Reforming the payment of health care providers: experiences in France and Germany

A full-day workshop with the title “Reforming the payment of health care providers: Experiences in France and Germany” has been held on 19 February 2016 at the CVV in Paris. A total of 14 experts from both France and Germany participated, including decision makers, researchers and provider representatives.


France and Germany represent the two largest health systems based on statutory health insurance in Europe. Both systems provide universal coverage mostly funded by employer-employee contributions and managed by not-for-profit sickness funds. In each country, the ambulatory sector is largely private with a generous supply of GPs and specialist physicians, while in the hospital sector public and private facilities co-exist. Additional commonalities are seen in the pressures that have driven policy makers in both France and Germany to explore provider payment reforms to improve the quality and appropriateness of care while reducing costs.

Among such reforms payment for performance (P4P) has proven to be particularly contentious. P4P is the most developed Innovative payment mode among OECD countries. Its principles are to link quality targets to bonus payments or financial penalties. Despite large evaluations, there is limited evidence about quality improvements and cost reductions. Both countries began exploring P4P in 2007, and France adopted this innovation in the ambulatory sector in 2009, while Germany has not done so to date. In the hospital sector, both countries have undertaken experiments with payment reform, although France is the first to expand this initiative nationwide in 2016.

The workshop shed light on these divergent policy pathways, by presenting case studies of recent provider payment reforms in ambulatory and hospital care in both countries, before analyzing and discussing underlying issues.

Setting the ground

In providing the necessary background in terms of health policy, an overview of the structure and recent structural health reforms in France and Germany was provided by P. Hassenteufel. It was followed by an international perspective on current trends in provider payment models in OECD countries, presented by M. Müller, who highlighted the role of P4P experiences and a more recent trend towards bundled payments. To close the session, the role of foreign experience in the introduction of P4P was discussed by M. Brunn.

Case studies on provider payment reforms

In the following sessions, case studies from different sectors compared the experiences in France and Germany. Experiences and perspectives in ambulatory payment systems were discussed using the example of P4P in France, presented by P.-L. Bras. This nationwide payment reform contrasted with a local example of a local provider network with bonus payments in Germany, presented by A. Lipécz. For the hospital sector, E. Minvielle provided insight into the pilot experiences and the current national roll-out of performance-based bonus payments, while W.-D. Leber from Germany presented the challenges of the recent hospital reform, permitting hospitals to set up local or regional quality programs with bonus payments. Finally, M.-C. Clément and R. Schaffert discussed the current state-of-play in terms of information systems and potential new payment models for inpatient psychiatry, where in both countries there still is high uncertainty about the exact paths to be taken.

Summary and outlook

Overall, contributors engaged in very vivid discussions, owing both to the exchange of information and opinions as well as the search for common issues and solutions. The latter were diverse and included more technical issues such as patient selection and external validity of indicators, i.e. the fact that some quantitative measures do not necessarily always have a high implication for real-life patient care. Another transversal challenge seemed to be the question of data collection, especially since the ownership of performance data may come with power gains for the holder. In this context, investment in IT systems (for improved data collection and exchange) seemed to be a more or less explicit objective of many provider payment reforms. Finally, the way whereby care providers interact with other system actors (for instance negotiations between hospitals and health insurance) appeared to be an important factor in shaping distinct reform responses in both countries.

In the end, the workshop agreed to continue their interaction and exchange of ideas, potentially at the occasion of a follow-up workshop. In the meantime, more detailed conclusions are being made available via a common publication.


Matthias Brunn

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