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3.3. Common Explanation Approach
This short overview of the development of drug expenditure in the last 20 years casts
a negative picture of the long-term impact of political attempts at cost-containment.
The question arises: why has politics failed to construct an effective control system to
achieve the of? cially declared goal of cost-containment?
As a major reason for the unassertive reform process, it is usually alleged in scienti? c literature that the German SHI is characterised by the qualities of the so-called
“negotiation democracy”. The concept “negotiation democracy” was used for the ? rst
time in the 1970s to describe political systems in which essential decisions were not
reached by a majority of votes, but by the way of negotiation processes.33 Especially
health policy is highly affected by this because of a multiplicity of negotiation arenas.
On the one hand, most health care reforms require the approval of both the Bundestag
(Lower House of Parliament) and the Bundesrat (Upper House of Parliament). Different political majorities in each chamber often lead to con? icts in the negotiations
through the competition of parties, causing blockades of the reform process for tactical
reasons (Schreyögg et al. 2004). On the other hand, the organisational build-up of the
SHI provides special associations and interest groups with several possibilities to exert
in? uence on the decision-making process (Gäfgen 1988). In the context of the SHI’s
self-administration, associations of SHI physicians and the central associations of the
sickness funds possess the decision making authority. Decisions take place under supervision, but without direct participation of government. Other institutionalised forms
of involvement of interest groups in special committees are without decision-making
power, but they are nevertheless very important in forming political opinion (Bandelow 2004), e.g. the “Concerted Action in Health Care” (disestablished in January
2004) or the “Advisory Council to the Assessment of the Development in Health
Care”.34 Apart from this, it is normal for more than 70 interest groups to take part in
parliamentary hearings on health care reform acts (Schreyögg et al. 2004, p. 5). The
analysis of the political decision-making process is getting even more sophisticated by
the fact that the process is characterised by unstable protagonist coalitions. Every single issue of reform package generates diverse interest coalitions among the representatives involved (Perschke-Hartmann 1994, p. 21).
The concept of “negotiation democracy” assumes that the described multiplicity of
negotiation arenas prevents effective health care reform acts. Hence politicians would
not be able to assert strong control instruments against the will of the powerful health
33 The term “negotiation democracy” was introduced into German-speaking political science by
Lehmbruch as “Proporzdemokratie” (Lehmbruch 1967). Later on he replaced this term with the
Swiss concept “Konkordanzdemokratie” (Lehmbruch 1968), which is the German equivalent to
Lijphart’s “consociational democracy” (Lijphart 1968). See also Lehmbruch 1996. The theory
of “negotiation democracy” was extended in the 1980s by the compromise and negotiation enforcements of the federal structure as well as the neo-corporatism con? ict-settlement in Germany (Czada 2000).
34 Bandelow (1998) gives a survey of all included interest groups.
49
care providers and the pharmaceutical industry respectively. But a closer look at the
history of health care reform acts reveals that the government is not as helpless as this
theory hypothesises. In the past, government was able to accomplish – from the view
of the suppliers – uncomfortable SHI-modi? cations, e.g. the introduction of the drug
budget in 1993 or the inclusion of patent-protected drugs into the reference-price system in 2004.35 Consequently, one can adhere to the fact that, contrary to the presumptions of the theory of “negotiation democracy”, government is able to implement
strong control instruments even against the ambitions of associations and special interest groups.
But it must also be recognised that health policy repeatedly had a split personality
in the past: in contrast to the of? cial stated goals of cost-containment and contribution
rate stability, the same government which introduced reference pricing excluded patented drugs and thus offered health care suppliers the possibility of circumventing
price controls. Equally astonishing is that the same government which established the
drug budget, counteracted it itself abstaining from claiming regresses in cases where
the budget was exceeded, not to mention that this most restrictive control instrument
was ? nally abolished. Another example is the non-consideration of a positive list, although this control instrument had been discussed several times. Thus it can be stated
that succeeding governments were either unable or unwilling to vigorously pursue the
announced goal of cost-containment in the last decades.
3.4. The Perspective of Public Choice
The main failure of the theory of “negotiation democracy” is it basically assumes that
politicians are really interested in decreasing drug expenditure. An investigation into
the self-interests of politicians reveals a different picture:
Politicians aspire towards vote maximization. They do not act unsel? shly to satisfy
the preferences of people, but they try to attain or stay in power (Downs 1957). Since
health politics is always one of the most followed policy ? elds, especially during election campaigns, it is understandable that it plays an important role in election chances.
People react highly sensitively to reductions in health care provision or increasing
fees. Therefore politicians at least of? cially call for a comprehensive standard bene? t
catalogue and contribution rates stability. However, since the concurrent ageing of the
population demographics and technological progress cause health care cost escalation,36
another sector which pays is needed. Instead of burdening the electorate, it should be
attractive for politicians to cut costs at the expense of the suppliers. But the medical
fraternity is especially disposed to having a close relationship to patients and act as
35 A detailed overview of the history of health care reform acts and negotiation democracy is given
in Blankart and Wolf (2005).
36 For the interrelation of the ageing demographics, technological progress and increasing health
care costs see e.g. Knappe (1995), PROGNOS (1998), Breyer and Ulrich (2000), Hof (2001),
Postler (2003).
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References
Zusammenfassung
Der Arzneimittelsektor der Gesetzlichen Krankenversicherung stand wiederholt im Fokus zahlreicher Gesundheitsreformen. Dennoch ist es bislang nicht gelungen, den Trend steigender Ausgaben nachhaltig zu bremsen. Die vorliegende Untersuchung leistet einen Beitrag dazu, die Ursachen dieser Entwicklung zu erklären und Lösungsansätze aufzuzeigen. Mittels Hauptkomponenten- und Cluster-Analyse wurden Gruppen von Arzneimitteln mit vergleichbaren Konsumeigenschaften gebildet. Jede Gruppe wurde auf den Einfluss der Altersabhängigkeit und des technologischen Fortschritts hin analysiert. Aufbauend auf diesen Ergebnissen wurde eine Prognose der zukünftigen Ausgabenentwicklung bis zum Jahr 2050 erstellt. Obwohl die Hauptkostenfaktoren exogen sind, steht der Gesetzgeber dem vorhergesagten ansteigenden Kostenpfad nicht hilflos gegenüber. Im Gegenteil: Anhand ökonometrischer Tests wird gezeigt, dass die Gesundheitspolitik in der Vergangenheit durch wahl- und klientelorientierte Interessendurchsetzung geprägt war. Mehr Effizienz in der Arzneimittelversorgung könnte durch die Einführung individueller Gesundheitssparkonten erzielt werden. Dies bestätigen die Resultate eines vertikal differenzierten Wettbewerbsmodells.