicians will have to sacrifice part of their autonomy.^[29] This might lead to a potential hold-up problem. The corresponding effect on quality might be ambivalent, as the discussion on the use of evidence based guidelines shows.^[30] These guidelines have been used for outpatient treatment and recently their compliance has been shown to tie in to the financial incentive system.^[31]

Despite having introduced the most commonly applied MC instruments in this section, a more extensive overview is provided in Table 2-1.

Table 2–1 Managed Care Instruments – An Overview

illustration not visible in this excerpt

Source: See Amelung/Schuhmacher (2000) as quoted by Schwiedernoch/Özyurt (2004), p. 17.

2.3. Evolution of Managed Care

“Managed Care has a long history”.^[32] Early notations date back to 1849.^[33] Nevertheless, the surge in importance and growth [in the US] has not taken place until recently. Reformers suggested prepaid practices already in the 1930s, yet, there was strong resistance and regulatory practices were largely successful. In 1973, the US government passed the HMO Act, which encouraged growth and provided start-up funding. Until the 1990s, the HMO was predominantly a phenomenon of the private sector. In the late 1980s, the government started to open the market to federally-qualified HMOs as well. Despite remaining contractual barriers to these organizations, MC is well established in the US today.^[34]

The historical background could be described in much more detail. Nevertheless, it is more interesting to look at the economic groundwork of MC. Why should MC structures address market failures in the health sector more appropriately than traditional structures? Have results in the US been empirically proven? And which potential is there for HMOs in the German health sector?

Due to strong informational asymmetries in the health sector, the market suffers from problems of adverse selection and moral hazard.^[35] This is the case in many insurance markets. Hence, it is particularly important to address the issue of risk selection by insurance providers, as “insured individuals with bad risks find it increasingly difficult in the US to receive reasonable coverage for justifiable premiums”.^[36] Providers are likely to select among good and bad risks (as was shown in Figure 1-1 already) and, thus, prefer lower risk profiles over higher ones (screening). Thus far, these problems were circumvented in Germany by enforcing legally binding provisions such as the obligation to contract and the prohibition of discrimination (of risks).^[37]

“A fundamental problem in the health market is that individuals have more information about their propensity to use services than do insurers”.^[38] This might lead to a segmentation process. MC structures ration the provision of care and manage to encourage consumers to reveal their preferences with respect to their expected usage rates (signaling). Depending on their individual evaluation they will choose a plan that suits their needs.^[39] “MC plans use both explicit prices (consumer cost-sharing rules) and implicit prices (provider selection and incentives) to set different shadow prices for different services”.^[40] An objection is raised to the extent that successful MCOs will only drive up the costs of their competitors, which will hold total costs in the system constant and simply lead to a redistribution of health costs.^[41]

Moral hazard leads to an over-utilization of provision “because the patient does not bear the marginal cost of care”.^[42] Traditional insurances reacted to this phenomenon by demand-side cost-sharing schemes (co-payments and deductibles), whereas MC introduced additional supply-side mechanisms (utilization review, guidelines, Gatekeepers, and closed panels), which effectively limited the quantity of the care provided (→ see Table 2-1 for a full list of references).^[43] Those supply side restrictions may have gained importance as control mechanisms over time, which would help to explain the recent increase in the significance of MC.^[44]

Other reasons for market failures are the public good character of care provision and industry competitiveness (market power).^[45]

Industry competitiveness is closely linked to a functioning internal market for relevant information. Performance evaluation can be used to measure outcomes and, therefore, differentiate one MCO from another. The corresponding results help consumers to choose among the given plans.^[46] “Plans, in turn, can use their control over provider patterns and practice guidelines to improve their performance on these quality measures, although it is not clear to what extent they actually do this”.^[47]

For market power, the literature suggests:

“In a perfectly competitive marketplace, where search is costless, price-sensitive consumers should seek out low-cost producers. In practice, search is costly, especially where provider advertising is prohibited. […] Under indemnity insurance individuals gain only a small fraction of the total benefits of search for lower prices. Providers may collude to keep prices uniformly high, limiting the benefit of search”.^[48]

To conclude this section, it is worth emphasizing that MC structures do not completely solve any of the market failures completely, nonetheless, the combination of incentives mentioned above smoothes out some of the severe contingencies of the traditional indemnity insurance.

2.4. The Three Pillars of Managed Care

According to Preuß, there are three pillars in the health sector that can be defined as the basis for MC concepts. These are Information- (IT) and Communication-Technology (CT) as well as Networking.^[49] Each of the factors will be shortly described in the following section. For an overview of utilization rates of information technologies and computer applications used by respective actors in the health economy, consult Figure 0-2 in the Appendix.

There could be significant cost reductions in the Home Care sector if IT and CT were to be used more extensively. For instance, the shipping and mail-ordering services are believed to have great potential. Apart from this, the permanent monitoring of self-medication by physicians could be enhanced by online applications allowing direct access to this data.^[50] As far as general practitioners are concerned, the introduction of the electronic health pass, e.g., could significantly improve information flows. A trial version is currently being tested by the CompuGroup in the region of Trier in Germany.^[51] Specialists may receive future help by so called decision support systems (DSSs), or expert systems, which help to secure and optimize decision processes.^[52] An innovative start-up in the area of DSSs is the company knowledgeTools, which recently visualized several medical guidelines and integrated them into the respective software systems of the care providers.^[53] The system of German Refined – Diagnosis Related Groups can be named as an example of IT and CT progress in the inpatient sector.^[54]

The costs for provision of services in the IT and CT sectors are expected to decrease over the years to come just as prices for communication and storage devices. The Internet will gain in importance as a source of online-services and information research. A general trend from push to pull strategies of information provision is likely to occur. Further simplifications of software are to be expected; voice recognition might become increasingly important. Disciplines such as interface management will be established in the market and the younger generation of physicians will be better accustomed to new technologies. These factors make the gradual incline of technology usage in the health sector inevitable.^[55]

Network characteristics can be distinguished by spatial means. International, national, and regional setups will be used, accordingly.^[56] Cooperation and integration are considered to be crucial features of network organizations. A prerequisite for cooperation is communication, e.g. the exchange of information among providers, which can only be guaranteed by the IT and CT standards discussed above.^[57] A more detailed discussion of network organizations is provided in section 3.4. of this paper.

2.5. Applicability of Managed Care from the US to the German System

When considering the advantages and disadvantages of MC, it is critical not to neglect the underlying structural differences. Referencing Williamson’s Institutional Framework, as it was presented in the introduction (Figure 1-1), there are a variety of factors which are not comparable and, thus, may not generate the outcomes inherent in the US system. “Due to the strong heterogeneity of care provision and financing, a comparison with the German system is only possible under certain constraints”.^[58]

Intensive competition in the US provides incentives for risk selection, which, in this form, would endanger the German solidarity principle.^[59] In the US, the provision and financing of care are provided by the same organization, which is unheard of in Germany, since the Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, KVen) have a so called security mandate. “In view of international experience this separation is regarded to be advantageous”.^[60]

The German system can be considered to be a social insurance system based on Bismarck’s ideas, whereas the US implements its policies in a more market or profit oriented way.^[61] This can be well illustrated by the fact that only part of the population in the US enjoys an adequate plan of coverage.^[62] To the contrary, there exists a compulsory system of health insurance in Germany. Attempts to combine both approaches have lead to a reconsideration of the socio-political aspect within the MC concept.^[63]

“As a matter of fact, for the establishment of such a cost-effective and efficient provision structure, a [rather time-consuming] adjustment process is necessary which requires additional qualification measures, improved budget sharing, organizational learning, and further legal reforms”.^[64] It seems that the American based MC provides a more appropriate incentive system to ration and allocate resources in the health sector, yet, adverse effects such as risk selection and quality hazards or potential hold-up problems should not be neglected when adapting the system in Germany.

3. Integrated Service Delivery Systems

“Multi-institutional arrangements have grown rapidly over the past [decades]”.^[65] These cooperative efforts have also been accounted as “stabilization strategies”.^[66] Apparent reasons for the use of such strategic alliances are the “improved ability to deal with persistent problems, economies of scale, easier recruitment and retention of personnel, and various organizational benefits such as increased political influence”.^[67]

A classification between vertical and horizontal integration can be made where “horizontal integration refers to the linkage of similar organizations at the same stage of production [e.g. various hospitals] and vertical integration refers to linkages of organizations at immediately related stages of production [inpatient and outpatient treatment]”.^[68] ISDSs are generally viewed as the most advanced form of MC.^[69] Their profitability is closely related to the degree of integration.^[70] ISDSs are organization networks that “organize and conduct the full continuum of care provision and, at the same time, take full legal responsibility in terms of financial and medical risk”.^[71] Participation in such networks is voluntary and based on contracts. The German version of ISDSs is called ‘Integrierte Versorgung’ (IV) and has just been politically decided upon.^[72] From now on, IV and ISDS will be used interchangeably. In April 2006, there have been about 2,200 IV contracts that were registered legally at the Federal Agency for Quality Assurance (Bundesgeschäftsstelle für Qualitätssicherung, BQS) with roughly 3.5 million enrollees and a compensation volume of 500 million Euros.^[73] For more details see Figure 0-3 in the Appendix.

3.1.1. Current Deficiencies and Goals to be achieved

According to Transparency International (TI), there is an excess supply of goods and services in the German health sector. Demographic changes do not challenge the health system as much as the cost increases for service provision or the prevailing corruption. Due to the market power of certain players (or their federations) and the intransparent, sectoral self-governance of institutions in the health economy, there are yearly losses ranging in the billions.^[74] Misallocations of care provision, commercial predominance of interests, and fraudulent accounting practices are specified as further deficiencies.^[75]

Mühlbacher names a variety of flaws that impair the current health system, among others are the diversity of providers, prevailing disincentives to organize a holistic approach to optimization of care provision, over- and under-provision of services, mistreatments, inadequate prevention, and aftercare as well as interface problems.^[76]

Inpatient and outpatient care, rehabilitation centers, and pharmacies use “disjoint, incompatible systems that focus mainly on the analysis of historical data to support accounting procedures. Tools which support medical processes and decision support systems are rather exceptional”.^[77] Furthermore, there is “a lack of standards, norms and classification rules for medical documentation […] and a proper documentation culture is still to be established”.^[78]

According to Augurzky et al., the three main socioeconomic factors adversely affecting the cost side consist of: demographic changes, technological progress, and numerous inefficiencies resulting from an ineffective regulation of the system.^[79] Expenditures of the public health insurance (GKV) in 2003 amounted up to 144.5 billion Euros, roughly 4 billion Euros above the income level at that time.^[80] Potential reductions are estimated to be 40 billion Euros, which can be separated into the effects from primary care, secondary care, and system regulation.^[81] The strategic positioning of hospitals (portfolio structure), introduction of clinical pathways, the use of IV, outsourcing or centralization of services, reduction in administrative costs, and restructuring of incentives in the health sector are all regarded as effective cost reduction strategies.^[82]

TI has launched an anti-corruption initiative, which contains a wide array of measures aimed at increasing transparency. The following items are core elements of their agenda: professionalization of public bodies, legal tightening in cases of granting of undue advantages, publication of relations to sponsors, and registration of clinical studies.^[83] Moreover, increased information on quality and performance measures, an obligation to report critical events, and a fortification of patient rights are demanded by TI, among others.^[84]

Generally, the abolishment of the sectoral approach is believed to be highly efficient in reorganizing the health sector, and should result in a more patient-oriented care provision.^[85] For an ex ante/ex post comparison of relations between various actors in the health economy under the traditional and the IV system, see Figure 0-4 and Figure 0-5 in the Appendix.

3.2. Development and Concept

3.2.1. Legal Aspects

Originally, IV structures were introduced with the GKV Health Reform in 2000. Those changes were aimed at integrating the different health sectors and provided more room for negotiations of contracts between the providers and insurance companies. The compensation, which was traditionally agreed upon through collective bargaining involving the KV, could then be determined in the respective agreements providing the possibility for contracting parties to reap the benefits of their cost reductions. In the initial proposal, only groups of physicians could be contracted. Due to rather limited success, the changes were re-discussed and, in the end, revised.^[86]

With the amendment of the GKV Modernization Act (GMG) in 2004, a new and more liberal set of rules was introduced, the accomplishment of which was far greater than the initial reform. This can be demonstrated by the recent increase in the number of registrations, which almost quadrupled from 2005 to 2006.^[87]

The main extensions of the GMG can be summarized as follows: Insurance companies can now contract a single physician as well as medical provision centers. The KV is barred from participation in IV contracts, hospitals may partially open themselves for IV activities, and outpatient provision of services may be done in inpatient facilities (hospitals) under certain conditions. The constant premium level is abolished and a free compensation system established.^[88]

“The legislator provided a description of an ideal case where inpatient and outpatient care, pharmacies and rehabilitation are part of an integrated, specialized network which ensures the treatment of patients within a given range of provisions in a defined region. A secure electronic data exchange is guaranteed. The patient enrolls voluntarily and selects a physician from the given network. Additional features such as call-center services might be offered”.^[89]

The legal reasoning behind IV structures is to “provide enrollees as ‘normal, publicly-insured patients’ with an additional (if not better) provision of services in the health sector”.^[90]

3.2.2. Contracting Partners

The primary contracting parties are the different types of insurance companies, e.g. statutory health insurances in specific areas (Ortskrankenkassen), company health insurance schemes (Betriebskrankenkassen), or substitute health insurance schemes (Ersatzkassen), inter alia. Each individual insurance company may or may not write specific IV contracts. This freedom of choice is regarded to be advantageous since not a single company can block the combined efforts of others.^[91] Vis-à-vis are the following partners: single medically approved physicians or dentists, other authorized providers, or an association of the former, responsible bodies for hospitals, inpatient or outpatient prevention, and rehabilitation facilities or associations of the former, medical competence centers as well as management organizations.^[92] For an illustration of possible partners in IV structures, see Figure 3-1.

Figure 3–1 Potential Partners in IV Structures

illustration not visible in this excerpt

Source: See Specke (2005), p. 215.

Authorized providers “are persons or organizations which directly render a service to the insured individual according to the social security code number five (SGB V). [T]he provider obtains a remuneration and is the economic risk bearer”.^[93] Pharmaceutical companies are indirectly involved with the provision of health services and can, therefore, only contribute financially to IV structures. Examples of authorized providers are home care facilities, patient transport ambulance, midwives, and dental technicians.^[94] The overview of care providers in already existing IV contracts is provided in Figure 0-6 in the Appendix.

[...]

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^[1] Williamson (1996), pp. 326-328.

^[2] Seitz/König/Stillfried (1997), p. 5.

^[3] Glied (2000), p. 709.

^[4] Schwartz/Wismar (1998), p. 571 as quoted by Mühlbacher (2002), p. 42.

^[5] See Seitz/König/Stillfried (1997), pp. 4-6.

^[6] See Glied (2000), p. 713.

^[7] See Seitz/König/Stillfried (1997), p. 6.

^[8] Glied (2000), p. 709.

^[9] Glied (2000), p. 711.

^[10] See Schmidt (1997), p. 14 as quoted by Mühlbacher (2002), p. 8.

^[11] Glied (2000), p. 717.

^[12] See Schwiedernoch/Özyurt (2004), p. 12.

^[13] Glied (2000), p. 713.

^[14] See Seitz/König/Stillfried (1997), p. 12.

^[15] Schwiedernoch/Özyurt (2004), p. 12.

^[16] See loc. cit., p. 13.

^[17] See Seitz/König/Stillfried (1997), p. 15.

^[18] See Seitz/König/Stillfried (1997), p. 13 and Cutler (1994), p. 15.

^[19] See loc. cit.

^[20] Glied (2000), p. 714.

^[21] Seitz/König/Stillfried (1997), p. 11.

^[22] See loc cit., p. 16.

^[23] See Glied (2000), p. 716.

^[24] See ASQ (2006a).

^[25] See Porter (1985), p. 11-14.

^[26] See Klein/Leffler (1981) as quoted by Glied (2000), p. 725.

^[27] See Schwiedernoch/Özyurt (2004), p. 21.

^[28] See Seitz/König/Stillfried (1997), p. 17.

^[29] See Schwiedernoch/Özyurt (2004), p. 12 and Ray (2005).

^[30] See Hoffmann (1998).

^[31] See Glied (2000), p. 717.

^[32] See loc. cit.

^[33] See Friedman (1996) as quoted by Glied (2000), p. 717.

^[34] See Glied (2000), pp. 717-721.

^[35] See Glied (2000), p. 721 and Cutler/McClellan/Newhouse (2000), p. 530.

^[36] Seitz/König/Stillfried (1997), p. 6.

^[37] See Kifmann (2002).

^[38] Arrow (1963) as quoted by Glied (2000), p. 721.

^[39] See Glied (2000), p. 722.

^[40] Frank/Glazer/McGuire (1998) as quoted by Glied (2000), p. 722.

^[41] See Glied (2000), p. 723.

^[42] Cutler (1994), p. 14.

^[43] See Glied (2000), p. 731.

^[44] See loc. cit., p. 724.

^[45] See Cutler (1994), p. 15.

^[46] See Glied (2000), p. 725.

^[47] See loc. cit.

^[48] Newhouse (1978) as quoted by Glied (2000), p. 726.

^[49] See Preuß (1997), pp. 259-300.

^[50] See loc. cit., pp. 264-265.

^[51] See Krüger-Brand (2005).

^[52] See Preuß (1997), p. 271.

^[53] See Saller (2005).

^[54] See GKV/PKV/DKG (2001).

^[55] See Preuß (1997), p. 293.

^[56] See loc. cit., pp. 278-292.

^[57] Mühlbacher (2002), p. 81.

^[58] Arnold/Lauterbach/Preuß (1997), p.VIII.

^[59] See Mühlbacher (2002), p. 47 and Seitz/König/Stillfried (1997), p. 18.

^[60] Rosenbrock (1999), p. 27 as quoted by Mühlbacher (2002), p. 47.

^[61] Mühlbacher (2002), p. 49 and Arnold/Lauterbach/Preuß (1997), p.VIII.

^[62] See Schwiedernoch/Özyurt (2004), p. 22.

^[63] See Baumberger (2000).

^[64] Schwiedernoch/Özyurt (2004), p. 27.

^[65] Fottler et al. (1982), p. 67.

^[66] Longest (1980) as quoted by Fottler et al. (1982), p. 67.

^[67] Brown (1976) and Zuckermann (1979) as quoted by Fottler et al. (1982), p. 72.

^[68] Fottler et al. (1982), p. 74.

^[69] See Amelung/Schuhmacher (2000), p. 30 as quoted by Mühlbacher (2002), p. 47.

^[70] See Seitz/König/Stillfried (1997), p. 11.

^[71] Amelung/Schuhmacher (2000), p. 30 as quoted by Mühlbacher (2002), p. 47.

^[72] See Bundesministerium der Justiz (2006a).

^[73] See BQS (2006a), p. 1.

^[74] See Transparency International (2006a).

^[75] See Transparency International (2006b).

^[76] See Mühlbacher (2002), p. 52-53.

^[77] Preuß (1997), p. 259.

^[78] Preuß (1997), p. 261.

^[79] See Augurzky et al. (2004), p. 9 and Cutler (1994), pp. 17-18.

^[80] See Specke (2005), p. 151.

^[81] See Augurzky et al. (2004), pp. 10-11.

^[82] See loc. cit., pp. 13-31.

^[83] See Transparency International (2006a).

^[84] See Transparency International (2006b).

^[85] See Sachverständigenrat für Konzertierte Aktion im Gesundheitswesen (1995), Ziffer 212 as quoted by Mühlbacher (2002), pp. 52-53.

^[86] See König (2006), pp. 23-27.

^[87] See BQS (2005), p. 1 and BQS (2006a), p. 1.

^[88] See König (2006), pp. 27-28.

^[89] Schwiedernoch/Özyurt (2004), p. 28.

^[90] König (2006), p. 40.

^[91] See Schwiedernoch/Özyurt (2004), pp. 34-35.

^[92] See Bundesministerium der Justiz (2006b).

^[93] Schwiedernoch/Özyurt (2004), p. 35.

^[94] See loc. cit., p. 36.