Zero Disease. Angelo Barbato

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СКАЧАТЬ Reform, this was targeted towards precise incentivizing objectives to enhance the efficiency of Services. Therefore the hierarchical and monolithic model was shattered in favor of a separationist approach between buyer and distributor, introducing competition mechanism between producers; nevertheless maintaining the underlying principles of solidarity financing and access to the proper services of a public system.

      In the late '80s, the proposal of the economist Enthoven [1988] to reform European healthcare systems in the light of the US HMO integrated organizations meets the favor of conservative governments, such as Reagan and, precisely, Thatcher. With the reform of 1990, England adopts a quasi-market variant called the internal markets model, in which the competition between public or private producers is enabled by special public agencies that act as patient representatives (sponsors) and, given a default loan, buy from producers through health services contracts for the assisted population. The idea of the quasi-market goes from England to the rest of Europe, with diverse applications in different European healthcare systems, oscillating between the two opposite poles of the total programming and pure market, thereby adopting intermediate hybrid forms of health care organization with various combinations of hierarchical mechanisms of control and competition¹⁸ .

      In the Bismarck model, born in Germany in 1883 and introduced by Chancellor Otto von Bismarck to help reduce the mortality and injury in the workplace and to establish an early form of social security, the systems are financed by social insurances. The private style Bismarck model is characterized, on one hand by contributions generally assessed based on salaries, and on the other hand the organizations, which are called Funds diseases, act as administrative structures of the system and payers for care. The number of funds and their size vary widely with respect to the number of members and their employment status. In most cases up to the government to determine the contribution rates. In some countries you can choose the fund to support, (as is the case for example in Germany, Holland, and Switzerland), in others not. As regards to the German health system we must go back in time, until January 18, 1871 at the time of birth of the German Empire or Deutsches Kaiserreich, the Second Reich, following the victory of Germany in both the Austro-Prussian and the Franco-Prussian wars. After which, comes a period characterized by a strong fear by the part of the monarchies of the various states that the French Revolution could also happen in Germany. German nationalism rapidly moves from its liberal and democratic character in 1848 to Otto von Bismarck's authoritarian Realpolitik, which uses the "carrot and stick approach". The socialist movement was banned, but an especially advanced welfare state is created; based on compulsory social insurance, financed by contributions from companies and workers. In 1883, insurance for illness is established, in 1884 for accidents on the workplace, in 1889 disability and old age pensions are institutionalized.

       This created what was at the time the most advanced welfare system in the world. A model (Bismarck model) that became an example, since the early twentieth century, adopted in most of the industrialized countries and which still exists in Germany and other countries. An expensive model, since - after the US - in the Organisation for Economic Co-operation and Development (OECD) ranking regarding the percentage of GDP spent on health care (year 2012), appear all countries belonging to the Bismarck model, with Germany in 5th place with 11.3%.

      The same applies to the health expenditure per capita, which is $ 4,811 in Germany in 2012 (of which $ 3,651 - 75.9% - public health expenditure). This represents a much lower cost than the one corresponding to the US ($ 8,745), but much higher than the OECD average ($ 3,484), or that of Britain ($ 3,289) and Italy ($ 3,209).

       Following the financial crisis of 2008, Germany, parallelly to the average of the OECD countries, has seen a sharp slowdown in annual growth in health spending that from + 4% in 2008 rose to a little less than +1%, while other Southern European countries have suffered a net reduction of resources available in real terms: -2% Spain, Italy -3%, Portugal 6%, Greece -10%.

      In terms of burdens on citizens, Germany spends a lot on health care, but still produces a huge amount of services, with a low level of direct spending by patients. This shows that we are faced with a technically efficient system.

       The German population consists of 81.8 million citizens. The 85% of them are enrolled in one of the 132 social "compulsory" insurances (Krankenkassen). These are "non-profit" insurances, "friendly societies", not definable as public, nor private. Until 1996 the inscription was attached to the profession; since then a liberalization has taken place, thereby allowing the possibility of choice between different insurance companies competing with each other for charges and coverings offered to its members.

       The registration requirement applies to all employees (and their families) with a gross monthly income equal to or less than € 4462.60. It is the state itself that pays, through specific funding of the Länder, for assistance of the disabled, the unemployed, minors or for categories that otherwise can not subscribe to insurance.

       The contribution paid to the Krankenkassen varies depending on the employee's income and corresponds to 15.5% of the monthly salary (53% of which is paid by the employee and 47% by the employer). Thus a financial equalization is applied to compensate for the different capacity of contribution of members: Each person pays proportionally to their income. The contribution of employees and businesses has grown over the past 15 years, going from 13.6% in 1998 to currently 15.5% of the monthly income.

      On top of the monthly contribution, supplements (Zuzahlungen) are added: you have to pay € 10 every three months to take advantage of medical consultations with all doctors recognized by the health insurance funds, and thereafter each time that you are using one visit to the doctor or dentist (including those covered by the policy) you have to pay a fee of 10 € (this "Praxisgebühr" has led to an observed reduction of 10% of the accesses). Even for the medicines you pay 10% of the price, and 10 € per day for hospitalization. Recently, an annual limit for additional expenses has been set (generally 2% of annual income, 1% for recipients of a continuing care because of a serious chronic disease), those who pass such percentage are reimbursed their insurance. Minors do not pay any additional charge.

       In Germany there is an obligation to be insured; those with a monthly income of more than € 4462.60 may choose to subscribe to private insurances (Private Krankenversicherung-PKV), rather than social ones.

      Private insurances, unlike the mutualistic funds in which the contribution depends on income, calculate the premium depending on the personal risk (in fact, it is provided thorough medical examination before enrolling). Private insurances often offer superior services of social insurance, pay better doctors, and also offer reimbursements for hospitalization in non-contracted private clinics. For young people with a high salary and no health problem, the contribution towards the private enterprises often costs much less; with age the insurance policy increases in price. However, even in case of serious diseases it may not exceed certain standard levels (for this reason it is custom for young people to appeal to insurances to create a capital backup with their savings). Nine million Germans, equal to 11% of the population are privately insured. The use of private insurance can also be a complementary purpose for those who are enrolled in the Krankenkassen (about 23 million). The main reason is to expand the financial protection in case of illness or hospitalization. The remaining 4% of the population is represented by people who get insurance coverage through special channels, such as the military or those with refugee status.

       The funding of the German health system is mainly based on the takings of the compulsory social insurance (57%) and on private insurances (9%). The central government is not involved in the health system neither as a financier nor as manager, or as the owner of sanitary manufacturing companies (except detailed cases, such as military hospitals). However, it governs the whole system, defining the rules by which the actors can move. Mutual aid societies and associations of physicians operate within administrative rules, only modifiable by the central government, just as they are regulated by laws and relations between the different actors of the system. Although the general health policies for the country are decided by the Central State, the management and the СКАЧАТЬ