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
Project Management & Reimbursement
Ellen Holtmann is our team member for Quality Management, Quali cation for market access (incl. national and international requirements for the development and manufacture of medical products also in respect to product liability), national and international requirements for clinical assessment and approval of medical products, national and international aspects of the bringing to market and monitoring of products during the product life cycle. Ellen Holtmann holds a University certification being a qualified Manager Regulatory Affairs Medical Devices International.
During her work in the Medical Device Market since 2000 and besides collecting multiple experiences in the field of Customer Service, Customer Relation Management, Office Management, Marketing, Healthcare Compliance, Quality Management , International Sales Management (Austria and Switzerland) and Business Development. Ellen Holtmann is looking back on a working partnership with Marco Kalms for more than 14 years. She is a native speaker in German and fluent in English.
HOLGER SCHAFFRATH, Ph.D.
Market Access & Reimbursement
Dr. Holger Schaffrath has 25 years of experience in sales, marketing, operations and General management for entities of primarily US based medical device companies in Central European markets. This has included working for Boston Scientific for 5 years and in aggregate for Medtronic and AVE 13 years, acquired by Medtronic in 2000. In recent years he has focused on managing startups launching vascular intervention and neurostimulation products, and has steered related therapies through the phases of market access and adoption in Germany, including clinical, reimbursement related and commercialization aspects. As a Senior Consultant he provides our clients with a broad portfolio of profound knowledge of the German health care system combined with insider knowledge of the medical device industry and related markets.
Holger received a diploma in information sciences and holds a Ph.D. degree in biomedical engineering. To round his professional skills off he is a certified psychological adviser and management coach.
MEMBER OF PARLIAMENT AT LIVE SURGERY WITH DaVinci
Intuitive Surgical is the leading company in robotic assisted surgery and has developed the DaVinci surgical system. Kalms & Partner Consulting is supporting Intuitive Surgical in the field of Public Affairs. To demonstrate the impact of the technology for high quality surgery, we have initiated a visit by Dr. Georg Kippels, Member of the German federal Parliament, to the St. Antonius Gronau hospital - the leading center for robotic surgery in Europe. Dr. Kippels was able to take part in a 3D live transmission of a minimally invasive prostate surgery - an impressive experience for a policy dialogue on quality medicine.
PROGRESS FOR OUR CLIENT ALLERGAN
Curing severe forms of incontinence - this is the aim of the Botox injection to the overactive bladder. Kalms & Partner Consulting is supporting Allergan, the producer of Botox, in regard to the application of the method to the outpatient sector. One instrument are contracts with major health funds. Allergan and Kalms & Partner Consulting can now report further progress in the efforts to improve access of patients in ambulatory surgeries.
After a DAK contract in the region of Westphalia-Lippe two more contracts have included the Botox injection to the overactive bladder: DAK in Bavaria and AOK in Baden-Württemberg.
This is good news for the patients and for the physicians who nally get a much better reimbursement than before.
KALMS & PARTNER CONSULTING IS SUPPORTING THE U.S. COMMERCIAL SERVICE'S CORPORATE EXECUTIVE OFFICE (CEO) PROGRAM AT MEDICA.
Taking place in Düsseldorf November 14th – 17th, MEDICA is the world’s largest event for the medical sector with more than 5,500 exhibitors (including more than 500 U.S. exhibitors) in 19 exhibit halls and expected and 130,000 trade-only visitors from 120 countries.
The CEO program was developed by theU.S. Commercial Service in order to offer US companies a unique opportunity to promote their exports and to meet customers and qualified distributors from all over Europe and the world at affordable cost.
Kalms & Partner Consulting is happy to participate in this event in order to continue our activities in successfully supporting US based companies with their German and European activities.
KALMS & PARTNER CONSULTING EXPERT MEETING ON NEW BENEFIT ASSESSMENT
In July 2016, Kalms & Partner Consulting successfully gave an expert workshop on the New Benefit Assessment (NUB) implemented in the German reimbursement system. It applies to certain methods with medical devices provided an NUB application is submitted by a hospital.
In the workshop, Kalms & Partner consultants explained details of the new law, its implications for the medtech companies and strategy recommendations for our clients. Additionally, participants had the opportunity to discuss the matter with high-level representatives of the Association of German University Hospitals and of the Joint Federal Committee, the most important self-administration body of the German health system.
If you missed the workshop, but are planning an NUB application in 2017, please contact your Kalms & Partner consultant as early as possible, as applications that may be subject to a benefit assessment have to be carefully prepared several months ahead of the deadline.