Cardiology Practice in Germany

Dr Frank Sonntag
Henstedt-Ulzburg, Germany

National Health Care Systems of industrial countries show great differences in organisation and financing. Especially in these countries the gap between demand, medical progress and financial resources is growing.

Health Care in Germany

Germany has 82.4 million inhabitants. The National Health System in Germany covers most of them. Beyond an income of more than 49,550 Euros per annum private medical insurance is allowed as an alternative. Many people prefer private insurance as an "add on" to the obligatory part in the National Health System which cannot cover all medical options and offerings, for example during hospital treatment. Some patients have no insurance and pay for each medical service. On the other hand a well established social network of public institutions exists.

Health care expenses per inhabitant in Germany total around 3,000 USD (compared to USA 6,000; Switzerland 4,000; Turkey 600).

At the end of the year 2009 there were:

• 325,945 medical doctors in Germany
• 95,417 without any speciality
• 42,897 general practitioners (as a speciality!)
• 42,703 internal medical doctors (including about 4,000 cardiologists as a subspecialty in hospital and private practice).

Germany has a physician density of 103 – 240 inhabitants per doctor with great local differences. The density of 3.4 doctors per 1,000 inhabitants (OECD 3.0) is rather high. Nearly all regions in Germany have a close regulation of the number of medical doctors especially of specialists such as cardiologists. During the last two decades many hospitals had to be closed or at least had to reduce the number of beds due to local "overcapacity" (too many hospital beds unoccupied) and as a result of very short in–hospital stays, strictly controlled by insurances which only pay up to a predefined number of days per pre-specified diagnosis.

There is a free choice of medical care in private practice for all patients even when consulting a specialist. There is no strict "gate keeper" role of the family doctor.

Cardiology in Germany

As in many other countries the speciality of cardiology in Germany is a sub- speciality in general internal medicine. To obtain credentials as a cardiologist one has to serve in a cardiology department of a referral hospital at least 2 years after obtaining the credentials of internal medicine.

Cardiologists in Germany are well organised. The DGK ,(Deutsche Gesellschaft für Kardiologie) is the scientific organisation and includes more than 6,000 members including trainees, young scientists and associated members and forms an "umbrella" for several groups of cardiologists having their own organisation:

• The ALKK (Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (non university departments)
• The BNK (Bundesverband Niedergelassener Kardiologen Deutschlands).

Almost 90% of cardiologists in private practice are members of the BNK and most of them are also members of the DGK. The BNK is one of the founding members of the Council for Cardiology Practice (CCP) of the ESC. Only cardiologists in private practice can become members of the BNK. At the moment about 1,100 cardiologists are listed.

Continuous medical education, evaluation of quality control systems and representation of out of hospital cardiology in the ongoing discussions between politicians, representatives of insurance companies and, last but not least, the population are the main goals of the BNK.

Typically a cardiologist in private practice has 3,200 to 4,000 consultations per year. The patients are usually sent by general practitioners or other specialists with special problems or questions to be answered.

The following examinations are available in most of the offices: ECG, exercise testing, coloured doppler ultrasound, stress echocardiography, doppler ultrasound to examine peripheral arteries and the carotic vessels, ambulatory 24 hour ECG and blood pressure examination, pace maker control systems for most of the pm available.
Transoesophageal Echocardiography (TEE) and special pacemaker supervision (AICD, CRT) as well as Chest X-Ray are available in some offices.

During the last two decades the number of cardiologists in private practice who perform invasive procedures like coronar angiography and interventions like PTCA or PTA is rising. Usually there are cooperation agreements with hospitals.
In 2005 cardiologists in 136 private practices performed 124,585 diagnostic coronar angiographies and 6,371 interventions which means about 18% of the diagnostic procedures and about 11% of the interventional procedures in Germany at that time were performed by cardiologists in private practice. The number of pure diagnostic procedures is rising due to reimbursement contracts with the insurance companies.
There exists a well established and accepted quality controlling system the "QuIK" registry (Quality in Kardiology) which was first developed by members of the BNK and was introduced on a voluntary basis more than ten years ago.
In the meantime it is worldwide a unique quality assurance project in cardiology. Many of the cardiologists are members of local networks as well with regard to medical, logistical and economical considerations.

Reimbursement

Concerning the national health system there have been important changes during the last years with a strong trend to a complex reimbursement number system including most of the above mentioned examinations in a so called "Regelleistungsvolumen(RLV)".
This means that a cardiologist in private practice receives about 50 to 70 Euros in reimbursement every 3 months –widespread in some regions-for consultation, examination and treatment of a typical patient. There is no difference with regard to the severity of the underlying disease or to the frequency of consultations during these three months.

Only a few numbers of very special procedures like transoesophageal ultrasound or supervision of special pacemakers (AICD, CRT Systems) have individual reimbursement.
Patients with a private insurance have a specific method of payment whereby the real number and type of examinations are individually reimbursed which is more attractive - and justified.

Compared to other European countries there are huge differences in the reimbursement of the work of cardiologists in private practice (but not only in private practice) which cannot be explained by medical reasons but more by socio-economic and political ones.

Conclusion 

Cardiology in Private Practice is a fundamental part of medical support of patients in Germany. More than 1,000 cardiologists in private practice with about 4 million consultations, examinations and treatments per year,  work together with general practitioners and almost all other specialists as well as with university and non-university hospitals. Thus the number of hospital days and the duration of hospital treatments could be reduced by pre- and post-hospital management which is of high socio-economic importance.
Quality controlling systems do exist. Continuous medical education is mandatory.