• K Vilmar.
• Bundesärztekammer, Köln.
• Z Arztl Fortbild Qualitatssich. 2000 Dec 1; 94 (10): 870-6.

AbstractThe progress in medicine has contributed to the fact that for 50 years life expectancy in Germany has increased by three to four years per decade. The number of older people has considerably increased and at the same time there has been a decline in the birthrate with the effect that the portion of the people over 60 years, now a quarter of the population, will rise to a third of the population in 2040. The dual relationship between patient and physician has changed due to the extension of the statutory health insurance to more than 90% of the population. Today collective contracts made with the statutory health insurance determine the preconditions for entitlement, but often with uncertain legal concepts. The expenditure which occurred due to the demographic and epidemiologic changes caused the limitations of the contribution rates by the legislator. The health insurance funds have implemented further regementations by means of health care duties and action for recourse in case of exceeding the budget. Thus the politically intended limitation of the resources can bring the physician in a decision emergency condition or even in an ethical dilemma. He has to observe legal rules, especially in the field of the criminal law and the liability law. Thus the financial, organizational and structural deficits in the health care system that are resulting from the social legislation are shifted by means of the liability law to the individual physician or to other service providers. Even treatment guidelines cannot protect them from this because the "standard patient" does not exist. What we really need are appropriate reforms including adjustments of the insurance structures which offer the insured alternatives: Expansion of the financial elements of the statutory health insurance Adjustments of the health care structures with integration between the outpatient and inpatient sector Restriction of the legislator to the definition of framework provisions and service limits Orientation of the health care necessities to the health care needs of the patients Economy must not dominate over humanity Adjustment of the social legislation and the liability law Settlement of the details by the joint self-administration of physicians and health insurance funds.

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