¹ For Patients’ Rights, A Quiet Fadeaway. Amy Goldstein, WASHINGTON POST, Sept. 12, 2003, At A4.Google Scholar

² “Patients’ Rights Bills … have unintended consequences because they deal with the effects, rather than the underlying causes, of the system's failure. … what many americans don't realize is that our employment-based health care system is entirely voluntary. … the fundamental problem is that it is impossible to regulate a strictly voluntary system. attempts to do so lead to the paradox of less rather than more coverage. … the answer is a single-payer system that covers everyone and more efficiently uses the resources we allocate to health care.” Martha Angell, A Wrong Turn On Patients’ Rights, N.Y. TIMES, June 23, 2001, At A13.Google Scholar

Cite as: Ursula Weide, Law and the German Universal Healthcare System: A Contemporary Overview, in: 6 German Law Journal 1143 (2005), at: www.germanlawjournal.com/pdf/Vol06No08/PDF_Vol_06_No_08_1143-1172_Developments_Weide.pdf Google Scholar

³ Sozialgesetzbuch Fünftes Buch, SGB V (Title Five, Social Code), “The Health Care Reform Act” (Gesundheitsreformgesetz, GRG), Adopted In 1988 (Hereinafter SGB V). The Social Code today consists of 11 titles which include job pPlacement, Retraining And Unemployment Benefits (Title Iii: Arbeitsförderung), Social Security (Title Vi: Gesetzliche Rentenversicherung), Workers Compensation (Title Vii: Gesetzliche Unfallversicherung), and Longterm Care Insurance (Title Xi: Soziale Pflegeversicherung).Google Scholar

⁴ The Court Is Located In Kassel, In The State Of Hesse.Google Scholar

⁵ In the present article, comparative German-American comments are mostly limited to the footnotes. For a comprehensive discussion of comparative German and American Health Care Law, see already Ursula Weide, Coverage And Medical Necessity Determinations: U.S. Managed Care Treatment Decisions Vs. German Administrative Rulemaking, 8 Ilsa Journal of International and Comparative Law 508 (2002); id., Health Care Reform and the Changing Standard of Care in the United States and Germany, In: 20 Journal Of International And Comparative Law 249 (2000); id., A Comparison of American and German Cost Containment in Health Care: Tort Liability of U.S. Managed Care Organizations vs. German Health Care Reform Legislation, 13 Tulane European And Civil Law Forum 47 (1998).Google Scholar

⁶ This section is based on Heinz Lampert, Lehrbuch der Sozialpolitik [Compendium Of Social Policy] 1998 [Hereinafter Lampert].Google Scholar

⁷ This section is based on Michael Freund, Deutsche Geschichte [German History] 811 (1974).Google Scholar

⁸ Id., 813.Google Scholar

⁹ Krankenversicherungsgesetz.Google Scholar

¹⁰ Bundestag.Google Scholar

¹¹ Sozialgesetzbuch Fünftes Buch. Gesundheitsreformgesetz (Grg). BGBl. I 2477 (Dec. 20, 1988).Google Scholar

¹² Gesundheitsstrukturgesetz (GSG), published in BGBl. (Federal Gazette) I 2266 (Dec. 21, 1992). Neuordnungsgesetz I Und Ii (Nog I, BGBl. 1518; Nog Ii, BGBl. 1520, June 23, 1997). Gkv-Gesundheitsreformgesetz 2000. BGBl. I 2626 (Dec. 22, 1999). Gkv-Modernisierungsgesetz (Gmg) 2004. BGBl. I 2190 (Nov. 14, 2003).Google Scholar

¹³ Grundgesetz [Bacis Law] Art. 20(1) (May 23, 1949). “Die Bundesrepublik Ist Ein Demokratischer Und Sozialer Bundesstaat.” [The Federal Republic of Germany is a parliamentary democracy].Google Scholar

¹⁴ Sozialstaat. English translation provided by Robert Gerald Livingston in: P.R. Range & R.G. Livingston, The German Welfare Model That Still Is, Wash. Post, Aug. 11, 1997, At C2.Google Scholar

¹⁵ Eberle, Gudrun, Die Entwicklung der GKV zum heutigen Stand [The History Of The Statutory Health Care System], 47 Sozialer Fortschritt 53 (1998).Google Scholar

¹⁶ Decision of the Federal Administrative Court (Bundesverwaltungsgericht) of 24 June 1954, published in BVerwGE, Vol 78, 159 [161], June 24, 1954. Decision of the Federal Constitutional Court (Bundesverfassungsgericht) of 18 June 1975, published in BVerfGE 15, 121 [133].Google Scholar

¹⁷ BVerfGE 7, 187 [228], of 21 June 21 1977.Google Scholar

¹⁸ Deutsch, Erwin, Ärztliche Berufspflichten Im Konfliktfeld Zwischen Artzhaftung And Sozialrecht [Conflicts Between Medical Liability And Social Law: Physicians’ Professional Duties], Richterwoche, Bundessozialgericht (1996).Google Scholar

¹⁹ Solidarität, Subsidiarität, Selbstverwaltung. This section is based on Lampert, supra note 6.Google Scholar

²⁰ Genossenschaften Und Körperschaften (Associations, Cooperatives, Corporate Entities Under Public Law) are both terms used in Otto Von Gierke, Die Genossenschaftstheorie und die Deutsche Rechtsprechung [The Law of Associations and German Jurisprudence] (Weidmann, 3. Nachdruck der Ausgabe Berlin 1887) (Third Reprint Of The Edition Of 1887). These concepts have survived several consecutive systems of government and are the foundation of the public system of self-governance of the federal republic.Google Scholar

²¹ For an in-depth discussion of the influence of individualism in the United States and communitarianism in germany on the respective contemporary legal systems and the resulting differing approaches to health care, See Weide (Note 5), 47 Tulane European And Civil Law Forum 94-104.Google Scholar

²² 277 U.S. 438 (1928)Google Scholar

²³ Prof. Dr. Jürgen Wasem, Sozialpolitische Grundlagen der gesetzlichen Krankenversicherung (Social-Political Foundations of the Universal Health Care System), in: Handbuch des Sozialversicherungsrechts 90, Vol. 1, [Handbook Of Social Insurance Law] (Bertram Schulin, Ed., 1994).Google Scholar

²⁴ The common german term is “patient“ since most of the population receives cradle-to-grave coverage by the statutory health care system, making everyone a patient as of the first day of life. the term is used in this article interchangeably with “members, insured, subscribers.”Google Scholar

²⁵ Krankenkassen.Google Scholar

²⁶ SGB V, Art. 1) Sozialgesetzbuch – Fünftes Buch (SGB V). BGBl. 2477, 20 December 1988.Google Scholar

²⁷ Pflichtversicherungsgrenze. In 2005, membership is mandatory up to an annual income of the insured of $46,800 euro ($57,000 at $1.22 per euro). benefits for dependents are included.Google Scholar

²⁸ The universal health care revenue surplus of 2004 and 2005 prompted the minister of health to call on the sickness funds to lower their premiums. A 13.3% average is expected for 2005. Hartz-Reform sichert krankenkassen überschuß (Hartz-Reform provides surplus for sickness funds). Frankfurter Allgemeine Zeitung, 3 June, 2005, at 13. By law, sickness funds are required to return surplusses to the insured by lowering rates.Google Scholar

²⁹ Beitragsbemessungsgrenze. For 2005, it was set at 42,300 euro ($51,600 at an exchange rate of $1.22 per euro).Google Scholar

³⁰ SGB V, Art. 3)Google Scholar

³¹ As of 2006, members will be assessed an additional 5%, resulting in a 55/45% split.Google Scholar

³² Subsidiarity is also an important principle of the european union, leaving as many tasks as possible to localities, regions and individual states, while the eu itself is focussed on economic integration and the harmonization of legislation.Google Scholar

³³ All association members are elected according to the democratic process.Google Scholar

³⁴ So far, this has remained hypothetical.Google Scholar

³⁵ Körperschaften des öffentlichen Rechts. Von Gierke's historical concept of “associations” was recognized under public law which endows them with normative functions. Other examples are municipalities and counties. See also, supra, note 20.Google Scholar

³⁶ Sgb V, Art. 77(5)Google Scholar

³⁷ Id., Art. 4(1), (4)Google Scholar

³⁸ Id. Art. 72(2) Sicherstellungsauftrag. SGBV, Art. 72. This concept has been the subject of heated public debate for several years as some have suggested to limit the mandate of adequate health care delivery to the sickness funds. This would provide them with bargaining power similar to managed care companies in the united states and eliminate most of physician influence.Google Scholar

³⁹ Id. Art. 2Google Scholar

⁴⁰ Kein Wunder (No Miracle Yet). Frankfurter Allgemeine Zeitung, 21 August 2004, at 1.Google Scholar

⁴¹ Leistungserbringerrecht, Vertragsarztrecht. Sgb V, Chapter Four (Health Care Delivery), Arts. 69-140.Google Scholar

⁴² Id. Relationships between sickness funds and physicians, dentists and psychotherapists (Arts. 72-76); hospitals (arts. 107-114); providers of adjunct and alternative therapies (Arts. 124-125); providers of personal and home health equipment (arts. 126-128); pharmacists and pharmaceutical manufacturers (Arts. 129-131); other providers (household help; home care; social therapy; patient transportation; midwives, Arts. 132-134). Chapter four also covers the system of self-governance (associations, contracts between associations, compensation), Arts. 77-94.Google Scholar

⁴³ Leistungsrecht. Id., Chapter Three (Coverage), Arts. 1-65. Medical care must reflect the current standard of care and the progress of medical science. Arts. 28, 2(1).Google Scholar

⁴⁴ Bundesmantelvertrag. Id., Arts. 82- 83.Google Scholar

⁴⁵ Hermann Plagemann, Vertragsarztrecht – Psychotherapeutengesetz 33 [SGB V: Health Care Delivery – SGB V Plan Physician Sections – SGB V Psychotherapy Sections] (1998).Google Scholar

⁴⁶ Decision of the Bundessozialgericht (Federal Social Court) of 5 May 1988, published in BSGE 81, 73 (May 5, 1988).Google Scholar

⁴⁷ Gesamtverträge. SGB V, Arts. 82, 83.Google Scholar

⁴⁸ If the United States were to introduce a universal system of health care in order to remedy the deficiencies of the current system, medicare would provide an excellent model. “The answer is a single-payer system… that is tantamount to extending medicare to all americans. Medicare is not perfect, but it provides a uniform set of benefits to nearly everyone who qualifies, and it does so much more efficiently than the private employment-based system.” Martha Angell, A wrong turn on patients’ rights, N.Y. Times, 23 June 2001, at A13.Google Scholar

⁴⁹ SGB V, Art. 112.Google Scholar

⁵⁰ Gesamtvergütung. Id., Art. 85.Google Scholar

⁵¹ SGB V, Art. 92. Kopfpauschale. Compensation for standard care is a flat fee per patient per quarter.Google Scholar

⁵² Honorarverteilungsmaßstab (Hvm – Unterschiedlicher Verteilungspunktwert Nach Facharztgruppe). Sgb V, Art. 85(4).Google Scholar

⁵³ Arzneimittelbudget. SGB V, Art. 84.Google Scholar

⁵⁴ Gemeinsamer Bundesausschuss. SGB V, Art. 91. Originally, the term denoted several committees, individually responsible for ambulatory care physicians, dentists, and hospitals. all were composed of representatives of the respective federal specialty associations and the sickness fund associations. The health care reform bill of 2004 (the GMG) merged all of these into one committee under one chairmanship, with uniform rules of procedure and independent funding.Google Scholar

⁵⁵ Richtlinien der Bundesausschüsse. SGB V, Art. 92.Google Scholar

⁵⁶ Established in id., Art. 91.Google Scholar

⁵⁷ For a comparison with benefit and medical necessity determination procedures by managed care organizations, see Weide, Coverage And Medical Necessity Determinations: U.S. Managed Care Treatment Decisions Vs. German Administrative Rulemaking, 8 Ilsa Journal Of International And Comparative Law 508 (2002), at 514, 556.Google Scholar

⁵⁸ SGV, Arts. 135-139. Arts. 137-137(c) cover the quality control of hospitals and hospital care.Google Scholar

⁵⁹ This is comparable to the evaluation of what managed care organizations would consider “experimental treatments.” Sickness funds, however, do cover many treatments and procedures considered “experimental” by managed care standards. Furthermore, in contrast with the german notice and comment administrative rulemaking procedure, managed care organizations often make coverage decisions behind closed doors, according to in-house “proprietary” criteria. See Weide, Health Care Reform and the Changing Standard of Care in the United States and Germany, In: 20 Journal Of International And Comparative Law 249 (2000).Google Scholar

⁶⁰ SGB V, Art. 70(2).Google Scholar

⁶¹ Decision of the Federal Social Court of 30 September 1999, published in BSGE 85, 36, at 45. See also the decision of 16 November 1999 (Reg. No. BSG B 1 Kr 9/97 R), unpublished.Google Scholar

⁶² Viagra for erectile dysfunction.Google Scholar

⁶³ Clemens, Thomas, Verfassungsrechtliche Anforderungen An Untergesetzliche Rechtsnormen (The Constitutionality Of Rulemaking By Non-Legislative Bodies)“, 9 Medizinrecht 436 (1996).Google Scholar

⁶⁴ Jung, Karl, Rechtliche Grundlagen des Bundesausschusses auch nach der GKV-Reform 2000 unzureichend (Inadequate Legal Foundations For The Federal Committee Persist After Adoption Of The SGBv Reform 2000), 3 Krankenversicherung 52 (2000).Google Scholar

⁶⁵ SGB V, Arts. 4, 12.Google Scholar

⁶⁶ Id., Art. 106.Google Scholar

⁶⁷ Praxisbesonderheiten.Google Scholar

⁶⁸ Dr. Gisela Groscurth-Galm, Med., Personal Communication (28 April 2002). On file with the author.Google Scholar

⁶⁹ Freie Arztwahl. SGB V, Art. 76.Google Scholar

⁷⁰ Id., Art. 75(1)Google Scholar

⁷¹ Hausarztzentrierte Versorgung. Id., Art. 73(B).Google Scholar

⁷² BSGE 68, 291, 298. Also see Heinrich Lang, Die Vergütung der Vertragsärzte und Psychotherapeuten im Recht der Gesetzlichen Krankenversicherung 44 [Physician And Psychotherapist Compensation Under The Universal Health Care Law] (2001).Google Scholar

⁷³ BSG Soz-R 3-2500, § 85 SGB V, No. 30, at 228; BSGE 77, 279, at 288. Heinrich Lang, Die Vergütung der Vertragsärzte und Psychotherapeuten im Recht der Gesetzlichen Krankenversicherung (2001), at 45.Google Scholar

⁷⁴ Dr. Klaus Schnetzer, Med., Rastatt (Germany), personal communication, 28 April 2002. On file with the Author.Google Scholar

⁷⁵ Heinrich Lang, Die Vergütung der Vertragsärzte und Psychotherapeuten im Recht der Gesetzlichen Krankenversicherung 51 (2001).Google Scholar

⁷⁶ Id., at 45.Google Scholar

⁷⁷ Id., at 114, also at note 583.Google Scholar

⁷⁸ Bedarfsplanung. SGB V, Arts. 99-101. The main purpose of these articles is to ensure adequate access to care by making available the appropriate number of physicians but restrictions are permitted as well. See also Lang, at 120. Today, there are 375,000 physicians for close to 80 million inhabitants, yielding a statistical average of one physician per every 276 residents (1992: 321; 1970: 616). Heinz Stüwe, Traumberuf Ade? (A Dream Profession No More?) Frankfurter Allgemeine Zeitung of 30 April 2002, at 1.Google Scholar

⁷⁹ Soz-R 3-2500 § 103 Nr. 1 (10 February 1996); B 6 Ka 35/97 R (18 March 1998). This includes capping the number of admissions to medical school, nothing out of the ordinary since many fields limit the number of students.Google Scholar

⁸⁰ “Physician compensation may not primarily depend on the financial situation of the sickness funds but on morbidity and therefore the subscribers’ need for care.” Bt-Dr. 15/1525, at 74 (GMG Draft Bill, 2003).Google Scholar

⁸¹ Arztgruppenbezogene Regelleistungsvolumina. SGB V, Art. 85(A).Google Scholar

⁸² Arztbezogene Regelleistungsvolumina. Id., Art. 85(B).Google Scholar

⁸³ Einheitlicher Bewertungsmasstab. Id., Art. 87.Google Scholar

⁸⁴ Thomas Clemens. Ärztliche Berufsfreiheit aus juristischer Sicht: Der niedergelassene Kassen- bzw. Vertragsarzt. (Legal Aspects of Physicians’ Professional Autonomy: Physicians Practicing under the SGB V), in: Die Ärztliche Berufsausübung in den Grenzen der Qualitätssicherung 17 [Practicing Medicine Within Quality Control Limits] (A. Wienke, H.D. Lippert, Eds., 1998).Google Scholar

⁸⁵ Laufs, Adolf, Immer Weniger Freiheit Ärztlichen Handelns. (Increasing Limitations On Physicians’ Activities), 37 Neue Juristische Wochenschrift 2717 (1999), citing: Haage, Bundesärzteordnung, Kommentar [Federal Law Regulating The Practice Of Medicine Annotated], (Das Deutsche Bundesrecht, 824. Lieferung, 1999).Google Scholar

⁸⁶ 24 Deutsches Ärzteblatt 1 (1994).Google Scholar

⁸⁷ Karl Hauck, SGB V: Gesetzliche Krankenversicherung, Kommentar [SGB V Annotated], 50^th Addition To The SGB V Annotated. K § 27, at 4 (July 2000).Google Scholar

⁸⁸ BSGE 73, 271, at 279; BSG Sozr 3-2500 §30 No. 8, at 32. Contrary to American physicians practicing under managed care requiring “preauthorization” for many procedures, the “medical necessity” determination of treatment lies exclusively with the physician, not with the insurer. For a comparative german-american analysis of the constraints imposed on physicians’ exercise of clinical judgment, see Ursula Weide, “Health Care Reform and the Changing Standard of Care in the United States and Germany.” 20 Journal of International and Comparative Law 249 (2000), at 348.Google Scholar

⁸⁹ BSG 14a Rka 7/92, 8 Sept. 1993 (“Amalgam Decision”), leaving the choice of filling with the dentist.Google Scholar

⁹⁰ Under the SGB V, the same social, civil and criminal law norms apply to all providers.Google Scholar

⁹¹ BGB, Sec. 611. Dienstvertrag (German Civil Code, Service Contracts).Google Scholar

⁹² Id., Sec. 276. Haftung für eigenes Verschulden (Liability For Individual Negligence).Google Scholar

⁹³ BGH, in: Versicherungsrecht 428 (1980).Google Scholar

⁹⁴ For an in-depth discussion of the role of u.s. practice guidelines and a comparative german-american analysis of guideline legal and clinical relevance, see Ursula Weide, Coverage And Medical Necessity Determinations: U.S. Managed Care Treatment Decisions Vs. German Administrative Rulemaking, 8 Ilsa Journal of International and Comparative Law 508 (2002).Google Scholar

⁹⁵ BGH, VI ZR 171/80 (11 May 1982); BGH VI ZR 56/87 (2 February 1988); BGH VI ZR 132/88 (12 June 1988).Google Scholar

⁹⁶ Hart, Dieter, Ärztliche Leitlinien und Haftungsrecht (Clinical Practice Guidelines and Malpractice Liability), in: Ärztliche Leitlinien: Empirie und Recht Professioneller Normsetzung [Medical Guidelines: Empirical And Legal Foundations For Setting Professional Norms] (Dieter Hart, Ed., 2000).Google Scholar

⁹⁷ Hart, Dieter, Ärztliche Leitlinien und Haftungsrecht (Clinical Practice Guidelines and Malpractice Liability), in: Ärztliche Leitlinien: Empirie und Recht Professioneller Normsetzung [Medical Guidelines: Empirical And Legal Foundations For Setting Professional Norms] (Dieter Hart, Ed., 2000), at 92-93.Google Scholar

⁹⁸ Hart, Dieter, Einleitung und Kommentare, in: Clinical Practice Guidelines, at 7, 16.Google Scholar

⁹⁹ Thomas Clemens, Leitlinien und Sozialrecht (Clinical Practice Guidelines and Social Law), in: Clinical Practice Guidelines, 147, 156.Google Scholar

¹⁰⁰ Id., 147, 161.Google Scholar

¹⁰¹ For a discussion of the extremely limited bargaining power of American physicians, see Ursula Weide, Health Care Reform and the Changing Standard of Care in the United States and Germany, 20 Journal of International and Comparative Law 249 (2000), at 286.Google Scholar

¹⁰² Jörg-Dietrich Hoppe, Wirtschaftliche Zwänge belasten zunehmend das Arzt-Patienten-Verhältnis (Economic Pressures Increasingly Burden the Physician-Patient Relationship), available at http://www.bundesaerztekammer.de (27 October 2000). (Statement by the President of the Federal Physicians’ Chamber)Google Scholar

¹⁰³ Krimmel, Lothar, Was Ist “Medizinisch Notwendig”? (What Is “Medically Necessary”?), 94 Deutsches Ärzteblatt C16 (1997).Google Scholar

¹⁰⁴ 25 Jahre Bundessozialgericht, Chronik 1954-1979 [The Federal Social Court – 25 Years, Chronic 1954-1979] (1979).Google Scholar

¹⁰⁵ Germany has a system of limited jurisdiction. different state courts have jurisdiction over Administrative, Social, Labor, and Civil and Criminal law cases. Each field of law has one Federal Court for Appeals from the State Supreme Courts.Google Scholar

¹⁰⁶ Reichsversicherungsamt.Google Scholar

¹⁰⁷ Anstalt des Öffentlichen Rechts mit begrenzter Rechtsfähigkeit mit der Aufgabe der Konkretisierenden Rechtssetzung. BSG 6 Rka 62/94, 20 March 1996 (Methadonurteil), 3 Medizinrecht 123 (1997).Google Scholar

¹⁰⁸ Decision of the Federal Social Court of 20 March 1996, published in BSGE 78, 70.Google Scholar

¹⁰⁹ BSG 1 Rk 28/95, Sozr 3-2500 §135 No. 4.; BSG Az 1 Rk 17/95; 1 Rk 14/96; 1 Rk 30/95; 1 Rk 32/95 (all 16 September 1997). Panel one rejected patients’ claims for reimbursement of acupuncture treatment of Neurodermitis, and for Immuno-Augmentative therapy for Multiple Sclerosis. according to the Court, neither therapy was considered covered under the SGB V, the latter having been specifically excluded by the JFC.Google Scholar

¹¹⁰ Decision of the Federal Social Court of 18 March 1998 (Reg. No. B6 Ka 37/97).Google Scholar

¹¹¹ SGB V, Art. 135 (evaluation of novel diagnostic and therapeutic procedures).Google Scholar

¹¹² Jung, Karl, Leitlinien aus der Sicht des Bundesausschusses der Ärzte und Krankenkassen – Rechtspolitische und rechtspraktische Probleme (Clinical Practice Guidelines Viewed By The Federal Committee Of Physicians And Sickness Funds – Problems Of Law, Application And Policy.), in: Medical Guidelines, supra.Google Scholar

¹¹³ Budget and compensation decisions made by sickness fund and physician associations are called “meso-level” allocation within the German universal system of Health Care.Google Scholar

¹¹⁴ For a comparative german-american analysis of health care cost containment approaches, see Ursula Weide, A Comparison of American and German Cost Containment in Health Care: Tort Liability of U.S. Managed Care Organizations vs. German Health Care Reform Legislation, in: 13 Tulane European And Civil Law Forum 47 (1998).Google Scholar

¹¹⁵ Krankenversicherungskostendämpfungsgesetz. BGBl. 1069 (27 June 1977).Google Scholar

¹¹⁶ Heinrich Lang, Die Vergütung der Vertragsärzte und Psychotherapeuten im Recht der Gesetzlichen Krankenversicherung 44 (2001).Google Scholar

¹¹⁷ Gesundheitsreformgesetz (GRG). BGBl. 2477 (20 December 1988).Google Scholar

¹¹⁸ Festbeträge. SGB V, Art. 35. Before SGB V limitations on reimbursement, drugs were sold in Germany subject to one of the highest profit margins in the world. even though per capita spending on health care in the united states was almost twice that of germany, in 1988, german prescription drug expenditures per patient exceeded those of the United States. General Accounting Office, German Health Care Reforms (Gao/Hrd-93-103, 1993).Google Scholar

¹¹⁹ SGB V, Art. 213(2)(3).Google Scholar

¹²⁰ Bagatellarzneimittel.Google Scholar

¹²¹ To this day, compared with current co-payments and deductibles in the united states, the German patient contributions remain negligible.Google Scholar

¹²² this mandate applies to the entire public sector and is deeply rooted in administrative law.Google Scholar

¹²³ Gesundheitsstrukturgesetz (Gsg). BGBl. 2266 (21 December 1992).Google Scholar

¹²⁴ Historically, sickness funds had developed to cover members according to their profession (farmers, miners, office employees, merchant marine, public service, tradesmen's guilds, company-sponsored plans, and local/regional plans for those not covered by any other sickness fund.)Google Scholar

¹²⁵ Neuordnungsgesetz I und II (NOG I, BGBl. 1518; NOG II, BGBl. 1520, 23 June 1997).Google Scholar

¹²⁶ Krankenhausnotopfer.Google Scholar

¹²⁷ This eliminated the reduction in RVU value occurring with increasing services provided, making physician incomes once again predictable.Google Scholar

¹²⁸ GKV-Solidaritätsstärkungsgesetz [Law on Strengthening Solidarity within the Statutory Health Care System), BGBl. I 1998, at 3857 (19 December 1998).Google Scholar

¹²⁹ GKV-Gesundheitsreformgesetz 2000 (GRG). BGBl. I, at 2626 (22 December 1999).Google Scholar

¹³⁰ Members of the Bundesrat are not elected but appointed by state governments, Representing the majority parties. only legislation affecting state sovereignty must receive Bundesrat approval. Therefore, as in the case of the “Reform 2000”, only some sections of the act had to be ratified.Google Scholar

¹³¹ Arzneimittelausgabenbegrenzungsgesetz (Law On Prescription Drug Cost Containment), BGBl. I Nr. 11, 22 February 2002. SGB V, Arts. 73(5), 92, 115b, 129, 130(1), 131(4), 300(2), 302(2).Google Scholar

¹³² While politicians were arguing over raising the mandatory income cap, 325,000 voluntary subscribers with higher incomes preventively switched to private insurances, causing the universal system to lose 1 Billion Euros in revenue. Ausgaben für Arzneimittel steigen stark (Prescription drug expenditure increases), Frankfurter Allgemeine Zeitung, 10 May 102002, at 15.Google Scholar

¹³³ Sicherstellungsauftrag. SGB V, Art. 72.Google Scholar

¹³⁴ Ärztetag lehnt “Checklisten-Medizin” Ab (National Physician Assembly Opposes Checklist Medical Care), Frankfurter Allgemeine Zeitung, 31 May 2002, at 15.Google Scholar

¹³⁵ Id.Google Scholar

¹³⁶ GKV-Modernisierungsgesetz (GMG) 2004. BGBl. I 2190 of 14 November 2003.Google Scholar

¹³⁷ Till-Christian Hiddemann/Stefan Muckel, Das Gesetz zur Modernisierung der Gesetzlichen Krankenversicherung (The Law Modernisizing The Universal Health Care System, in: Neue Juristische Wochenschrift 7 (2004).Google Scholar

¹³⁸ Medizinische Versorgungszentren. SGB V, Art. 95.Google Scholar

¹³⁹ Integrierte Versorgung. Id., Art. 140(A). Once established, these delivery systems could resemble ambulatory care centers but also potentially involve case managers. the law allows incorporation and the involvement of management companies. again, individual contracts outside of the collective system may be concluded with the sickness funds. although already permissible under the reform of 2000, this alternative so far has found few takers. See Hiddemann/Muckel, supra, note 137, at 8.Google Scholar

¹⁴⁰ The SGB V expressly rejects an “any willing provider” stipulation.Google Scholar

¹⁴¹ Clement lehnt Ausweitung der Einnahmen für das Gesundheitssystem ab (Minister Clement Rejects Increasing The Revenue Base Of The Universal Health Care System), in: Frankfurter Allgemeine Zeitung, 4 August 2003.Google Scholar

¹⁴² . “Peoples’ heads are still spinning from the heated debate between CDU and CSU how to best reform the Health Care System.” Die Basis ist Vertrauen (Confidence is the Foundation). Frankfurter Allgemeine Zeitung, 28 May 2005.Google Scholar

¹⁴³ This section is based on Nico Fickinger, Andreas Mihm and Manfred Schäfers, Gesundheit, Arbeitsmarkt, Steuern – Was die Parteien ihren Wählern anbieten (Health Care, Labor Market, Taxes – What The Parties Are Offering Their Voters). Frankfurter Allgemeine Zeitung, 24 May 2005, at 16.Google Scholar

¹⁴⁴ Bürgerversicherung.Google Scholar

¹⁴⁵ Beamte.Google Scholar

¹⁴⁶ Prämienmodell.Google Scholar

¹⁴⁷ Sozialpolitik wird wichtiges Thema (Social Policy will be an important subject). Süddeutsche Zeitung, 24 May 2005, at 1.Google Scholar

¹⁴⁸ Steuermittel Für Krankenkassen (Subsidies For Sickness Funds). Frankfurter Allgemeine Zeitung, 23 May 2005, at 5.Google Scholar

¹⁴⁹ OECD Gesundheitsdaten 2005 (OECD Healthcare Data). 8 June 2005, available at http://www.oecd.org/dataoecd/14/16/34987469.pdf.Google Scholar

¹⁵⁰ Thomas S. Bodenheimer/Kevin Grumbach, Understanding Health Policy 116 (1998).Google Scholar

¹⁵¹ Highlights, National Health Expenditures. Centers For Medicare and Medicaid Services. Available at http://www.cms.hhs.gov/statistics/historical/highlights.asp. Last modified 11 January 2005.Google Scholar

¹⁵² 1991: 5.13.%, 2002: 5.7%, 2005: 5%. Kassen Sollen Verwaltungskosten Senken (Sickness Funds Must Lower Administrative Expenditures). Frankfurter Allgemeine Zeitung, 5 August 2003, at 13. Hartz-Reform Sichert Krankenkassen Überschuß (Hartz-Reform Provides Surplus For Sickness Funds). Frankfurter Allgemeine Zeitung, 3 June 2005, at 13.Google Scholar

¹⁵³ Uwe Reinhardt, 'Mangled Competition’ And ‘Managed Whatever.' 18 Health Affairs 92 (1999).Google Scholar

¹⁵⁴ OECD Healthcare Data, supra note 149.Google Scholar

¹⁵⁵ Hartz-Reform Sichert Krankenkassen Überschuß (Hartz-Reform Provides Surplus For Sickness Funds). Frankfurter Allgemeine Zeitung, 3 June 2005, at 13.Google Scholar

¹⁵⁶ Id.Google Scholar

¹⁵⁷ Id.Google Scholar

¹⁵⁸ Reinhardt, Uwe, 'Mangled Competition’ And ‘Managed Whatever.' 18 Health Affairs 92 (1999).Google Scholar

¹⁵⁹ Reinhardt, Uwe, Managed Care – An Imperative For German Health Care? Presentation to the Federal Association for Managed Care, Berlin (12 September 2000). On file with the author.Google Scholar

¹⁶⁰ these concerns are similar to those of american practitioners, and the supreme court has coined the term “Mixed Treatment and Eligibility Decisions”, implying the inseparable link between therapeutic and administrative (cost-saving) decisions, necessary for the “rationing” of health care, seen as natural by a conservative Court. Pegram V. Herdrich, 86 U.S.L.W. 4501 (12 June 2000) (No. 98-1949). 2000 U.S. Lexis 3964. In the United States, Managed Care Organizations often preauthorize or deny care, seriously limiting the clinical decision-making autonomy of providers, which is protected by law in Germany.Google Scholar