>> Mr Mehl, what are the signs in your opinion that the fee reform has misdirected functions?
For me, these are neither protests nor public debates, but facts. The rather mediocre remuneration of doctors for years has produced a dramatic shortage of young primary care physicians for more than ten years. This is not propaganda, but is verifiable as evidence-based graduation figures for specialists in general medicine and specialists in internal and general medicine: depending on the state regulations, the graduation figures are continuing to decline. Furthermore, a large proportion of doctors with further training are not going into primary care as they used to, but are choosing careers that are safer and also better paid. One cannot blame young doctors for no longer seeing any economic incentives to pursue a career as a general practitioner.

In addition, the already high age structure of general practitioners is leading to a high rate of departure from this profession and will lead to an even higher rate in the future.
It is certainly a serious problem that there are already more doctors retiring than young doctors willing to take on these vacant positions. This is particularly the case in rural or structurally weaker areas. The fact that there will be fewer doctors in the future than today is a trend that is already visible today, but this is only one side of the coin. The other, but far more serious, is the increasing density of morbidity in general practice. This is a result simply of the fact that, due to the effects of the changing age pyramid, there are more and more older people and, thanks to the blessings of modern medicine, they can be treated successfully for much longer than before, despite the equally increasing incidence of chronic illness. But this also means that these people are in a constant process of treatment, which is largely handled by the general practitioner.

Is it still being processed?
Sure. Just look at how full the waiting rooms already are. But they also contain many patients who are being discharged from the hospital in a much worse state of care than before.

The so-called bloody dismissal.
This isn't just a rumor; many members of our association confirm this. The reduction in hospital stays due to the introduction of the DRG system in hospitals will lead to a significant tightening of the burden on physicians' practices and thus on the entire healthcare system.

Are there any figures on this? This would be a viable approach for health services research based on the facts and figures collected by general practitioners – perhaps in the form of discharge registers. This would allow general practitioners to not only assert, but also prove, the systematic shift from hospital to primary care.
So far, we have received testimony from hundreds, even thousands, of primary care physicians who describe their current experiences of daily care in a completely unscientific and unstructured manner. We would have to translate this into an evidence-based study format in collaboration with a health insurance provider, because the hospitals would naturally claim that the discharges took place at a medically appropriate time. Whatever that might mean.

The interest of the family doctor and the health insurance fund must be to improve the quality of care, which brings us to the family doctor-centered contracts, which - according to Thomas Ballast of the Association of Statutory Health Insurance Funds (vdek) - will result in billions of euros in additional expenditure for the system, even though the aim should actually be to improve quality.
I believe Thomas Ballast is pursuing a very short-sighted policy. The situation is actually quite different: Currently, general practitioners in private practice treat around 80 percent of all problems that patients encounter – based on the number of cases. The more serious cases naturally end up in hospitals or even university clinics, where they belong. We will face a serious supply and budget problem when general practitioners can no longer manage normal multimorbidity because there simply aren't enough of them. The effect will be that some of the cases previously treated in the general practitioner system will be treated by specialists, but mostly as inpatients. But this will inevitably lead to a less economical outcome than before, because care in other sectors is simply more expensive.

But maybe better for that?
I doubt that. Take Berlin as a healthcare location, which has the highest self-admission rate in all of Europe. However, there is no greater need to go to the hospital there than anywhere else in Germany or Europe. This is simply part of a healthcare culture that developed in former West Berlin and has persisted to this day. Berlin's island location has led to an extremely high hospital density, which is also used accordingly. This, in turn, means that the highest healthcare costs in Germany are concentrated in Berlin, even though neither morbidity nor public health in Berlin are better or worse than in Munich or Cologne.

The simple system: more doctors, more costs, more hospitals, even more costs?
The higher the structural level, the more significant the increase in total costs, especially in diagnostic costs.

Then general practitioners would first have to prove that their profession not only plays an important role in the overall healthcare structure, but is also the more cost-effective alternative for providing quality care to the German population.
That would certainly be provable. But one could almost as well use the number of bypass surgeries. If more cardiologists are active, the number of cardiological diagnostics automatically increases without changing morbidity. In Italy, with the same morbidity, this results in around 50 interventions, but in Germany it results in 150 interventions, which doesn't improve the quality of care, but only increases costs.

This is called classic malpractice.
Sure. But even over-provision is often declared to be high-quality, which it isn't. Adequate care is always right. And for that, we need, above all, dedicated, well-trained physicians in primary care who can assess the progression of a disease and know when the patient needs to be transferred to the next level of care.

Regarding committed physicians, do you think the fee system actually encourages physician commitment?
Anyone looking at the KBV's income statistics will likely come to a different conclusion. General practitioners and pediatricians, and sometimes neurologists, always rank at the bottom. They are followed at the lower income level by almost all patient-related disciplines, even if they are specialists. But at the top of the list are always laboratory physicians and radiologists—essentially specialists who work in the industrial sector and who, due to their structure, can handle a high volume of patients.

A kind of Taylorism?
You could say that. Patient-focused disciplines are gradually being devalued by Germany's fee structure, because services that can be provided industrially are valued more highly than patient care. This also plays a role in a young doctor's career choice. But all of this has nothing to do with the current fee debate; it's a development of the past few years, during which a high level of frustration with the statutory health insurance associations has built up among the German medical profession.

Which, in turn, has made your association such a large interest group.
We are by far the most successful advocacy group in the German healthcare system in the private practice sector. However, we must also mention the Marburger Bund, which fought a similar fee phenomenon for employed physicians. This is also reflected in the numbers: While we had just under 20,000 members eight years ago, we now have 34,000 members – and that's with a retirement rate of around 700 physicians per year.

According to the Federal Ministry, the medical care system will receive 2.9 billion euros this year. Where did that go?
The German Association of General Practitioners (GDP) had previously voiced strong criticism of the fee schedule reform, which unfortunately was fully implemented. Due to the intended structural effect, a large portion of the additional funding flowed to eastern Germany.

What is wrong?
That's not really the case. In the East, we're already experiencing the same situation that still lies ahead in the Western states: There's still adequate care in the cities, but in rural areas, around two-thirds of the practices vacated by general practitioners are no longer available for young doctors.

There could be MVZs of a hospital or an economically oriented provider that fill this gap.
It could. But why would a large hospital operator open a medical care center in rural or structurally weak areas? In our opinion, it's not that easy to implement an economically sound model. However, a commercially viable model could well be one where a hospital operator's medical care center has, let's say, a specific assignment in its mandate. Although there is a very heated professional debate in the private practice sector, our association does not share the view that medical care centers are always the devil's work.

Why?
It may be that, for example, a general practitioner's medical care center (MVZ) makes absolute sense in terms of working time models and employment relationships. Young female doctors in particular—and based on the graduation rate in the field, medicine is increasingly female—can no longer be easily integrated into established individual practices, but they can be integrated into new care structures. Thus, both MVZs and employment relationships within practices could have a structurally improving effect. It is, of course, critical if MVZs only serve to direct patients to specific hospitals. That would then be a kind of continuous flow heater. Such MVZs are destroying the German healthcare structure.

What problems would need to be solved with a new fee system?
First, the underfunding must be addressed, as even the additional €2.9 billion in the system is not enough. Second, the high administrative burden must be eliminated and greater reliability in remuneration must be ensured.

That is why there is the Euro Fee Schedule EBM 2009.
This ultimately creates false incentives for care through false generalisation on the one hand and frequency-dependent individual services on the other.

Could you please explain this with an example?
Take sonography, which is now a standard component of primary care. If sonography is included in the flat-rate fee, it makes no economic sense to purchase a sonography machine, because the flat rate remains the same whether I use sonography or not. It would make more sense to supplement the basic flat rate with quality surcharges. This is exactly what AOK-Württemberg was the first health insurance company to attempt.

Thomas Ballast from the vdek now says that this will make the system more expensive.
If, to stick with the example, sonography is paid for based on frequency, as in the EBM, that will also be correct. That doesn't make sense either, because it would always lead to overdiagnosis. It makes far more sense to pay the doctor a surcharge for each insured person enrolled, provided that the doctor proves that they can perform sonography correctly and also submits to quality assurance. Therefore, incentives are necessary to ensure that a service is only provided when it is actually medically necessary. The doctor should not and must not be economically compelled to perform sonography or acupuncture or whatever on everyone who walks through the practice door.

The patient no longer has to do this under the general practitioner contract; the doctor gets his fee either way.
This is also the major difference to the EBM. The doctor, mind you, only receives a basic fee. For the flat-rate group P1, there is an annual flat rate, regardless of whether the registered patient visits their doctor or not. P2 is the contact flat rate, which is not charged for the first quarterly contact, but only depending on the contact starting in the second quarter when a patient visits a practice. And P3 is an additional flat rate for chronic care, which per se is particularly intensive and therefore must be well remunerated.

Where is the economic, but also qualitative, incentive of this system, which the EBM will only introduce in a similar, at least qualitative, form from 2010?
The economic aspect is also the qualitative one. It will be beneficial for the doctor to keep relatively healthy patients out of the practice, because they receive payment through the basic flat rate P1, whether they come or not – even if the patient has a quarterly visit, the amount of remuneration does not change. This is a fundamental difference from the previous EBM: Until January 1 of this year, it was economically important for the doctor that every patient came to the practice every quarter, whether it made therapeutic sense or not. This is precisely why we have such a high doctor-patient contact density in Germany.

That's 13, or even 18 doctor-patient contacts per year according to GEK. Statistically speaking.
This is uniquely high worldwide. Yet every doctor-patient contact also triggers a cash flow. Typically, this is partly the doctor's fee. However, since the patient is already in the practice and has a treatment expectation, the frequency of prescriptions also increases.

Interestingly, the high doctor-patient contact density seems to have no influence on mortality at all.
None at all. The Dutch have about half the doctor-patient interactions we do. No one dies a minute earlier than the rest of us.

So get the “healthy” people out of the practice.
This is the stated goal of the three-tiered flat rate. The previous economic incentive system within physician fees was clearly misguided.

This will also lead to a kind of de-economization, as can be seen in pharmacy dispensing prices and in the wholesale flat rates in the upcoming 15th amendment to the German Medicinal Products Act (AMG). Is this the system of the future: Eliminating the pressure of having to constantly supply patients?
This only applies to healthy or relatively healthy patients for whom a visit to the doctor is actually not advisable and who - if we take the development in general practitioners' practices described above - will no longer be able to be treated in the future.

Doctors should actually be happy if they can now care for those who need them.
Actually, yes. You just have to tell them what opportunities this presents. In the future, the patient who had and still has the greatest need for treatment will be the most valuable: the chronic patient.

Will this also help improve public health?
That's what will happen. In the future, doctors will simply have more time to care for chronic patients in their practices. This is urgently needed, because morbidity in general practice is constantly increasing. Just take the prevalence of diabetes at 7 to 8 percent and that of asthma at 5 to 6 percent. And the trend is rising. This also means that there will be more and more chronic patients in practice who have both. But these are patients who really need a lot of time to treat. The doctor gets this time through the other economic incentive system.

Hopefully this will also lead to better quality of care in Germany?
To make this a reality, quality targets are agreed upon in the GP contracts with the health insurance company. While they're still in the early stages, two targets have already been agreed upon: the checkup rate and the vaccination rate. For the doctors, this means they can earn additional, substantial income if their vaccination rate meets WHO standards.

And there is an article in the news magazine “Spiegel” that suggests that vaccination can also be harmful.
Of course, there are side effects. But it's clearly proven that vaccination saves lives. I also believe that a high vaccination rate makes a lot of sense from a health policy perspective. Let's just take the current situation with swine flu. From a virological perspective, it's completely irrelevant when you consider that in Germany alone, we have 10,000 to 30,000 flu deaths per year. Vaccination saves lives in a very real way. Especially those of chronic patients. After all, it's not healthy 35-year-olds who die from the flu, but rather multimorbid chronic patients aged 60 and over.

So here too, better quality of care is achieved through other economic incentives?
This is the basic idea that is truly improving the quality of care in Germany. The vaccination rate has increased by 30 percent in the last three to four years. This is a success story.

Doctors would then be strongly advised to define more of these quality indicators for public health or for indications themselves, rather than allowing the health insurance companies to dictate how they view these quality indicators.
Absolutely right. However, one shouldn't base everything on indicators; instead, one should simply set priorities. For example, one could introduce a home visit quota, because the number of home visits has dropped dramatically. However, this would be absolutely sensible, especially for people with chronic conditions or older people.

This is where the new VERsorgungs-Assistent (care assistant) in the general practice, VERAH for short, comes into play, which is intended to contribute to the qualification of the general practice.
Through 200 hours of further training, the experienced medical assistant is enabled to carry out home visits on her own.

A kind of “doctor light”?
More of a physician-oriented case management approach. With VERAH, there are still clear responsibilities regarding who is responsible for the patient: that is and remains the primary care physician. However, with VERAH, the primary care physician can assign a well-trained staff member specifically to specific problems, which can also be seen as a bridge to greater patient proximity. With the higher chronic care surcharge, the physician can also use this VERAH in a cost-effective manner, of course also to better manage the morbidity density in their practice. But the goal must always be higher quality of care.

Ultimately, this is also an alternative concept to the patient coaching model of health insurance companies.
This often doesn't work because it bypasses the doctor. The system originates from the USA, which has a completely different healthcare structure than Germany. One reason is the health insurance company's approval requirement, which we don't have here. This means: In America, a call center agent calls a patient, follows their classic triage program, and recommends a specific medication. The American patient can act accordingly, but the German patient cannot. They will first see their doctor, who will prescribe a completely different medication if in doubt. This leads to information chaos, uncertainty, and exacerbates the already serious compliance problem. Instead of trying to establish case management that bypasses established structures, we need new interfaces with clear responsibilities.

Even if the will itself is good.
I'm not saying the programs are bad. It's just that programs that work perfectly at Kaiser Permanente in California don't necessarily work here in Germany. This also applies to a guideline developed in the Netherlands, which may work here, but doesn't necessarily have to. Rather, it depends on how a care program is integrated into established care processes. But health insurance companies often make this mistake under the influence of global management consultancies.

Behind all this there appears to be a concern for supply policy, which, if one believes the media, is being sacrificed to the economy.
It's wrong to portray doctors as rip-off artists. Of course, the medical profession wants and needs more budget, but it should then be used in a way that achieves healthcare goals that have not yet been achieved in Germany. Whether that's vaccination rates, checkup rates, or even better care for chronic patients, all of this has a direct impact on public health. But all of this has so far also failed in German healthcare policy—especially by those responsible at the top association level—in a way that is truly embarrassing.

It is a shame what we achieve with the amount of money we spend on healthcare in Germany compared to many other countries.
But I don't want to say that we've identified all the problems or solved them all with the family doctor contract. Far from it. Perhaps that's also because we don't yet have health care research in Germany that would clearly reveal the shortcomings, but also the good approaches. Essentially, we're flying blind with the €300 to €400 billion project known as the German healthcare system. That should be changed as soon as possible, and doctors will play their part in that.

The interview was conducted by MVF publisher Prof. Dr Reinhold Roski and MVF editor-in-chief Peter Stegmaier