REIMBURSEMENT OPTIONS IN THE
GERMAN HEALTHCARE SYSTEM
DIRECT CONTRACTS AS AN OPPORTUNITY FOR
INNOVATIVE MEDICAL DEVICES
In outpatient medical care, the direct contract is the counterpart of the collective contract. Collective contracts are agreed on the national level by the associations of physicians and the association of health insurance companies. Collective contracts are binding for doctors and health funds. The direct contract, on the other hand, offers individual agreements of health funds with service providers and producers of medical devices.
This enables contractual partners to flexibly respond to needs that exist in specific types of care or when treating particular illnesses. The areas in which direct contracts can be used have been widened considerably in the past few years. For patients this results in better care from one provider. The implementation of the new law for strengthening the provision in statutory healthcare insurance (Versorgungsstärkungsgesetz) in 2015 created new opportunities for direct contract arrangements.
It also simplified existing forms of contractual arrangements. The new law envisages a systematic continued development of opportunities for direct contracts for all service providers. So far, the types of contracts were regulated by different sections of the health code (Sozialgesetzbuch V). They have now been condensed in a new clause (§ 140a SGB V) as ‘special care provision’.
These contracts can cover matters such as services for early diagnosis, specialized outpatient care, as well as new examination and treatment methods whose applications follow medical good practice.
Content of the new article of law
§ 140a SGB V Special Care Provision
Health funds may enter contracts concerning special care provision for insured persons with service providers shown in Illustration 1.
It enables a cross-sector care concepts or an interdisciplinary approach (integrated care). These are legal prerequisites and not negotiable. It also allows contracts for special medical outpatient care involving approved contracted medical service providers or their associations. Insured persons who want to benefit from the special care of their health fund have to submit their voluntary participation in writing to their health fund. Insured persons can revoke their consent with the health fund within two weeks of submission either in written form or as a written transcript without giving a reason. It needs to be stressed that treatments already rejected by the Joint Government Committee (Gemeinsamer Bundesausschuss) may not be part of the contracts. The contractual parties also have to prove within a certain fixed timeframe (usually four years) that the treatment specified in the contract constitutes an improvement with regard to quality and cost effectiveness for the community.
The number of direct contracts will rise
We are aware of approximately 800 contracts in 2012. In 2014 the Association of Statutory Health Insurance Physicians reported 1,850 direct contracts. This trend points towards a considerable rise in the coming years.
Great opportunities for medical device companies
It is an aim to promote competition for members between health funds as well as competition between service providers. Direct contracts should therefore increase the efficiency and quality of patient treatment and also facilitate innovation. Kalms and Partner have excellent contacts in the German healthcare sector, also in the health funds. We would be pleased to support our customers with initiating contacts with individual health funds to initiative contracts – if the legal prerequisites.
According to the new law healthcare insurance companies may enter contracts with the following entities:
- Individual medical suppliers or associations of suppliers e.g. physicians, practices.
- Boards of institutions offering special treatments for insured persons on the basis of Chapter 4 of the law
- Statutory nursing care insurers and approved care institutions on the basis of §92b Book 11
- Healthcare centres on the basis of §115 Section 2 Sentence 1 Number 1
- Pharmaceutical companies
- Medical device companies as de ned by the law for medical devices
- Associations of Statutory Health Insurance Physicians in order to support members taking part in special care provision
Author | Barbara Senger
Market Access & PR