Physician and other ambulatory care services in Germany.

The Germany multipayer universal health insurance plan in 1992 consumed 8.7% of its nation's total expenditures. Nevertheless, its macromanaged approach has allowed until recently for pluralism, decentralization, and self-regulation among providers and sickness funds (not-for-profit, third party payers). With 34.8% more physicians per 1,000 persons, German doctors provided twice as many patient contacts per capita than in the United States. Due to economic constraints and increases in payroll taxes, the Federal Republic of Germany's parliament, with its 1993 health reform plan, virtually froze all payments to providers for a 3-year period. Among other contentious provisions were the following: (1) limiting the entry of new physicians into municipalities that are considered by government health manpower planning experts to be oversupplied in that specialty; (2) requiring community-based physicians to participate in controlling pharmaceutical costs; and (3) eliminating some of the German traditional barriers between their in- and out-of-hospital physicians. This article focuses on how the Germans now micromanage their physician and other ambulatory care services within a macromanaged system that, in terms of patient access, benefits, quality, and cost, should be the envy of the Americans.