This article is a reprint, approved by the authors, from the book “Need for reform in the hospital and pharmaceutical sector after the election - 22nd Bad Orber Conversations on Controversial Topics in the Health Care System”, Peter Lang Publishers 2018

>> When presenting and appreciating the two currently existing fee schedules, it is also important to take their respective relationship to the associated service catalogs into account. The uniform assessment standard (EBM) in the GKV is based on a collective agreement. The evaluation committee, which consists of three representatives from the National Association of Statutory Health Insurance Funds and the National Association of Statutory Health Insurance Physicians (KBV), approves the EBM. All GKV insured persons have the same legal right to the associated catalog of benefits. The only exceptions are the quantitatively relatively insignificant statutory benefits, with which the health insurance companies can differ in terms of what they offer.
In contrast, in private health insurance (PKV), the fee schedule for doctors (GOÄ), which is based on a legal regulation from the Federal Ministry of Health, corresponds to a very flexible catalog of services that offers those with private insurance a variety of contractual agreements for specific services. Those with private insurance therefore have the opportunity to put together their own special catalog of services according to their preferences. This individual selection can include more or fewer services than the corresponding GKV catalog. In addition, the individual services in these two catalogs do not have a uniform or identical definition and delimitation. These differences in the service catalogs of GKV and PKV, on which the two fee schedules are based, already illustrate the problems of combining both systems into a uniform fee schedule.
The GKV and the PKV are solidarity insurance systems in that ex post, largely healthy insured people financially support the claims of very sick patients. Both systems also strive for the best possible service quality in conjunction with high patient satisfaction as well as optimal efficiency in the provision of services, but have different priorities in achieving these goals. In addition to greater flexibility when selecting services, PKV offers a particularly low barrier to the entry of new innovative services, while GKV places greater emphasis on the cost-effectiveness of the services in conjunction with the evidence of their (net) benefits. Accordingly, the GKV also uses targeted instruments to limit quantities.
When choosing between the two current fee schedules, the EBM of the GKV with around 72.5 million insured people should have clear priority over the PKV with almost 8.8 million insured people in the spirit of the supporters of a uniform fee schedule. With the GOÄ as a uniform fee schedule for both insurance systems, there would be a risk of a significant increase in volumes with a corresponding (additional) increase in expenditure due to their individual service reimbursement. In keeping with its objective, the uniform fee schedule excludes surcharges for the same or identical services insofar as these relate to the GKV's catalog of services. However, the pricing system for services that go beyond the GKV's catalog of services, for example as part of supplementary insurance, remains unclear. However, the prices for these services can certainly influence the decisions made by practicing doctors when making appointments - at least to a limited extent.
Influence of a uniform
Fee schedule on budgeting and rationing

The introduction of citizens' insurance, which would require a transition phase of at least one generation regardless of constitutional problems, would also necessarily involve the introduction of an EGO in the outpatient sector. The current fee schedules would have to be standardized in terms of the amount of remuneration, functionality and billing arithmetic.
Both billing systems have a different monetary valuation and, in some cases, a different definition of the services. Therefore, a treatment carried out may be accompanied by different reimbursement depending on the patient's insurance coverage. In principle, service providers receive higher remuneration for the treatment of privately insured patients, which is usually not budgeted for. The situation is different for the inpatient sector, as hospitals largely have a uniform price for remuneration using flat rates per case. Ultimately, an EGO in a premium-financed insurance market dominated by the GKV is only conceivable if the system of the GKV comes into play, since only here would the volume control previously carried out in the GKV continue. A pure individual benefit system without quantity limits is rather out of the question for citizens' insurance. The EBM's regulatory apparatus with budgeting, quantity limits, quotas and graduations would then also apply to private health insurance.
But such a reorganization raises even more questions. Not only according to the structure of the fee schedule, but also according to the scope of services or after the design of a convergence phase and possible compensation payments, especially to practicing doctors, due to the loss of income from the GOÄ. Although the private insurance share in Germany is only 11%, these insured people generate 24% of the practice's turnover. Current empirical work emphasizes that the additional turnover of privately insured people in the outpatient sector amounted to up to 6 billion euros in 2015. For every practicing doctor in Germany, this would correspond to an average additional turnover of around 50,000 euros per year. Based on the data from 2010, another study comes to a compensation volume of over 4 billion euros (with full compensation) with calculated surcharge factors on the previous outpatient compensation amount of 13% to 17% for the years 2010 to 2030. There is also no compensation without compensation the basis of financing for personnel and investments. Many practices would not be able to withstand the economic pressure. Either the supply landscape would be further thinned out and/or the quality of care would have to decline.
In addition, in this case a market with additional insurance offers for premium patients is likely to emerge, since private health insurance cannot be prevented from taking out additional insurance. This situation also arose in Switzerland and the Netherlands after a unified insurance market was initiated by the legislature there.
Quantity control
However, the differences between GOÄ and EBM only partially explain the increased PKV sales in the outpatient medical sector. In addition, the GKV has mechanisms for quantity control that aim to limit spending, which does not exist in this form in the PKV.
The invoices of the contracted doctors are subjected to a plausibility and profitability check by the KVs, which also limits expenses and quantities. The plausibility check checks whether the medical services are billed correctly and the performance check checks whether the contracted doctors provide sufficient, appropriate and economical services. Medical services must not exceed what is necessary (Section 12 Para. 1 SGB V).
The so-called standard benefit volumes in the GKV also contribute to limiting expenditure. The regional associations of statutory health insurance physicians (KVen) are now free to apply standard benefit volumes or make other regulations. The standard benefit volume is a portion of the practice's income from contract medical work that is determined ex ante. The standard benefit volume makes it more difficult to expand benefits excessively, as services provided are only remunerated with a fixed EBM point value up to the agreed amount, whereas if this is exceeded, the point value is scaled down.
For those with private insurance, benefit expenditure is controlled solely via the private insurance contract. The scope of services, maximum reimbursement limits and deductibles are agreed there. In the GOÄ, the expenditure volume is limited by restrictions or limitations on the number and parallel billability of individual fee items. However, there are no further quantity restrictions. Differences in supply can arise due to system differences. This particularly applies to new treatment methods. For private patients, the doctor can calculate medical services not included in the GOÄ in the same way as an equivalent medical service from the GOÄ (Section 6 Para. 2 GOÄ).
In the GKV, however, new treatment methods in the outpatient sector may only be prescribed as a health insurance benefit once a review has been carried out by the Federal Joint Committee (G-BA) and this classifies the result as beneficial, necessary and economical for the patient. In the outpatient sector, new treatment methods are therefore subject to approval by the statutory health insurance. These different innovation drivers are certainly part of the additional sales of privately insured people.
EGO’s fee volume
The EGO would lead to a loss of the above-mentioned additional sales of 6.1 billion euros for outpatient reimbursement and/or for financing the medical infrastructure. Alternatively, there would be an additional burden on contributors. Those with statutory health insurance would then have to bear the additional sales of those insured under GOÄ. The contribution rate in the new citizens' insurance would increase by around one percentage point from 15.7% to 16.7%. The maximum monthly contribution in the GKV would rise from today's 683 euros to 725 euros.
The additional burden would not only affect higher earners, but also skilled workers and middle-class employees. Calculations show that, for example, a skilled worker in the construction industry would have to pay an additional 393 euros annually, a locomotive driver up to 417 euros, a master craftsman in the automotive industry 486 euros or a senior nurse in the public sector 506 euros additionally in citizens' insurance.
Performance and price differentiation despite EGO?
When it comes to the question of service and price differentiation in an EGO, the first question that arises is how extensive the underlying service catalog is. The previous assumption that the basis for an EGO would tend to be the EBM is not necessarily sufficient here, as the EBM currently also includes services that are not part of the GOÄ, for example inpatient preventative care or rehabilitation treatments.
The reverse is true, for example, with regard to non-prescription services or homeopathic remedies. The scope of the service contract concluded with the PKV can therefore generally be less extensive or more extensive in comparison to the GKV service catalogue. Differentiation of benefits, for example via statutory and optional benefits, would still be possible.
If parts of the GKV service catalog were more extensive, this service catalog would now be offered to all insured persons. This could result in the entire system becoming more expensive. However, the opposite is more likely: the previous scope of benefits provided by private health insurance was larger, so that ceteris paribus there would be a need for additional insurance, which would then have to be financed.
While in the general medical sector a common basic range of services can be identified for the majority of patients and chronically ill people in particular require special treatment effort, the reasons for treatment in the specialist medical sector are more differentiated. The EGO therefore particularly threatens the medical infrastructure in specialist care. An EGO would deprive highly specialized medical care of necessary financial resources.
Competition policy consequences
for GKV and PKV
The participation of insured persons in medical progress is one of the essential criteria for the quality of medical care. Health systems are also measured by how quickly they are able to incorporate innovations into standard care. From an international perspective, Germany is doing very well when it comes to access to innovations. Insured persons and patients have quick and comprehensive access to innovations.
The fact that this is the case is also thanks to the system competition between GKV and PKV. If an insurance system takes on a pioneering role in medical innovations, the other insurance system must deal with this innovation in system competition, justify its own position and react if necessary. Ultimately, system competition not only protects against service cuts, but also supports the introduction of innovations. In Germany, PKV often takes on the role of driver of innovation in system competition with GKV. In private health insurance, rapid financing and reimbursement of medical innovations is the rule, while in statutory health insurance, slower access to innovations and the relatively low level of financing are the rule, which can only be broken through selective contracts. This makes PKV a central competitive factor for quick and comprehensive access to innovations in Germany. In the long term, EGO will become the sole standard for remuneration in the outpatient sector. In particular, the modernization of the medical infrastructure is being put to the test.
Different waiting times:
Surveys on their relevance

Waiting times can significantly impede access to medical care, thereby delaying the treatment process for patients with the risk of poorer health outcomes. In principle, waiting times per se do not allow any well-founded statements to be made about their medical appropriateness, because it remains unclear whether this represents an acute need for treatment or whether the doctor in question is making an appointment that is harmless to health and justifiable. This statement applies regardless of the respective scheduling wishes of the patient concerned. Nevertheless, there is an interest in health policy to shed light on the differences in waiting times in national and international comparisons, to question them critically and, if necessary, to derive reform measures. Due to the lack of official statistical data, the respective results are based on various surveys.
According to a representative survey of the population and insured persons by the KBV, 43% of those with statutory health insurance received an appointment with their family doctor or specialist on the same day in 2016. For general practitioner appointments, this percentage is the same at 56% for those with statutory and private insurance, and for specialists it is almost identical at 22% (GKV) to 23% (PKV). With a waiting period of up to one week, those insured by the GKV will see their family doctor with 88% only slightly later than those insured by the PKV with 91%. For specialists, this ratio is 60% to 40% in favor of those with private insurance. These differences in waiting times between those with GKV and PKV insurance have decreased since the first surveys in 2008. In 2016, 15% of those with statutory health insurance had to wait longer than 3 weeks for a doctor's appointment, with the range from 10% in Bremen and Saarland to 22% in Brandenburg in terms of the federal states. In order to improve this situation, the federal government used the Care Strengthening Act to install regional appointment service centers at the KVs, which are intended to arrange patients with a referral marked as urgent an appointment with a specialist or psychotherapist within 4 weeks. The use of these service points, which have existed since the beginning of 2016, was comparatively low, with 110,000 appointments made for 580 million treatment cases.
In an international comparison, which is based on a representative patient survey by the Commonwealth Fund, Germany consistently has the shortest waiting times for doctor's appointments of all the countries included in this study. In 2016, the proportion of respondents who had to wait longer than 2 months for an appointment with a specialist was 3% in Germany and e.g. B. in the Netherlands 7%, in Sweden 19% and in Norway 28%. The proportion of patients who received an appointment with their family doctor on the same or the next day was significantly higher in Germany with 64% in 2015 than, for example, in the Netherlands with 51%, Norway with 39% or Sweden with only 19%. In view of these results, it is not surprising that in 2014 only 9% of the patients surveyed in Germany viewed or classified “no waiting time” as an important criterion for high-quality healthcare in their own country. In contrast, these values are significantly higher in the Netherlands with 23%, Sweden with 35% and Denmark with 41%. In terms of seats, Finland ranks here with 54%. In these countries there is obviously a virulent and understandable interest among patients in significantly reducing waiting times for doctor's appointments. These surveys on waiting times for general practitioner and specialist appointments in Germany and, above all, corresponding international comparisons indicate that citizens and patients in Germany see the current waiting times as far less problematic or as a relevant burden than the discussions in certain countries suggest political committees suggest.
A uniform fee schedule promises only an extremely small improvement for those with statutory health insurance in terms of their waiting times, which can be deduced from the market share of private health insurance of only approx. 10.9%. If doctor's appointments were allocated in the same way, ie without the existence of privately insured people, the waiting time for an appointment with a specialist for those insured by the GKV would at best be shortened by one day. This calculation does not take into account various attempts to circumvent the situation, which may, for example, consist of personal and social relationships with the respective doctors as well as incentives through lucrative income from additional insurance or attractive gifts from patients. Finally, within the framework of the current system, ie if the two fee schedules continue to exist, there are still opportunities to shorten the waiting times for those with statutory health insurance. For example, selective contracts between health insurance companies and selected doctors can stipulate certain waiting times. For example, the AOK Baden-Württemberg agreed a waiting period of a maximum of 14 days with the participating doctors for its family doctor-centered care and the specialist contracts based on it. In addition, a change in the quarterly flat rates for certain specialist services could also reduce waiting times. The current fee provides financial incentives not to provide the individual services for a specific flat rate in one appointment, but rather to spread them over two quarters. Overall, the current waiting times of GKV and PKV insured persons do not provide any relevant reason for a uniform fee schedule in GKV and PKV from a health care perspective.
Further hurdles to accessing healthcare
In addition to long waiting times, a limited catalog of services with numerous exclusions, mandatory gatekeeping with a restriction on the free choice of (specialist) doctor and sensitive mandatory co-payments can also hinder patients' desired use of health services. Compared to other social health insurance systems, the GKV provides a very extensive catalog of benefits compared to other countries. In contrast to the GKV, for example, the basic package of social health insurance in the Netherlands does not include physiotherapeutic or dental services. Dental care is not part of the compulsory health insurance catalog in almost any of the tax-financed health systems, nor in Switzerland. In almost all countries, drug supply is based on positive lists that limit patients' entitlement to benefits. In contrast, the GKV is the only social or statutory health insurance company in the European Union (EU) to reimburse all new prescription medications immediately after their approval.
Mandatory gatekeeping represents a barrier to accessing the desired healthcare for patients because it restricts the freedom to choose a doctor. While patients in the statutory health insurance have the freedom to choose between general practitioners and specialists according to their preferences, mandatory gatekeeping requires registration with the general practitioner and for treatment by a specialist the patient either needs a referral or has to have access to the specialist purchase with an additional payment. Germany, along with a few countries such as Luxembourg and Austria, offers patients free access to a specialist in the GKV. However, freedom of choice is not restricted if an insured person voluntarily enrolls in a gatekeeping system and thereby contractually accepts the need for a referral to a specialist.
Sensitive co-payments can deter patients, especially those with low incomes, from medical care or outpatient treatment that may be necessary. In the GKV, the insured persons or patients only have to make moderate additional payments, even in international comparison, although income-dependent overpayment clauses also apply. The proportion of additional payments, which accounts for almost 50% of the cost sharing for dentures, currently accounts for around 3.2% of total statutory health insurance expenditure, with a downward trend. In the area of outpatient medical care, the GKV does not charge any additional payments at all. When it comes to dental care, the German healthcare system has a relatively low proportion of patients who forego appropriate treatment for financial reasons compared to other countries.
In almost all countries, insured persons have the option of taking out private supplementary insurance for certain desired services that are not offered by the social health insurance service catalog or of paying for the relevant services out of their own pocket. It is obvious that, especially in countries with a limited catalog of social health insurance benefits, strong rationing and mandatory gatekeeping with long waiting times, many insured people switch to the private health insurance market.
In Great Britain, for example, those insured who want to avoid rationing of services or excessive waiting times are forced to privately insure the entire health care system or to pay for it out of their own pocket without offsetting the benefits provided by the National Health System (NHS). The class differences in outpatient medical care are therefore significantly greater in most tax-financed health systems than in Germany, where the GKV guarantees all insured people high-quality health care with a very extensive catalog of services, a moderate co-payment, free choice of doctor and short waiting times.
Regardless of the financing of the respective health systems, in almost all European countries there is an unequal distribution of practicing doctors in the outpatient sector between urban centers and structurally weak rural regions. In this respect, health policy in Germany is also faced with the task of guaranteeing citizens comprehensive medical care at an equally high level. In this context, a uniform fee schedule means that, due to regional differences in the distribution of privately insured people, with a revenue-neutral leveling of EBM and GOÄ, doctors in private practice in metropolitan areas receive lower fees and those in structurally weak areas receive higher fees. This regional redistribution of fees could counteract the migration of practicing doctors to rural areas in the spirit of the supporters of a uniform fee structure. However, this thesis overestimates the importance of fees on the location choice of practicing physicians. First of all, general practitioners and specialists in structurally weak rural areas already tend to receive not lower fees, but often higher ones than in metropolitan areas, albeit with a noticeably increased workload. In addition, as surveys show, the environment for the family, i.e. the work opportunities for the partner, the care and education opportunities for the children, the transport structure and the leisure activities, plays a decisive role in the location decisions of outpatient doctors, and only after that come financial factors . Finally, the KVs have the opportunity to financially support resident doctors in these regions with the help of security surcharges in accordance with Section 105 SGB V.
Conclusion: Uniform fee schedule with more disadvantages than advantages for the insured
In an international comparison of social health insurance systems, the GKV stands out through a unique combination of an extensive catalog of services, unlimited freedom to choose between general practitioners and specialists, short waiting times for patients, moderate co-payments and quick access to innovative treatment options. These advantages when using the desired health services also arise for those with statutory health insurance from the duality between GKV and PKV and the associated different fee schedules. Since, in contrast to the GKV, the PKV does not have any reservations about the approval of new health services by the GBA in the outpatient sector and also remunerates them higher, it takes on the role of pioneer in innovations in the overall system. As a result, the GKV comes under pressure from a political and competitive perspective, so that those insured by the GKV also indirectly benefit from the innovative flexibility of the PKV. A transition to a uniform fee schedule that would be revenue-neutral for all practicing physicians would initially bring those insured by the GKV an increase in their rates, but almost no advantages in terms of waiting times. In addition, this intervention in the existing duality of the two systems threatens to permanently jeopardize the current access options for those with statutory health insurance to the desired health services, which are almost unique in international comparison.
According to a survey by the Allensbach Institute for Demos-copy, 91% of those with private insurance and 86% of those with statutory health insurance rate health care in Germany as “good” or “very good”. 96% of those with private insurance and 85% of those with statutory health insurance expressed satisfaction with their own medical care. This extremely positive response from citizens does not exclude the fact that the German health system still offers numerous opportunities, especially at the interfaces between the service sectors, to improve the efficiency and effectiveness of care. However, the reforms required for this clearly do not include a uniform fee structure. The partly ideological debate on this topic tends to distract from the actual problems of the German healthcare system. <<