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Family physicians as gatekeepers

Partner Institute: 
Bertelsmann Stiftung, Gtersloh
Survey no: 
Sebastian Hesse, Sophia Schlette
Health Policy Issues: 
System Organisation/ Integration, Access
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no
Featured in half-yearly report: Health Policy Developments Issue 4


The health care reform act of 2004 introduced a new family physician?centered option for primary care delivery in the German health care system. The family physicians serve as gatekeepers and ?navigators? through the health care system. A specialist can be seen only upon referral from the family physician. With this new model of care the German Ministry of Health and Social Security aims to improve quality and to achieve more efficient use of available funding in the German health care system.

Purpose of health policy or idea

Improved coordination of care and the reduction of overuse, underuse and misuse have been long-standing issues in the German reform debate. More specifically, the new model aims to reduce hospital admissions, encourage more efficient use of pharmaceuticals and avoid redundant examinations. The recent reform act requires all sickness funds to offer their members the option of family physician centered care. The insured person can choose whether to register for the model or to remain in the regular system. An individual who enrolls in the new model is eligible for a bonus from the sickness fund: The quarterly € 10 user fee is waived. Depending on the contract physicians receive quality-related additional payments or registration fees, if they manage to enroll their patients in the model.  

The recent reform act requires all sickness funds to offer their members the option of family physician-centered care. To receive such contracts, family physicians must meet criteria established by agreement between the sickness funds and the Federal Physicians' Association: They must participate in quality circles, treat their patients according to evidence-based guidelines, run a quality management program within their practice, and meet minimal administrative standards (technical equipment, IT for patient records and billing information, etc.).

Main points

Main objectives

Improve quality of care; foster further integration of the health care system, increase competition between sickness funds and between providers, cost- containment

Type of incentives

Physicians: Additional reimbursement for specific treatments (e.g. prevention); registration fee for family physicians enrolling patients into the contract;

Patients: € 10 user fee is waived, other bonuses from sickness funds possible

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Characteristics of this policy

Degree of Innovation traditional neutral innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent system-neutral system-neutral

Political and economic background

This legislation is part of an overal strategy within the German Health Care system to use more flexible ways of delivery of care and to implement selective contracting. With the same reform act the already existing possibilities of integrated care were strengthened and so called  "Medical Centers" (Medizinische Versorgungszentren) a polyclinic-type of care center were allowed. The Ministry of Health and Social Security aims  to establish more competition in the system with this legislation.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no yes no no

Origins of health policy idea

Main purpose of this idea is a better coordination of care especially to save money and increase quality of care. Driving forces behind this idea were the family physicians and their organisations and the Ministry of Health and Social Security. The idea of family physician centered care is not new in the European context and has as well been discussed for a while in Germany. Countries like Denmark and the Netherlands have organised their system on a family physican centered basis since years.

Initiators of idea/main actors

  • Government
  • Providers
  • Payers
  • Patients, Consumers
  • Political Parties

Approach of idea

The approach of the idea is described as:

Innovation or pilot project

Local level - QualiNet e.V. a network in Mannheim, Baden- Württemberg

Stakeholder positions

Gatekeeping in ambulatory care is not uncontroversial. Opposition comes from specialists who claim that freedom to choose a physician is an important asset of the German system that ought to be safeguarded. Obviously a gatekeeping model weakens the position of specialists within the system what might explain their criticial position. Criticism also comes from the Federal Physicians' Association and the German Family Physicians' Organization, who object to the special criteria for family physicians who participate. They argue that two thirds of the family physicians already qualify as general practitioners (GPs) and that even those who do not qualify as GPs have a high level of education. Another criticism is that if even certain highly qualified family physicians are not eligible for contracts, the sickness funds might take advantage of the situation to exclude those physicians with a high percentage of elderly and high-risk patients with certain chronic conditions.

Actors and positions

Description of actors and their positions
MoHvery supportivevery supportive strongly opposed
Family Physiciansvery supportivesupportive strongly opposed
Specialistsvery supportiveopposed strongly opposed
Federal Physicians Associationvery supportiveopposed strongly opposed
Sickness Fundsvery supportivesupportive strongly opposed
Patients, Consumers
Patientsvery supportivesupportive strongly opposed
Political Parties
Social Democrates, Green Partyvery supportivevery supportive strongly opposed
CDU/ CSUvery supportivesupportive strongly opposed

Influences in policy making and legislation

The gatekeeping model is part of the Statutory Health Insurance Modernization Act 2004. The Social Democrats and the Green Party suggested in their reform proposal after the election in 2002 to give more power and influence to the sickness funds. They aimed to shift the responsibility for the security of the ambulatory care (Sicherstellungsauftrag) from the regional physicians associations to the sickness funds. This would have meant a fundamental shift of power and influence within the German health care system changing it in the direction of a more managed care/ HMO model. This change was averted by the opposition saving the powers of the regional physicians associations. Nevertheless new forms of the delivery of care - integrated care models, polyclinics and family physician centered care models were decided. The coalition between SPD and Green-Party and the Christian Democrats (CDU/CSU) agreed in more than one week lasting negotiations about the reform act including the gatekeeping system. Horst Seehofer from the Bavarian Christian Socialist Union (CSU) in charge of health and social policy within the CDU/CSU during that time used his strong personal position and the power and influence of the Christian Democrats because of their majority in the Bundesrat, the Chamber of the "Länder", to put through major changes to the reform act especially regarding the Sicherstellungsauftrag. The family physician centered care model was rather uncontroversial between the political parties.

Actors and influence

Description of actors and their influence

MoHvery strongvery strong none
Family Physiciansvery strongstrong none
Specialistsvery strongweak none
Federal Physicians Associationvery strongstrong none
Sickness Fundsvery strongvery strong none
Patients, Consumers
Patientsvery strongstrong none
Political Parties
Social Democrates, Green Partyvery strongvery strong none
CDU/ CSUvery strongvery strong none
MoH, Social Democrates, Green PartyFamily Physicians, PatientsSickness Funds, CDU/ CSUSpecialistsFederal Physicians Association

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

Family physician centered care contracts are agreed upon between sickness funds and the Federal Family Physician Organisation, regional family physicians organisations or single family physician networks. Sickness funds can as well sign contracts with family physicians in solo practices but this is rather unlikely because of the unbalance of the bargaining power between a sickness fund and a single family physician.

Several contracts were signed during the new program's first year. One of the first to take effect was between the QualiNet, a regional physicians' network in Mannheim, and the AOK sickness fund in Baden-Württemberg. The Barmer Ersatzkasse, the largest single sickness fund in Germany, recently signed a contract with the German Family Physicians' Organization that is valid nationwide and includes pharmacies.

Another prominent example is an agreement among the AOK, the regional physicians' association and the regional association of family physicians in Saxony-Anhalt. After just two months, about 1,000 of 1,600 family physicians had signed the agreement and some 200,000 out of 900,000 AOK members had registered.


Monitoring and evaluation

Certain contracts foresee an evaluation. An overall evaluation on terms of a policy impact analysis is not planned.

Expected outcome

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low high very high


Author/s and/or contributors to this survey

Sebastian Hesse, Sophia Schlette

Suggested citation for this online article

Sebastian Hesse, Sophia Schlette. "Family physicians as gatekeepers". Health Policy Monitor, 12/04. Available at