>> The federal government had hoped for calm within the medical profession in the election year. The reform of doctors' fees that came into force at the beginning of the year meets many of the demands that doctors had been advocating for years: the alignment of doctors' fees in the East with those in the West, the introduction of fixed prices for doctor's services and the consideration of the increasing proportion of older people Patients in fee negotiations with health insurance companies. In addition, the nationwide fee amount increased by ten percent within just two years.

Nevertheless, particularly in southern Germany, Schleswig-Holstein and North Rhine-Westphalia, many doctors are taking to the barricades. Because the reform not only creates winners, but also losers. There is a lot of redistribution within the medical profession. From West to East, within the West from richer to poorer regions and also between the different specialist groups.

There are good arguments for the changed financial flows. Why should a doctor in a region with high unemployment be paid less than his colleague in a wealthy federal state? And the previous differences in fees between the specialist groups often had more historical than factual reasons.

Against this background, one should not hastily declare the fee reform a failure. Whether the new system actually leads to greater fairness in fees will probably only be determined next year. Until then, the National Association of Statutory Health Insurance Funds and the National Association of Statutory Health Insurance Physicians will have to use their leeway to avoid excessive hardship.

However, the federal government can be blamed for introducing the new fee system overnight. A longer adjustment period would have been absolutely necessary. The introduction of the per-case flat rate system in hospitals could have been a model for this. But another omission is almost even more serious. It can be seen that the “new fee world” is no longer fresh. The controversy over them began in the 1990s. Since then, however, a paradigm shift has taken place in the international discussion about physician remuneration. The question of how remuneration and treatment success can be linked is playing an increasingly important role. However, this aspect is not taken into account in the fee reform. It further conveys the illusion that there are no differences in quality between doctors.

“Pay-for-performance” systems (P4P) have now achieved considerable importance internationally. Since 2004, British general practitioners have only received around 20 to 30 percent of their fees if they adhere to certain quality standards and guidelines. In the United States, about half of state Medicaid programs also include P4P components. An increase to 85 percent is expected over the next five years.

In Germany, the AOK Baden-Württemberg concluded a nine-year integration agreement with the medical network “Gesundes Kinzigtal GmbH” in 2006, in which the health gain for those insured by the AOK there is measured in comparison to the total population. The doctors' fees are calculated depending on the improvement in health achieved. Additional fees for carrying out early detection examinations or for good treatment results are also provided for in general practitioner and pilot contracts from various other health insurance companies and the chronic care programs. All in all, P4P in Germany has not yet gone beyond regional and indication-specific approaches. The federal government could have provided important impetus for accelerated further development with the fee reform. Unfortunately, she missed this opportunity. She obviously lacked the ability to assert herself against the vested interests in the medical profession and their stakeholders in the coalition.

This means that the expansion of P4P in Germany will only progress slowly in the next few years. However, given the increasing importance of selective contracts and the considerable interest in P4P among health insurance companies and innovative parts of the medical profession, the trend cannot be stopped in the medium term. This creates an extremely important field for health services research. And all the more so because research results abroad cannot simply be transferred to Germany. The healthcare systems and the expectations of patients are too different for this. What is meant by treatment success? How can it be measured? How can P4P be prevented from discriminating against seriously ill patients? Answering these and other important questions is also on the agenda for federal research funding. <<