Priority-setting and rationing in German health care.

While the framework for the German statutory health insurance system is determined at the national level and the states have a significant influence on the provision of hospital care and public health services, most decisions on the actual delivery of curative health care services are made through joint negotiations between the associations of the physicians and the sickness funds at various levels. Decisions with effects on priority-setting include the determination of the benefit package and financial regulations. The actual provision of care is further regulated through guidelines, e. g. about the prescription of pharmaceuticals. Financial regulations include both the setting of budget limits and the determination of relative point values which affect remuneration and serve as incentives to provide certain services (or not). A survey of 2000 citizens reveals, however, that the majority of the public favours unlimited funding for health services and that treatment decisions should be made by doctors. Limiting the benefits catalogue to a core of essential services is rejected as well as priorities based on age. Separately interviewed experts expect further limitations of therapeutic freedom, however. Germany seems to be just at the beginning of a public debate on priority-setting and rationing in health care.