Any change in the German healthcare system that is not associated with an increase in power or money is met with the toughest resistance from those affected. The opportunities and prospects of the interlocking legislative measures are rarely recognized and appreciated. The following article analyzes the development trends since Blüm's health care reform in 1988, shows options for action at the present time and gives an outlook on future changes.

> The Reich Insurance Code (RVO) from 1911 was in force in the Federal Republic of Germany until December 31, 1988. On the one hand, this is certainly proof of the stability of the health system and social system, both in times of growth and in times of crisis. The continued validity of Wilhelmine law until almost the reunification of two states separated by the Second World War is also evidence that the system of statutory health insurance successfully resisted the need to adapt to socio-economic development for a long time. Examples of this are not only two failed health reforms during Konrad Adenauer's time. The cyclical adjustment steps of the 1970s and 1980s with an uncontrolled expansion of benefits and a fragmented cost-cutting policy also provide plenty of illustrative material. It was only Norbert Blüm and his department head Karl Jung who, with the Health Reform Act (GRG) of 1988, attempted to combine the necessary recodification of health insurance law as the heart of health care management with structural reforms that were intended to lead into a new era. Even though many - including the author - believed at the time that they were achieving a reform of the century and were rightly proud of innovative instruments - such as benefits for those in need of serious care or fixed amounts for medicines and aids - the century only lasted four years before new adjustments were necessary until the part that was deliberately excluded from Blüm's health care reform was set the course for a competitive health insurance and health system in Lahnstein by an informal grand coalition associated with the names Seehofer and Dressler.
With the Lahnstein compromise on the Health Structural Act (GSG), the old regulatory system of the statutory health insurance companies, based on a combination of allocation and choice, was unhinged and gradually replaced by a competitive regulatory system based solely on the choice of the insured. As a prerequisite for the widely opposed introduction of the freedom to choose health insurance companies, risk structure compensation across all types of health insurance companies was introduced to ensure solidarity and justice. To this day, both instruments represent the essential basis for establishing the balance between competition and solidarity in the healthcare system. On the one hand, insured persons can vote with their feet if they do not like what a health insurance company offers at the price charged. On the other hand, the risk structure equalization prevents health insurance companies from only taking care of young, wealthy, healthy insured people and shielding themselves from old, poor, sick and/or large children insured people. In the period that followed, numerous adjustment steps were taken - especially in the organization of health insurance funds and in the benefits, membership and insurance law of the statutory health insurance - which almost inevitably resulted from the basic decision for a competitive orientation in the healthcare system.
Privileges for individual types of cash registers were abolished and special systems such as the Federal Miners' Association were opened up to competition. Above all, however, the risk structure adjustment was gradually expanded into a fine-tuning instrument. However, the opponents of this compensation, who were recruited almost exclusively from those funds that paid more into the compensation than they got out, managed again and again to delay the implementation of the morbidity-oriented risk structure compensation, which was decided at the beginning of Ulla Schmidt's term of office to hesitate. Only from 2009 onwards will the health fund provide full revenue compensation and introduce direct morbidity orientation for 80 disease groups, which include all major serious and/or chronic diseases.

Between corporatism and individual contracts - the relationship between health insurance companies and service providers
The development towards more competition in the relationship between health insurance companies and service providers was less consistent. A tough struggle between corporatist and individual contractual approaches has been observed here for 20 years. In principle, this applies to all supply areas. The system of statutory health insurance associations, which was restored under Adenauer and with compulsory membership for all practicing doctors who want to treat GKV patients, is holding its own against numerous attempts to initiate more competition through individual contracts. Blüm's health care reform took a first tentative step with the introduction of model clauses and testing regulations. For a limited time and with scientific support, all provisions of service provider law in SGB V could and can be suspended through contractual agreements. But the statutory health insurance doctors kept their ranks tightly closed. Deviations were only accepted if more money was transferred. Although some local supply projects with exemplary character developed from the test regulations, these did not have a comprehensive control effect. More extensive opening clauses in statutory health insurance law were already prevented during the discussion phase by the concentrated lobbying power of practicing doctors.
This power was particularly felt by polyclinics and specialist outpatient clinics in the former GDR, which came under the influence of West German corporatism during the reunification process. Hand in hand, doctors and health insurance officials let these institutions, which had no equivalent in the West, starve to death. It was solely thanks to the tireless efforts of Regine Hildebrandt, the health minister in the last, freely elected GDR government and later health and social affairs minister of Brandenburg, that a few exotic facilities were given a temporary and limited chance of survival. It took 15 years until the Health Modernization Act (GMG) of 2003 gave medical care centers with freelance or employed medical staff a permanent basis for their existence throughout Germany. Previously condemned as a socialist devil's work, this new form of organization and business is now growing as an attractive alternative to individual or group practice. The attempt to slow down or stop the modernization of the operational organization in the outpatient sector through professional legal obstacles has been largely unsuccessful. The Contract Doctors' Law Amendment Act (VÄG) from 2006 in particular has provided significant help in increasing flexibility.
The hospital sector appears to be even more resistant to competitive contract designs. Obstructors and blockers join hands across the boundaries of political ideologies and regional references. Those who prolong the status quo can be found in state governments, local governments, unions, churches and charitable organizations. But for a long time the health insurance companies were not full of creativity as to how competition in the hospital sector could be organized. In particular, the health insurance associations, whose antiquated structure Ulla Schmidt put an end to in the GKV Competition Strengthening Act (GKV-WSG) from 2007, could hardly get used to the idea of competition in the hospital sector until the end of the old century. Due to the complex constitutional situation - the federal government is only responsible for the principles of hospital financing, the federal states are responsible for the specific investment financing and the internal organization of the hospitals - and the concentrated resistance of the hospitals and their organizations, there is still a lack of individual contractual regulations. And unfortunately it will stay that way for the time being.
In view of the huge mismanagement in the old hospital financing system through same-day care rates, the hospitals and the German Medical Association were unable to prevent the gradual introduction of a modern flat rate system per case under Andrea Fischer's health care reform in 2000, which is now becoming an export hit in other countries. However, the increased competitive pressure on the individual companies resulting from this basic decision for a performance-oriented remuneration system that provides for the same prices for the same services has not yet been able to be translated into an adequate contract system. The federal states are clinging to their hospital planning competence and the obligation to contract, as well as to dual hospital financing, which not only seems anachronistic in view of the chronic financial difficulties in the states, but has also contributed significantly to an investment backlog in many states.
In the pharmaceutical sector, too, the battle between collective and individual control approaches rages back and forth. While Norbert Blüm was allowed to introduce fixed drug prices after tough arguments with the FDP, Horst Seehofer had to restrict them again under pressure from the same party. Ulla Schmidt restored the original legal status, but also had to recognize that the reach of this control instrument is limited to certain market segments. All health ministers since Blüm have tried to counteract the dynamic development of prices, quantities and structure in the supply of pharmaceuticals with special instruments, so that today there are a large number of regulations, the effects of which partially counteract each other. It remains to be proven whether the path of individual discount agreements taken by Ulla Schmidt has the potential to replace many other regulations.
In many other care areas, the financial dimensions of which appear to be insignificant individually, but which overall cause significant expenditure that generally grows faster than income, the legislature has created scope for competitive arrangements, but these are often not used in practice restrictively limited by supervision and case law. As an example, the tender for aids or freedom of contract in the rehabilitation sector are mentioned.

Tentative attempts to overcome sector boundaries – new forms of care
Above all, the strong sectorization of the German healthcare system itself is a major cause of mismanagement and an obstacle to improving the quality of care and the efficiency of the use of resources. Attempts to counter the isolation of sectors through integrative solutions date back to the 1920s, but were always met with resistance from established institutions and often remained stuck in the experimental stage. It also proved and continues to be difficult to formulate a regulatory framework for integrated care in a structure- and sector-oriented health law. Only under Andrea Fischer was it possible to anchor integration care as a new form of standard care in SGB V. However, the participation rights of the associations of statutory health insurance physicians and statutory health insurance physicians proved to be just as counterproductive as the attempt to create a legal adjustment to the total medical remuneration and hospital budgets. Only with the GMG was a financial start-up regulation created with a flat-rate exclusion of 1 % each of the doctor's remuneration and the hospital remuneration. This broke the spell, so that thousands of integration contracts were concluded in just a few years.
Since the legislature deliberately chose not to include an evaluation regulation, a real assessment of the provision of care in a cross-sectoral area is still difficult today. It is also hardly reliable to predict how integrated care will develop under the conditions of the health fund without start-up financing. However, it is unlikely that the dynamics that have developed across sectors in the supply chain through better communication, coordination and cooperation can be slowed down. The future financing of integrative services remains on the agenda of the upcoming healthcare reform. One possible way would be to reserve a special portion of the health fund for new forms of care - if necessary as co-financing. The integration process accelerates competitive approaches in statutory health care that are not limited to this sector. So-called special forms of care such as outpatient surgery, family doctor-assisted care or special quality contracts enable individual contracts between health insurance companies and individual or groups of doctors.
Particularly when it comes to the organization of primary care, statutory health insurance associations compete with independent medical associations and associations, which exert considerable competitive pressure on established monopolists, not only in Baden-Württemberg. And the fight is tough and sometimes unfair.
The ongoing discussion about family doctor contracts in particular shows how politically ambivalent the topic of contract competition is. Only the next few years will show whether the contractual privilege for general practitioner associations, which the GKV Organizational Development Act (GKV-OrgWG) wants to grant them, is constitutionally tenable and leads to an improvement in general practitioner care.

Approaches to competitive differentiation – the link between performance and contract law
Even if some critics from science and practice believe that the intensity of competition does not go far enough, while others complain about the economization of the healthcare system, no one can avoid differentiating the healthcare landscape through individual business contracts. This differentiation will increase further under the conditions of the health fund with additional contributions. The health insurance companies will take every opportunity to use their resources more efficiently and in a more targeted manner while maintaining or improving the quality of care. This is helped by the fact that health insurance companies can combine care offers with incentives for service providers and insured persons. Numerous contracts, especially in the structured programs introduced for the care of chronically ill people (new German: Disease Management Programs - DMP), have developed different incentive systems with a uniform program orientation, which must be questioned under the new morbidity-oriented risk structure compensation.
In the future, the focus of competitive differentiation with a uniform contribution rate and an additional contribution that is to be avoided or set as low as possible, which is to be borne solely by the insured person and sends out a strong price signal, will lie in the design of the care. In this field, health insurance companies will differentiate themselves through optional tariffs and new forms of insurance-related health management such as health coaching. They are not limited to simple PKV-based models with cost reimbursement, premium refunds and deductibles, but should be designed in such a way that they offer incentives for insured persons to choose care offers based on individual preferences and health needs. The legislator hopes that this will result in a change from the focus that was previously primarily focused on the contribution rate to quality-oriented competition in which the price-performance ratio is the decisive competitive parameter. This reorientation is supported by the morbidity-oriented risk structure compensation, which requires increased efforts from the health insurance companies to care for their insured persons within the framework of the differentiated standard cost profiles. Management failures there are reflected in additional contributions.

Cooperations and mergers - The effects on organizational and operational forms
It is relatively certain that the legal changes of the last five years will lead to significant changes for insurers and suppliers. The wave of mergers among health insurance companies has already begun. This will not – as some ideologically blind journalists try to lead their readers to believe – lead to uniform insurance, but it will nevertheless significantly reduce the number of health insurance companies and force the formation of units capable of management. Only those who know how to use competitive instruments in a targeted manner in relation to their own members and their own contractual partners have a chance of survival in the health insurance competition. Those who cannot or do not want to do this must merge or close. In extreme cases, according to the GKV-OrgWG, regional health insurance companies can also become insolvent in the future. Above all, however, all health insurance companies will have to prepare their balance sheets in accordance with uniform commercial law principles in the future, so that the financial situation of a fund becomes much more transparent.
But the service provider side will also change enormously. The individual practice is likely to become an obsolete model outside of primary care and specialist primary care. Group practices and, above all, medical care centers are likely to increase their market share significantly. This is clearly indicated by the activities of the National Association of Statutory Health Insurance Physicians to create their own sponsoring companies and the expansion plans of private hospital chains. Integrated healthcare companies are not only being intensively discussed in the scientific community and in the consulting world. Innovative forces are working on it.
The hospital market will also change noticeably. The number of houses and beds has been declining for years, even though Germany still ranks among the leaders in terms of bed density and length of stay. More and more public houses are being sold to private owners or management is being placed in private hands. Without hospital investment financing reform, this trend will accelerate. In general, mergers and collaborations ensure a better coordinated range of hospital services. The different possibilities for hospitals to open up to the outpatient area are by no means being used to the extent that the legislator imagines. This is also due to the fact that in most federal states the possibility of opening up for rare diseases or highly specialized services created with the GKV-WSG is handled restrictively. The opening up of hospitals through individual contracts with the health insurance companies is a good example of how it is not enough to create competitive scope for the players. Under the current organizational and financing conditions, the mere possibility of competitive differentiation is not sufficient. Sometimes the legislature has to force contracting parties to be happy. Above all, the legislature must set the economic incentives in such a way that it is advantageous for both contracting parties.

After the reform is before the reform - the continuation of the reform path
“After the reform is before the reform!” is an irrefutable principle of health policy. In 2009, all parties will once again prepare for the health policy discussion in the 2009 federal election campaign and in practical politics from 2010 onwards. The fundamental path of a competitive orientation in the healthcare system based on quality and efficiency is unlikely to be abandoned. It is true that quite a few players in the healthcare system and some political leaders dream of returning to the good old days, when resource limitations were not noticed or did not force painful adjustments. But the "mainstream" health policy will continue on the path it has taken - with noticeable differences between the individual parties. There is enough to do.

From corporatist control to individual economic competition
The relationship between corporatist control and individual economic competition must be shifted in favor of individual economic contractual options. This applies to both the outpatient and inpatient areas. The possibility of concluding individual contracts with doctors or groups of doctors should not be limited to special forms of care. In inpatient care, selective contraction should be possible for elective procedures. This entry could gradually lead to a contract model under the conditions of monistic hospital financing. The number and content of regulatory interventions in the supply of pharmaceuticals must be significantly reduced in favor of fewer but more effective control instruments, taking into account that the pharmaceutical industry will hardly develop any new blockbusters, but will instead concentrate on extremely high-priced special preparations and individualized drug therapy is foreseeable .
In order to intensify the competition between outpatients and inpatients, the field of which is becoming larger in view of the medical and technical possibilities, fair competitive conditions must be created for both sides. This includes comparable remuneration for comparable medical services, taking into account investment financing and maintenance costs and, above all, a reform of requirements planning in both sectors. Requirements planning in particular offers the opportunity to overcome these sector boundaries and increase the effectiveness of planning. To do this, bed- or doctor-specific planning would have to be dispensed with, which has so far prevented neither under- nor over-supply. Rather, requirements planning could be reduced to an indicator-based, integrative framework planning, the design of which is left to the free contracting of health insurance companies and service providers. The state should only come into play when the indicators provide indications of (threatening) undersupply or when an extremely uneconomic oversupply is not reduced. However, this presupposes that the supervisory authorities in the federal states are equipped in terms of content and personnel in such a way that they can fulfill this task - if necessary with the obligation to contract. The right of the insured to be able to make use of non-contractual partners should also exert beneficial pressure on the health insurance companies.

From structural description to process control
Overall, health law needs to be changed more from structural description to process orientation. In particular, the quality of results, which has so far played a rather subordinate role in quality assurance and quality management, must be given greater focus in regulation and contract policy. The cross-sector quality assurance introduced with the GKV-WSG is an important first step towards this. More must follow.

On the importance of competition and antitrust law
The question of how far a more competitive healthcare system should be subject to the limits of general competition and antitrust law must be intensively discussed. There must undoubtedly be regulation to ensure fair competition. However, the special features of comprehensive care and provider dominance in the healthcare system must be taken into account. So it seems more than strange that a merger of hospitals that was necessary for health care policy reasons was stopped by the Federal Cartel Office and only became possible through ministerial approval based on research aspects. It should also be taken into account that the intensification of competition should, in addition to improving quality, bring more efficiency in the healthcare system. Ultimately, comprehensive care must be guaranteed within a reasonable distance of all insured persons. The goal of competition in healthcare is not to protect existing provider structures or to maximize revenue. With the GKV-OrgWG, further parts of competition and antitrust law are declared applicable in social law, without ignoring the special features of the healthcare market.

On the convergence of GKV and PKV
In the medium to longer term, the convergence of statutory and private health insurance will raise these and other questions. The crisis on the international and national financial market has made mantra-like calls to convert the statutory health insurance to capital coverage quieter. Even within the private health insurance landscape, there are increasing numbers of voices questioning the extension of the status quo. Apart from the fact that it is not socially justifiable to only give certain groups access to private health insurance and to concentrate social burdens in statutory health insurance alone, the increasing cost pressure (in private health insurance premiums rise around twice as fast as contributions in statutory health insurance). ) encourage the insurance industry to assess harmonization with the aim of creating a uniform regulatory framework for statutory health insurance and private health insurance more positively than it does today.
Related to this is the question of the future financing of health services. In the next legislative period, it will be discussed again whether fixing the GKV contributions on wages and salaries or their replacement is future-oriented. It remains to be questioned whether contributing other income is the best way to broaden income and create greater equity in burdens. The alternative in the form of higher tax subsidies for health insurance is likely to remain in the running.

Best practice in system comparison
Finally, before the next reform, a look beyond Germany's borders might be helpful. The focus should be particularly on the experiences of the Dutch with their reorganization of the insurance landscape and financing. But the experiences of the Scandinavian countries, which have achieved a high degree of integration in health care, should also stimulate the discussion in Germany. National strategies will find their limits, especially in the pharmaceutical supply sector, where multinational manufacturers dominate the supply. Even a large German treasury is unlikely to mean an equal negotiating partner for a global corporation. Transnational solutions are therefore an option, as is looking at other countries, especially Switzerland, France or Great Britain, where the pharmaceutical industry also plays a major economic role. After all, visits to the USA and discussions with the experts there are always worthwhile. This does not affect the control panel as a whole at the macro level. The focus here is on fine-tuning instruments, which, following the managed care “backslash” in the 1990s, have condensed into a differentiated and increasingly effective management philosophy.

Conclusion
When the gun smoke settles around the current health care reform and the fund in Germany, you can see that the health care reforms of the last few years have paved the way for a consistent competitive orientation in the health care system without calling into question the solidary structure of the system. However, the transformation process is by no means complete. On the one hand, regulation in the healthcare sector is always sensitive to strategy. On the other hand, competitive incentives are completely lacking in the individual supply sectors or are fraught with obstacles. The requirement to establish integration care as standard care has not yet been met. To this end, new incentives must be discussed, such as a separate R + D pot in the health fund. Planning and financing structures must be aligned with integration goals and made less bureaucratic. The focus of regulations and agreements must be on insured people and patients, who can influence the management of the healthcare system in all areas through voting decisions and participation. The course towards competition is irreversible, although it can be designed in different ways. Only those who develop their own activities in this competition will benefit from this path in the long term. <<