Dr. Ahrens is Chairman, AOK-Bundesverband, Germany
Theme: The Mature Patient: Between Personal Responsibility and Solidarity

We have already discussed that the health system in Germany is in a major period of reform, but in spite of this we have to determine what the health service is and where the balance of solidarity and responsibility have a place.

Solidarity is one of the pillars of our healthcare system - it is a fact that we have the healthy taking care of the ill and rich taking on the expenses of the poor. This is a basic principle for us. In this morning’s reform the goal is to find a balance between what the community should be doing and what individuals are responsible for.

We don’t have a state system but we don’t have a private system either. It’s a system where everyone together has to find agreement on how much solidarity.

We need to ensure that financial support goes where it is needed. And if we take solidarity as a pillar, then everyone has to take responsibility in the risk structure for making it all work. We also have the right to make better use of spaces provided for by this new law which just went into effect. We think that competence can’t be restricted to 10% of the population. Solidarity is irreplaceable, it needs to be cared for and maintained and that’s the responsibility of everyone.

Responsibility is only considered as financial involvement, but it means more - taking on a personal responsibility for your actions and behaviors. One idea: beginning to employ bonuses and premiums. Our budget is 3,200 millon Euros per year so we have lots of leverage to influence people’s behavior. Bonuses can have unintended consequences. Insured parties have to take on some costs, e.g. over-the-counter medicines. Yesterday we talked about who had to pay what, but now we have a contribution of 9% which should help us to reduce the costs. We have seen that co-payments lead to a reduced number of visits - they make patients think twice. Of course, patients shouldn’t get to the point that they don’t see a doctor because they can’t afford it - this would be contrary to what we’re doing.

Personal responsibility must also try to underwrite private insurance for things that require a particular hospital or therapy. So now thanks to this new law there has been an increase in the personal responsibility. Asking people to do something is worthless if they don’t see the benefit. We offer different rates - if you’re willing to do something for your health, exercise, and you pay part of the costs, we can offer you a special price rate which may be up to one month’s payment. The reform has the advantage that we now have a greater playing field or margin to offer different incentives and price rates so we see that by doing this we also generate greater selection and choice but also that people need to be better informed in order to make that choice. That’s why we have an independent consulting department that offers information and transparency regarding quality - there are some competitive restrictions, but we can say A has X number of operations and B has Y - we can’t say yet, but we want to, that 10 out of X didn’t work. We think this is important.

We’re also looking at what the rights are of individuals against the rights of unions and associations.

We have different programs for disease management that we offer because we think it gives us the possibility of bringing more benefits and promoting competition.

We’ve seen that the personal situation of the patient improves if the patients feel better informed. Physicians also think, according to our surverys, that they are more able to influence patients and to care about them. I’ve seen that not only are subjective criteria important but objective studies are important too. We see that the training that we do is positive -patients feel that they are subjects that are given something, but we help promote their responsibility.

We also pay attention to self care. Not only do we have demographic problems like everyone else. When we looked at the physical state of children, we saw their ability is reduced 10-15%. Imagine what will happen to the German football team! We are concerned about this, but generations to come will not support these projects and will create a long term problem.

I think the most important thing is financial support and incentives. We have to think of how we can continue along this path of providing support and incentives. This probably involves private insurance. Do we go for public or private? What we say is that expenditure in recent years increased 67% and for private 122% because they were not able to control their costs.

We have also seen that we shouldn’t go for state solutions alone. I do think that we’ll be able to broaden this and carry on the road to a better balance betwwen personal responsibility and solidarity but we need information and transparency and competition which enables us to stand out from the rest.

Solidarity and Responsibility may seem contradictory, but we have to find this balance.

Questions

Q: You have a market share of 40% while others have a share of 10% and it’s becoming more and more difficult to get in. Traditionally AOK is 10% cheaper than others. There are extremely high statutory differences and that’s the reason for your success.
A: You’re right of course… I have no problem with the fact that some pay more and so they’re supporting the systems. I’m against treating a patient worse in public service than through private insurance.

Q: How do you ensure the principle of universal coverage is maintained for people who can’t afford co-payments?
We’ve got certain limits on co-payments of 2% and on the other hand, in the case of chronic patients, there’s an additional reduction of co-payments and some don’t pay any at all.