Determining the "Health Benefit Basket" of the Statutory Health Insurance scheme in Germany: methodologies and criteria.

ABSTRACT

The issue of defining health benefit catalogues has recently gained new importance in Germany as a result of the creation of the new Institute for Quality and Efficiency. The Institute was designed to support the Federal Joint Committee conducting effectiveness studies for benefit coverage decisions. The Committee and the contractual partners (sickness funds and providers) define the benefit catalogues for the Statutory Health Insurance in the framework of Social Code Book V, Germany's most relevant health care scheme. Unlike other countries, the German federal government limits its regulatory role to defining procedures that determine the scope of Statutory Health Insurance services. The explicitness of the benefit catalogues varies greatly between different sectors. While benefits in outpatient care are rather explicitly defined, benefit definitions for inpatient care are vague. It is argued that the establishment of the new Institute and the development of the DRG system are initial steps towards a more effective and explicit benefit catalogue.