Health governance in the aftermath of traditional corporatism: one small step for the legislator, one giant leap for the subsystem?

VerfasserBandelow, Nils C.

1 Introduction (1)

Until the late 1980s outpatient care in Germany was an "ideal-type" of sectoral corporatism (Rosenbrock/Gerlinger 2006: 280). Self-governance and the dominance of large provider associations were the main characteristics of the German outpatient health care governance (Lehmbruch 1988). Public corporations in particular were able to insure privileges for their members by being involved in every decision concerning the range of benefits and prices of outpatient care.

This system has come under increasing political pressure since the first oil crisis in the mid 1970s (Hegelich/Meyer 2008: 130-131). Governments led by both the CDU/CSU and the SPD have argued for sustainable solutions to contain the rising health costs. More than 20 attempts to introduce structural reforms have been undertaken, though most of these only lead to incremental change. The German consensus democracy, the patterns of semi-sovereignty and the powerful associations worked as efficient veto points in preventing a significant change in the German health system (Al-tenstetter/Busse 2005).

If the supporters of major reform policy look at the policy outcome there will be little cause for optimism: The proportion of the GDP on health expenditure has risen continuously. The most recent Statutory Health Insurance (SHI) Competition Strengthening Act of 2007 (CSA, GKV-Wettbe-werbsstarkungsgesetz), concurred with a further rise of contributions to the SHI (Green/Paterson 2009). Considering the financial and economic crisis that started in 2008 even larger problems in the German health system can be expected.

But there is another side to the German health policy that is revealed when investigating policy output instead of outcome: Despite the failure of sustainable cost containment there have been some considerable changes in the institutional structures. The first major changes were introduced by the Health Structure Act (HAS, Gesundheitsstrukturgesetz) of 1992. The HSA did not overcome the self-governance of the SHI but changed the legal framework of the negotiations significantly (Bandelow 1998: 206-208).

The subsequent attempts of both the former Kohl and Schroder governments hardly continued the structural conversion started by the HSA. So it was up to the grand coalition that came into power in 2005 to take up the dissolution of the power of the associations and to change traditional patterns of negotiations. Both the SPD and the CDU/CSU shared at least the wording of their ideas to strengthen competition within the system even though the parties have totally different views of the problem, the future health system and even the definition of competition (Bandelow/Schade 2009).

At present the structural changes introduced by the latest reform are about to be implemented. There is much change happening within outpatient care. Up to now we can only observe the output and impact of the changes. One has to complete the analysis of the changes that have occurred so far by looking at the long term perspective. What will be the outcome of these changes? This article aims at answering this question by combining the heuristics of the policy cycle with a perspective centered on the protagonists. Referring to the Actor-Centered Institutionalism (Scharpf 1997) it will argue that changes of institutional rules will result in predictable decisions of rational actors. Unlike most applications of the Actor-Centered Institutional-ism this observation will not only be used to create models that explain past policy results but to formulate scenarios of future policies.

Part 2 will focus on the changes in the legal framework. Health care policy has already led to major changes within the system of organized interests, especially concerning physicians' associations. These policy impacts will be presented in part 3. Subsequently the manifold changes in German regions are analyzed to develop ideal-typical scenarios of the possible future of hierarchy, market, and cooperation in outpatient care governance.

2 Policy Output: Legal Changes of Outpatient Care Governance

Outpatient care governance underwent several changes during the last decades. After World War II it took many years to re-establish the major elements of the Bismarckian health system. Against some opposition by the social democrats, the early Adenauer government not only re-introduced the separate systems of sickness funds, but also relaunched the corporatist institutions. The most important players within the system of outpatient care became the Associations of Statutory Health Insurance Physicians (ASHIP, Kassenarztliche Vereinigungen) that were provided with the full responsibility to guarantee the provision of outpatient services. The ASHIP negotiated with the sickness funds on both the regional and the national levels. On the national level the government refunded the National Committee of SHI-Physicians and Sickness Funds in 1956. The National Committee has increasingly gained authority and became the most important institution within the German health system (Dohler 2002).

During the first decades the governments aimed at providing a system that guaranteed solidarity within the limits of stratification and subsidiarity. This means, that the range of benefits and the proportion of public financed health services grew. Indeed, the solidaristic system still excluded parts of society like civil servants and high-income households. Furthermore, it relied on the separation of societal groups to be insured in different subsystems of the health insurance.

In the aftermath of the economic crisis of 1973, the ability to finance the system became the major goal of German health policy. To achieve this goal, the cost containment policy that started in the mid 1970s originally extended and deepened the system of self-governance and corporatism. The Health Insurance Cost-Containment Act (HICCA, GKV-Kostendampfungs-gesetz) of 1977 established the Concerted Action in Health Care (CAHC). The CAHC intentionally used the name of the tripartite economic Concerted Action that broke up in the same year (1977). Unlike the National Committee, the Concerted Action never became a central institution for outpatient governance. The Concerted Action suffered from the problem of unanimity by having to include a large diversity of interest groups. It never gained enough legitimacy to implement major policy changes (Wiesenthal 1981).

So the cost containment policy originally established sectoral committees of provider associations and sickness funds and strengthened the competencies of these committees. The state supervised these committees and used soft forms of governance to reach their own goals. Negotiations have been the most important type of governance while the governing capacity of the state was limited and there was almost no competition within the system. This strategy was pursued until the end of the 1980s.

Since 1992, there have been different and partly oppositional strategies concerning change of the health policy governance. The Health Structure Act occasionally pursued a strategy that aimed at weakening the traditional negotiation structures. It used several legal instruments of hierarchical steering like cost budgeting and limitation of approved physicians. Additionally, the HSA was a first step to enable competition by introducing an organizational reform of sickness funds.

After the HSA had been enacted by an informal Grand Coalition, the Kohl government returned to the strategy of strengthening self-governance. The SHI Reorganization Acts of 1997 (GKV-Neuordnungsgesetze) were communicated using the motto "right of way for self-governance" (Bande-low 1998: 219).

Nevertheless the second Reorganization Act already allowed decentralized competition (SVR Gesundheit 2005: 35). By introducing the possibility of pilot projects (article 63 of Social Code Book V) and structure contracts (article 63a of Social Code Book V) a test phase of new supply forms was initiated. Model plans served the development of organization and payment to increase quality and economic efficiency. Sickness funds got the chance to conclude contracts with individual doctors, doctor's teams or associations of Statutory Health Insurance Physicians. The act used financial incentives to stimulate competition within the medical profession.

The actual effect of the pilot programs has been limited by hurdles that came into force during the implementation phase. In particular the high start-up expenses proved to be an obstacle. Savings could only be reached in the medium term and were often only small and did not immediately go back to the model plan. At the same time the sickness funds aimed at limiting their expenses instead of increasing the quality of services. Therefore most actors would not consider the competitive elements of the 1997 reform as successful (Rosenbrock/Gerlinger 2006: 257).

In spite of these failures the red-green government continued the strategy of the Reorganization Acts. It introduced further contract options in 2000. In contrast to the Kohl government, the green health minister Andrea Fischer not only wanted to increase financeability but also to ensure better quality by changing the governance patterns. The government therefore focused on the idea of integrated care to combine primary with specialist and inpatient services (articles 140a-d of Social Code Book V). Although the implementation still relied on the negotiations between the different types of providers. In the end the results were not very satisfying. The reform enabled some networks of SHI practices but did not overcome the border between inpatient and outpatient care. It thereby demonstrated again the difficulty of introducing considerable changes by relying on the bodies of self-governance and corporatism.

After the replacement of Andrea Fischer with the social democrat Ulla Schmidt, the strategy of the ministry changed...

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