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德国法定健康保险:一个由 135 年的团结、自治和竞争塑造的健康体系。

Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition.

机构信息

Department of Health Care Management, Berlin University of Technology, Berlin, Germany; European Observatory on Health Systems and Policies, Brussels, Belgium.

Department of Health Care Management, Berlin University of Technology, Berlin, Germany; European Observatory on Health Systems and Policies, Brussels, Belgium.

出版信息

Lancet. 2017 Aug 26;390(10097):882-897. doi: 10.1016/S0140-6736(17)31280-1. Epub 2017 Jul 3.

Abstract

Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their health-care providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer-provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany's neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.

摘要

1883 年俾斯麦的《健康保险法案》建立了世界上第一个社会健康保险制度。德国法定健康保险制度建立在团结和自治的基本原则之上,这些原则在其 135 年的持续发展中一直处于核心地位。参保人群和福利覆盖范围的逐步扩大,导致了 2017 年全民享有广泛福利的医疗保险。自治最初主要适用于参保人(疾病基金),但在 1913 年扩大到涵盖疾病基金和医生之间的关系,这反过来又使参保人有权自由选择医疗服务提供者。1993 年,正式引入了选择自己疾病基金的自由,鼓励竞争和加强市场导向的改革在过去 25 年中逐渐变得重要;这些改革旨在保护团结和自治的原则。2004 年,通过建立联邦联合委员会来加强自治,该委员会是一个主要的支付方-提供者结构,负责制定统一的医疗准入和分配规则、福利覆盖、部门间护理协调、质量和效率。在联邦联合委员会的监督下,支付方和提供者协会确保了高质量医疗保健的良好可及性,而没有出现实质性的短缺或等待时间过长的情况。然而,自治导致了药品供应过剩、住院人数和住院时间过多以及在部门间提供连续护理方面存在问题。德国的健康保险体系不如一些邻国的成本效益高,考虑到目前的支出水平,这表明需要提高效率并为患者创造价值。

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