In Germany, there are currently (2011) around 2000 hospitals. These hospitals are held in roughly equal proportion by public entities, independent not-for-profit organizations and for-profit companies. Publicly owned hospitals are owned by municipalities, states or the federal government. The federal government only operates military hospitals, the states primarily own the university hospitals and mental health institutions. The municipalities are frequently the owner of the local general hospital in order to ensure the provision of health care in their districts. Independent not-for-profit hospitals are generally owned by charitable organizations including churches. The for-profit hospitals in Germany are largely comprised of hospital chains, with Asklepios, Sana, Helios und Rhoen being the dominate chains.
The funding for the hospitals is derived from two sources: the reimbursement of the operating costs and the investment costs. The operating costs have to be recouped mainly through lump-sum reimbursements per case (DRG), which in many cases is no longer particularly lucrative. As a result, some hospitals generate more profit from their ancillary operations than the treatment of patients. Public funding for investments is in principle available to any hospital which is included in the official hospital plan. (Obermann, Müller, Müller, Schmidt, Glazinski-2015 p:-240)
6.1.1 Rehabilitation Clinics
As in the case of hospitals, rehabilitation clinics can be operated by governmental, not-for-profit or for-profit organizations. For-profit companies dominate this sector. About 56 percent of the roughly 1 240 rehabilitation clinics are held by private owners, 26% by independent charitable organizations and 18 percent by public entities. In contrast to hospitals, rehabilitation clinics do not typically receive public grants and are therefore particularly exposed to competitive pressures. In order to save costs, the responsible payer generally prefers the rehabilitative care to be prescribed on an outpatient basis in the primary sector. Nonetheless, given the aging population, the long-term prospects for rehabilitation clinics are favorable. At present, rehabilitation clinics are increasingly providing the post-operative care following the hospital discharge. This is a result of the introduction of the diagnosis related groups and the incentive of the hospitals to discharge their patients as soon as possible. (Obermann, Müller, Müller, Schmidt, Glazinski-2015 p:-240)
6.1.2 Regulatory / Reimbursement system
Reimbursement system In Germany is usually categorized into different types. Mainly for intra hospital use and for ambulatory purposes. In both cases they have different decision makers and approval authorities. In this chapter we clearly explaining the types of organizations associated with the procurement and regulations.
Medical Practice Equipment (“Praxisbedarf”): – Praxisbedarf includes, for example, all necessary basic hardware (e.g. waiting room chairs) and technical equipment (e.g. ECG, ultrasound) of a medical practice; it is not patient-related. Praxisbedarf must be procured and paid for by the practitioner himself and is ultimately income-financed.
Medical Practice Supplies (“Sprechstundenbedarf”): – This refers to means that in their nature are intended for use on more than one patient within the scope of medical services. These include, among others
· Dressings and suture material (gauze bandages, swabs)
· Means of (local) anesthesia
· Disinfectants for use on the patient
· Reagents and quick tests
· Diagnostic and therapeutic means (e.g. plaster, disposable infusion sets)
· Drugs for emergency cases and instant use
Each KV district has a so-called Sprechstundenbedarf agreement in place detailing which products are billable as Medical Practice Supplies.
Hilfsmittel (Medical Aids and Appliances): – are prostheses, orthopedic gear, hearing aids or other products that serve to compensate or to prevent handicaps or to assist therapy. They include, among other items:
· Walking sticks
· Wheel chairs
All prescribing Hilfsmittel are listed in the Hilfsmittel index (positive list) and, if prescribed by a physician, are reimbursed by the patient’s health insurance fund.
The GKV-SV is responsible for compiling and maintaining the Hilfsmittel index as well as for defining reference prices for the Hilfsmittel. These prices cover both the actual costs for the Hilfsmittel and the associated service – the reference price for a bladder catheter, for instance, also includes the service of placing the catheter. The provision of services is subject to quality standards and falls within the responsibility of specially trained personnel (typically nursing staff). In Germany, services are mainly provided by so-called homecare companies specializing in the distribution and supply of Hilfsmittel and, where necessary, provision of instructions as to their use. The health care providers maintain agreements with these companies, that is, patients may not choose care providers freely. Manufacturers can file a written application with the GKV-SV to have the new product included. GKV-SV will forward the applications to medical and nursing experts for a medical and technical evaluation.
Individual Health Care Services (“Individuelle Gesundheitsleistungen”, IGeL) : – These are services that a doctor offers to statutory sickness fund members which are not billable to the insurance fund, i.e. the costs are to be borne by the patient. For the most part, IGeL refers to preventive and service-based medicine. IGeL have been criticized repeatedly over whether the offered services are actually necessary and reasonable.
Doctor’s Fee Schedule (“Gebührenordnung für Ärzte”, GOÄ) : – The GOÄ is a catalog for billing services provided to so-called private patients. In the broadest sense, the description of services in this catalog is comparable to the Uniform Evaluation Benchmark (EBM), although the services are more extensive and have a higher value. Doctors can therefore charge higher amounts. The services are typically charged directly to the patient. Such patients are usually covered by a private health insurance with which to file the doctor’s bill for reimbursement.