Germany's new user fee cuts doctor visits
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* Claudia Orellana

*   © 2004 Canadian Medical Association or its licensors

Visits to physicians have decreased after the German government introduced a controversial £10 (about Cdn$16.50) user fee in January. Patients must pay for their first doctor's appointment each quarter.

During the first quarter of 2004, there was an average decrease in doctor visits of 10%, according to figures the Association of Statutory Insurance Physicians (KBV) released in late April. General practitioners saw 9% fewer patients, and consultants 10.5%. 

The government introduced the fee in January 2004 as part of a health reform package to cut increasing health costs. After running a £2-billion (Cdn$3.3-billion) annual deficit for 3 years, the statutory health insurance system has moved into the black, making it possible to reduce monthly insurance payments. 

“The fee is accomplishing its regulatory effect,” Health Minister Ulla Schmidt said. 

But the physicians' association believes the crucial question is “not just how many people are staying away from the doctor's, but who is staying away,” says spokesperson Roland Stahl.

A June survey by the Employees Health Insurer, a public-private agency, indicates 9% of those insured went to work despite feeling slightly ill. Twenty percent of those who had reported in sick for less than 3 days in 2003 admitted they visited the doctor mainly to get permission to stay home.

“These results clearly suggest that unnecessary doctor visits are being avoided, which argues in favour of the fee,” says Rolf Mentzell, the Health Insurer's spokesperson in Hamburg. 

The physicians' association argues the fee will work well if it deters those with a compulsion to make multiple doctor visits. “Doctors will have more time for the genuine patients, which is what we and the lawmakers want. But if the fee keeps socially disadvantaged patients away, naturally it would be disastrous,” says Stahl. 

That's exactly what's happening, says the General Association of Patients, a lobby group. “The fee operates by social selection,” says Christian Zimmermann in Marburg. “For those who earn enough, £10 is nothing … while those who live in difficult financial circumstances have to think twice.” 

The initial drop in doctor visits may be partially explained by a last-minute rush to beat the fee at the end of 2003, says Stahl. — *Claudia Orellana*, Tubingen, Germany