Communal Responsibility for Health Care — The Example of Benefit Assessment in Germany (NEJM)

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Communal Responsibility for Health Care — The Example of Benefit Assessment in Germany

Peter T. Sawicki, M.D., Ph.D.
October 28th, 2009

Many German observers are bewildered over the U.S. health care reform debate. Most Europeans see affordable health insurance for everyone as a fundamental element of a stable and prosperous society — an element founded on the principle of communal responsibility. Like the United States, Germany is a wealthy, democratic society with strong nongovernmental community institutions. In Germany, 90% of the population pays affordable contributions into the community-based system of statutory health insurance funds, which is supplemented by employer contributions and some taxes. The remaining 10% of citizens, most of whom have above-average incomes, pay into private insurance schemes. For the small group of people who receive state income support or have no income, contributions are financed from taxes.

Most people in Europe believe that a strong community is a central driving force for both a good health care system and a prosperous society. Adequate medical care can be so expensive that few can afford it on their own. But if the risks are divided among us, optimal medical care can be offered to all. Communal responsibility is not an unrealistic ideal. Healthy people’s communal support of the sick is in their own interest, since one day they may need an expensive treatment for which they will have to rely on the working healthy — and if not, at least they are spared the worry that they will be on their own at a time of need. Such an approach is not communism or socialism but simply common sense. Indeed, this system was introduced 125 years ago by the conservative German politician Otto von Bismarck.

Some Americans may fear that in such a system their individual well-being might be sacrificed to that of the community. But U.S. physicians largely support the idea of limiting expensive drugs and procedures if doing so means being able to extend access to basic care to all. In a community-based health care system, every possible treatment cannot be provided to everyone — any more than everyone can have everything in a tax-based or private insurance system. But there are criteria for determining what will be restricted, and how. In Germany, these principles are laid out in law: a service must be necessary in order to be covered by the statutory health insurance system. This criterion builds on the individual-patient perspective: patients have a right to care that is objectively necessary to cure their disease, prevent a disease from progressing, or ease their suffering. But the perspective of the community is also considered: the costs must be reasonable in relation to the potential benefit.

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The method by which these criteria are applied, called benefit assessment in Germany and comparative-effectiveness research (CER) in the United States, is being debated in both countries. A community can meet its responsibilities to its members fairly only if there is a rational basis for coverage decisions. It is therefore no coincidence that virtually all European countries with community-based statutory health care systems also have a form of benefit assessment, intended to protect patients from harm and the community from misuse of finances.

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http://healthcarereform.nejm.org/?p=2199&query=TOC

© 2009 Massachusetts Medical Society