Integrated primary care in Germany: The road ahead

Abstract

Problem statement
Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult.

Description of policy development
Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’.

Conclusion and discussion
Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.

Full text

Sophia Schlette, Senior Expert Health Policy, Bertelsmann Stiftung, Carl-Bertelsmann-Str. 256, 33311 Gütersloh,
Germany
Melanie Lisac, Project Manager, International Network Health Policy and Reform, Bertelsmann Stiftung, Carl-Bertelsmann-
Str. 256, 33311 Gütersloh, Germany
Kerstin Blum, Project Manager, International Network Health Policy and Reform, Bertelsmann Stiftung, Carl-Bertelsmann-
Str. 256, 33311 Gütersloh, Germany
Correspondence to: Kerstin Blum, Bertelsmann Stiftung, Carl-Bertelsmann-Str. 256, 33311 Gütersloh, Germany, E-mail:
kerstin.blum@bertelsmann.de
The authors all work as project managers for the International Network Health Policy and Reform, a project of the
Germany-based Bertelsmann Stiftung (Foundation); Sophia Schlette is the Foundation’s Senior Expert Health Policy.
The network brings together health policy experts from 20 industrialized countries who report biannually on health policy
trends and developments in their countries. Reports and publications are published on the project’s internet database www.
healthpolicymonitor.org. The purpose of the International Network Health Policy and Reform is to narrow the gap between
international evidence and policy, providing timely information of what works and what does not work in health policy
reform.
Abstract
Problem statement: Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a
system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions,
or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve
coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians
traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers,
making coordination and cooperation within and across sectors difficult.
Description of policy development: Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the
German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care
as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery
side disease management programmes, medical care centres, gatekeeping and ‘community medicine nurses’.
Conclusion and discussion: Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment
by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers
for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination
and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms
need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of stan-
dardized IT systems and trans-sectoral education and training of providers.
Keywords
primary care, care coordination, continuity of care, disease management programmes, gatekeeping, medical care
centres
Policy
Special series: Integrated primary health care
Integrated primary care in Germany: the road ahead
International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care 1

This article is published in a peer reviewed section of the International Journal of Integrated Care 2
International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/
Introduction
Health care delivery in Germany is highly fragmented,
resulting in poor vertical and horizontal integration and a
system that is focused on curing single diseases instead
of managing patient populations. While it is now widely
accepted that a strong primary care system can help
to improve coordination and responsiveness in health
care, with the endorsement of the government, primary
care in the German system has only recently begun to
move in that direction. Traditionally there has been no
gatekeeper function; patients can freely choose and
directly access both primary and secondary care pro-
viders, making coordination and cooperation within and
across sectors difcult.
Since 2000, in an unusually long phase of program-
matic and personal continuity in health care policy in
Germany, the Federal Ministry of Health prepared sev-
eral decisive legislative moves to improve care continuity
with primary care as a hub. It promoted more integrative
forms of care via disease management programmes
and medical care centres, it induced competition via
selective contracting among providers and payers, it
fostered gatekeeping and introduced patient registries
for the chronically ill, and it began to align nancial
incentives for physicians, insurers, and patients.
In this article, we will rst give a brief working denition
of integrated primary care and then outline the current
status of the German health care system from an inte-
grated primary care perspective. We will identify exist-
ing barriers to integrated primary care in Germany.
Against this background, we will then present different
reforms and policies implemented in Germany since
2000. All these reforms have placed primary care in
the centre, strengthening its role as the patient’s navi-
gator through the health care system. As far as evalu-
ation results are available—implementation of most of
the reforms is ongoing and systematic evaluation is not
always a requirement—we will discuss the impact of
the new forms of care on coordination and health out-
comes. In the concluding section we will assess future
implications for policy makers: have these reforms
pulled the right levers for promoting stronger coordina-
tion and strengthening the primary care system’s role
as navigator through the health system? What other
barriers must be addressed by future reforms?
Primary care: at the centre of a
fragmented system
A brief working denition of integrated
primary care
A strong primary care system can help improve conti-
nuity and responsiveness in health care especially for
specic population groups such as frail elderly or peo-
ple with complex conditions, but also for the popula-
tion in general [1, p. 15]. According to Stareld, primary
care has four main functions. A primary care system
should enable rst-contact access for each new need;
provide long-term person-focused care; ensure com-
prehensive care for most health needs, and it should
coordinate care, both horizontally and vertically, when
services from other providers are needed [2]. This is
because person-focused, comprehensive care can
only be provided when primary care is supported by
other levels of care, including community services and
hospital care. For our purposes, we dene integrated
primary care as a system that fulls all these four func-
tions and especially the coordinative function.
In the following section, we will assess how well the
current German system is prepared to full this coordi-
native function and thus to provide integrated primary
care. How well does cooperation between different
professions work—within the primary care sector,
between the primary care sector and other sectors
of health care, and between health and social care?
What role does primary care play in the coordination
process, and what are the barriers to a more integrated
role of primary care?
Primary care in Germany: status quo
Primary care in Germany includes all ambulatory
care services provided by ofce-based, mostly single-
handed, private for-prot general practitioners/family
doctors, general internists or paediatricians. Primary
care providers make up 49% of ofce-based physicians
in Germany. The other half are specialists—almost all
specialities are offered in Germany by ofce-based
secondary care providers [3].
Traditionally primary care physicians do not have a for-
mal gatekeeper function. Individuals can freely choose
their primary care provider, and patients have free
choice of specialists, psychotherapists (since 1998),
dentists, pharmacists and emergency care [4, p. 5].
Since ofce-based primary and secondary care phy-
sicians work in solo practice, health care is often not
coordinated. Doctor hopping is a well-known phenom-
enon and consequence from the way the system is set
up [5].
Solo doctors and their support
Sixty-eight percent of primary care physicians in Ger-
many work in solo practice; 31% work in small group
practices with 2−4 full-time equivalent doctors [6]—shar-
ing ofce space but not patients or patients’ health care
les. Medical care in the primary care setting is exclu-
sively provided by physicians—other health care work-
ers with a ‘midlevel’ of training (like nurse practitioners
or physician assistants in the US, Canada, or the Neth-

International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/
This article is published in a peer reviewed section of the International Journal of Integrated Care 3
erlands) does not exist in German primary care [7]. Tra-
ditionally doctors have worked with medical assistants
(‘Arzthelferin’) who complete a three-year vocational
training, and whose role in physicians’ practices com-
bines administrative and some clinical tasks. In a medi-
cal assistant’s daily work administrative tasks prevail,
their clinical responsibilities are limited to minor tasks
like taking blood pressure, giving injections or taking
and analysing blood samples. There have been efforts
to develop the medical assistants’ profession into some-
thing closer to a nurse practitioner (see below in the sec-
tion on ‘Community Medicine Nurses’), but most doctors
in Germany (56%) oppose the idea of expanding the
role of non-physicians in delivering care to patients [6].
Health information technology is not very advanced in
primary care practice and still mostly used for admin-
istrative purposes, not for clinical decision support or
patient management. The most common feature is
electronic prescribing of medication (used routinely
by 59% of primary care physicians in Germany) [6]. In
the use of electronic medical records (used by 42%),
electronically ordering tests or accessing test results or
hospital records, Germany lags behind other countries
(see Table 1 Percentage of primary care physicians
using electronic support).
Cooperation between primary care and other
sectors
Care coordination between the ambulatory sector and
the hospital is a challenge for the German health care
system. Hospitals have legally been restricted to focus
on inpatient care and to provide outpatient emergency
care; only university hospitals have formal outpatient
facilities [4, p. 16]. Health care reforms in 2004 and
2007 have granted hospitals additional competencies
to provide outpatient services to patients. Today, the
main forms of ambulatory care provided by hospitals
are day surgery, highly specialised outpatient care,
and outpatient care as part of disease management
programmes and integrated care contracts.
If inpatient treatment is needed, ofce-based phy-
sicians refer their patients (but do not follow them
during their hospital stay) and usually—but not
systematically—receive them back after discharge.
Post-surgical care is usually also done by ofce-based
physicians. Not surprisingly is diverging pharmaceuti-
cal treatment, prior, during and post hospitalization,
hard to explain to patients, and it is a typical bone
of contention between hospitals and primary care
providers.
More than 50% of primary care physicians report that
it takes more than 14 days for them to receive a full
report from a hospital once their patient has been
discharged [6]; for 15% it takes more than a month.
Electronic access to their patients’ hospital records is
available only for 14% of primary care physicians [6].
Seventy percent of the respondents stated that bet-
ter integration of information systems between ofce-
based physicians and hospitals would be an effective
way to improve quality of care [6].
Poor linkages between the health care system and
services in the community like long-term care, social
services, self-help or patient groups, family and lay
carers, are also notorious in Germany, and constitute
another obstacle to more holistic care and better care
coordination. Social care in Germany is provided by
a myriad of mainly private organizations that comple-
ment family and lay support for people with special
needs and various levels of dependency, i.e. the
elderly, children with special needs, mentally ill and
the physically or mentally handicapped [4, p. 16]. One
major reason for poor coordination between health
and social care is nancing: services in these sectors
are nanced by different funding streams and insur-
ance regimes.
Thus, mainstream health care in Germany is still far
from being an integrated system with primary care
at its centre. Current access rules, i.e. free choice
of providers, do not provide incentives for coordina-
tion through a primary care provider. Moreover, the
nancing and the organisational set-up of the system
are two additional barriers to stronger cooperation.
Also, with the spatial separation of care providers and
poor use of health information technology, providers’
administrative costs for coordinating care are still
rather high and are not appropriately reimbursed in
the doctors’ fee schedule. Further, the development
of new professions such as academically trained
nurses who could complement GP services has only
just begun [8, 9].
Aware of these problems, the German government has
introduced a number of reforms during the last nine
years, which address the various barriers identied
above.
Table 1. Percentage of primary care physicians using electronic
support
Percent reporting
routine use of:
AUS CAN GER NL NZ UK US
Electronic patient
medical records
79 23 42 98 92 89 28
Electronic prescribing
of medication
81 11 59 85 78 55 20
Electronic access to
patients’ test results
76 27 34 78 90 84 48
Electronic access
to patients’ hospital
records
12 15 7 11 44 19 40
Source: 2006 Commonwealth Fund International Health Policy Survey
of Primary Care Physicians.

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Health care reform in Germany:
steps toward better care
coordination
Since the year 2000, the German government has
introduced a variety of managed care tools and struc-
tures, through three subsequent reforms [10–12]. The
most recent reform act of 2007 [12] has broadened
opportunities of care coordination between providers
and across sectors.
Gatekeeping, disease management programmes,
integrated care contracts, medical care centres and
community medicine nurses all can lead to a stronger
role for primary care. Receiving previously unknown
political support, primary care providers can now full
a more integrating function and act as patient naviga-
tors through the health care system. Other objectives
pursued in the series of reforms mentioned above are
quality improvement and cost control, as care coordi-
nation is expected to contribute to a more efcient use
of health care.
To make new forms of care possible, the government
changed the rules of contracting between health insur-
ance funds and providers. Prior to 2000, contracting
between ambulatory care practitioners and health
insurance funds had been compulsory and indirect—
for physicians contracting with statutory health insur-
ance funds, membership in a regional association of
statutory health insurance physicians has been (and
still is) mandatory. These regional associations nego-
tiate collective contracts for ambulatory care with the
health insurance funds that operate in their region.
They receive a total budget from the health insurance
funds based on historical data and distribute it among
their physician members on a fee-for-service basis.
The Reform Act of Statutory Health Insurance 2000
[10] for the rst time broke with the strict system of col-
lectively negotiated contracts and budgets, introducing
the possibility for physicians to selectively sign con-
tracts with health insurance funds for integrated care
schemes, gatekeeper models and disease manage-
ment programmes.
Integrated care contracts
The 2000 reform thus established the legal basis for
health insurance funds and providers to enter selective
integrated care contracts, besides the above-mentioned
unitary but mandatory collective contractual system.
Under integrated care contracts, care is provided in pro-
vider networks that can be managed by independent
management organizations. But uptake of integrated
care contracts was initially very slow. A key measure
toward accelerating care coordination was the offer
of nancial incentives for providers, introduced by law
but for a limited period of time: from 2004 to 2008, one
percent of the total Statutory Health Insurance budget
available for ambulatory and hospital care has been
earmarked to initially fund integrated care contracts.
In total, the start-up nancing scheduled until the end
of 2008 amounted to approximately e 800 million [13].
From just over 600 contracts in early 2005, by Decem-
ber 2008 their number had risen to more than 6000 with
about four million patients being treated under this con-
tractual form of integrated care (see also Figure 1 Fast
expansion of integrated care) [13].
Figure 1. Fast expansion of integrated care.

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This article is published in a peer reviewed section of the International Journal of Integrated Care 5
Family physicians willing to enter a gatekeeper con-
tract with a health insurance fund have to full certain
criteria: participate in quality circles, follow evidence-
based treatment guidelines, run a quality management
programme in their practice, and attend trainings in
areas like patient-oriented communication, basic treat-
ment and diagnostics of mental disorders, palliative or
geriatric care [19].
Gatekeeping is a very forthright provision of the law-
maker to strengthen primary care, installing the primary
care physician as the coordinating agent in patient
health care and restricting the patient’s free choice of
specialists. Through better care coordination and the
above-mentioned criteria for participating physicians,
gatekeeping contracts are to enhance the quality of
care and to reduce costs by preventing unnecessary
specialist visits.
There is no mandatory evaluation of gatekeeper con-
tract outcomes. However, a survey among health insur-
ance members conducted by the Bertelsmann Stiftung
between 2004 and 2007 revealed that in their current
set-up, gatekeeping arrangements do not achieve their
aims of controlling the number of patient visits to special-
ists or of improving health outcomes. Patients enrolled
in gatekeeper contracts do not report better health
outcomes than patients who are not enrolled, and the
number of visits to specialists does not seem to go down
[20]. In future contracts, more incentives for physicians
to improve the quality of care seem to be necessary if
gatekeeping models are to actually reach their goals.
Disease management programmes
Disease management programmes (DMPs) were intro-
duced in Germany in 2002, in continuation of an ear-
lier reform. In 1996, a risk equalization scheme based
on average spending by age and sex was introduced
between statutory health insurance funds. However,
the costs of providing care for chronically ill patients
had not been taken into account adequately, which led
to health insurance funds particularly targeting young,
healthy insurees. In 2004, a separate high-risk struc-
ture compensation scheme for patients enrolled in
disease management programmes was added. Under
the new scheme, DMP participants no longer generate
a decit: health insurance funds receive an additional
lump sum from the risk equalization scheme for each
person enrolled.
There are six requirements for DMP accreditation by
the German Federal Insurance Authority [21]:
•Treatment according to evidence-based guidelines
with respect to the relevant sectors of care;
•Quality assurance measures;
The Statutory Health Insurance Competition Strength-
ening Act of 2007 [12] established further integrated
care opportunities. Since then, long-term care provid-
ers can be included in contracts, and non-medical pro-
fessionals can become the main contractual partner to
health insurance funds, a position formerly restricted to
physicians. Also since 2007, integrated care contracts
now are to focus on population-oriented integrated care,
a term not dened by the lawmaker to allow for cre-
ativity in designing integrated care models. It is usually
understood as proactive, patient-centred health care
for a dened population with providers taking respon-
sibility for the coordination of care and for improving or
maintaining the health status of the insured population,
thereby putting a focus on health promotion or preven-
tion [14]. So far, however, disease- or procedure-ori-
ented contracts continue to constitute the bulk of the
integrated care contracts signed [15]. Only a few com-
panies are developing ambitious models of population-
oriented integrated care in Germany [16, p. 129–223].
Particularly the move towards population-oriented inte-
grated care can imply a strengthening of primary care
as the coordinating agent in a patient’s care process.
Population-oriented care implies a more comprehen-
sive concept of health care, in which a multidisci-
plinary group of providers is not only responsible for
curing illness but also for maintaining or improving the
health status of the population. This comes very close
to Stareld’s model of integrated primary care as an
ongoing, person-focused, comprehensive and coordi-
nating system of care [2]. Existing models of popula-
tion-oriented integrated care in Germany use either
a primary care physician or team as the coordinating
agent for participating patients [16].
Gatekeeping models
Gatekeeping based on primary care physicians was
introduced in 2000. Gatekeeping in primary care also
exists in other countries with SHI systems like the Neth-
erlands and has recently been implemented in France
in 2004 [17]. In Germany, patients are free to choose
a family physician who then serves as gatekeeper and
guide through the health care system. Once a patient
has subscribed to a gatekeeping scheme, specialists
can only be seen upon referral, although exceptions
apply for gynaecologists, paediatricians and ophthal-
mologists.
Since 2007 legislation requires health insurance funds
to offer gatekeeper contracts. For patients, enrolment
in gatekeeping arrangements is voluntary and can be
rewarded through nancial incentives by their health
insurance fund. About six million patients had signed
up for the gatekeeping scheme by the end of 2007 [18].

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International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/
•Required procedure for enrolment of insured,
including duration of participation;
•Training and information for care providers and
patients;
•Electronic documentation of diagnostic ndings,
applied therapies and outcomes;
•Evaluation of clinical outcomes and costs.
Disease management programmes currently exist
for six major chronic conditions: diabetes type 1, dia-
betes type 2, coronary heart disease, breast cancer,
asthma and chronic obstructive pulmonary disease
[21]. In June 2008, more than 5.2 million patients were
enrolled, the largest share (2.7 million) of which partici-
pate in Diabetes type 2 DMPs [Personal conversation
with representative of the German Federal Insurance
Authority (Bundesversicherungsamt) on February 6,
2009].
For patients and physicians DMP participation is volun-
tary. Incentives exist for both: patients are exempt from
out-patient fees and co-payments; physicians receive
a lump sum payment for coordination and documen-
tation activities. Usually, primary care physicians take
on the role of coordinating care for DMP patients over
time, referring them to specialists when necessary and
documenting the care process [22].
A growing number of DMP evaluations show them to
meet expectations and be successful [23–28]. All stud-
ies indicate a better care process as well as improved
clinical outcomes. Participants experience less compli-
cations and emergency hospital admissions; instead,
the number of early-stage hospitalization is higher.
Compared to non-enrolled control group patients,
diabetes type 2 patients enrolled in DMPs self-report
higher quality of life and a better physical and mental
health status; their abilities for self-management of their
condition are strengthened. Similarly, a representative
case-control study published in mid-2008 reported less
relapses, less pain, better results for blood pressure
and cholesterol for patients participating in a coronary
heart disease DMP [29]. Among physicians, accep-
tance is also rising, although initially documentation
requirements were perceived as an extra burden.
Most of the time in the implementation of disease
management programmes, primary care takes a
central coordinating position. Among diabetes type 2
patients, the largest patient group enrolled in DMPs,
90% have a primary care physician as their partner in
the programme [22].
When developing its disease management program-
mes, Germany had looked at managed care mod-
els in the USA. Meanwhile, with their clearly dened
requirements for documentation, evaluation and treat-
ment guidelines and their careful mix of incentives for
payers, providers, and patients, German DMPs have
themselves become a model for other countries. One
of the next challenges to solve is how to adapt DMPs
to multimorbidity. Most chronically ill patients suffer
from concurrent chronic conditions [30]—a fact slowly
taken into account in disease management. One of the
rst DMPs to address this problem is the programme
on coronary heart disease to which recently a module
on chronic heart failure has been added [31].
Medical care centres
Medical care centres are another innovation introduced
in 2004. While integrated care contracts (see the pre-
vious section on integrated care contracts) allow for
contracts between providers of inpatient and outpa-
tient care, medical care centres are legally required to
only provide ambulatory care. Medical care centres,
also referred to as polyclinics, build upon a state-run
primary care delivery model that was well established
in former East Germany. By law, they are dened as
interprofessional institutions, headed by physicians,
with other registered physicians working as employees
[11]. Medical care centres usually offer a primary care
delivery system that brings together general practitio-
ners and specialists under one roof. The average cen-
tre still only employs four physicians—just about the
size of a small group practice in other countries [6].
Today ownership and management arrangements may
vary—medical care centres can be run by hospitals or
medical groups; legislation also permits the integration
of pharmacies and non-medical health care services
(e.g. physiotherapy, ergotherapy).
Medical care centres offer physicians the possibility
to work as salaried employees in ambulatory care, an
option that did not exist prior to 2004. It is a particularly
attractive option to the rising number of women physi-
cians looking for a better work-life balance, or to doc-
tors who prefer team work over single-handed practice.
Medical care centres furthermore provide the opportu-
nity to practice in ambulatory care without taking the
nancial risk of a solo practice, enabling physicians
to concentrate on clinical work without having to deal
with practice administration or documentation require-
ments, and allow for exible work hours [5, 33]. For
patients, medical care centres are supposed to improve
the quality of care through fewer visits (the larger ones
offering one-stop-shop services), faster diagnosis using
electronic medical records, standardized processes,
coordinated care according to treatment guidelines and
better access to specialists. However, since medical
care centres are not systematically evaluated in Ger-
many, very little data exists to afrm these assumptions.
A patient survey published in 2007 showed that patients
treated in medical care centres gave better ratings for

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This article is published in a peer reviewed section of the International Journal of Integrated Care 7
quality of care, accessibility and service, infrastructure
and organisational structures than patients treated in
solo practices. Ninety-ve percent of patients stated
that they would return to the medical care centre for
receiving care and also 95% stated that they would
recommend the centre to others [5].
Some concerns regarding the introduction of medical
care centres were stated by an English study discuss-
ing the introduction of ‘polyclinics’ in the UK [34]:
•Bringing professions together under one roof does
not necessarily lead to integrated care—infrastructure
and processes have to be in place to assist integra-
tion. However, [5] about 50% of German medical care
centres still have no shared electronic patient record
in place.
•Integration of ambulatory care providers within a
medical care centre does not yet imply a good coordi-
nation of care between the centre and the hospitals.
•Lack of personal continuity of care can be a prob-
lem if a patient cannot choose a personal primary
care physician in a medical care centre.
•The existence of primary and specialist care within
the same institution might encourage overuse of
specialty care, thereby increasing costs.
•Whether medical care centres in less populated
regions of Germany lead to access barriers—
because of a concentration of physicians in one
place—or to improved access—exible working
conditions may as well attract further physicians
[32]—is still being disputed.
With medical care centres the lawmaker gave physi-
cians in ambulatory care and hospitals the option of a
new form of cooperation that allows for a shared use
of resources. Although the law does not include man-
datory participation of primary care providers, many
medical care centres offer primary care services. Since
2004, more than 1000 medical care centres have been
set up (see Figure 2 Medical care centres—growing
numbers), with ca. 4800 staff physicians—compared
to the total of 130,000 doctors who work in ambulatory
care in Germany. Among them are about 793 general
practitioners and 488 internists—making primary care
physicians the largest specialty group working in this
type of health care delivery system [32, p.3, 7].
‘Community Medicine Nurses’
As depicted in the previous section on a brief work-
ing denition of integrated primary care, medical care
in the German primary care setting is exclusively pro-
vided by physicians. Under the name of AGNES the
Institute of Community Medicine at the University of
Greifswald started several pilots in 2005 to test if nurse
practitioners, so-called ‘Community Medicine Nurses’,
can support primary care physicians in sparsely popu-
lated areas in prevention, nursing and assistance dur-
ing routine home visits. They are expected to ensure
regular access to basic health care services for elderly
patients.
‘Community Medicine Nurses’ act only by order of a
family physician. They visit patients at home, run basic
diagnostic tests, apply new bandages or take blood
samples and they serve as contact persons for mostly
elderly patients, supervise their medication, consider
preventive action, and offer advice and support. They
Figure 2. Medical care centres—growing numbers.

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International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/
are provided with a tablet PC that enables them to
transfer medical data from the patient’s home to the
doctor’s practice immediately and to reach the physi-
cian via video communication at any time.
Pilots in four states were evaluated for the rst time
in July 2008 by surveying participating physicians and
patients. Ninety-eight percent of the patients perceived
the nurse practitioner as a competent partner in health
care, 94% supported the delegation of regular home
visits to nurse practitioners. A large majority of primary
care physicians stated that the nurse practitioners pro-
vided valuable support (38 of 42 physicians) and had
a positive effect on patient compliance (37 of 42 physi-
cians). For 92% of patients, physicians perceived the
delegation of task as having no negative effect on the
quality of care [35].
To qualify physician assistants or traditional nurses
for the work prole of a ‘Community Medicine Nurse’
the University of Greifswald developed an advanced
training programme. The profession of ‘Community
Medicine Nurses’ implies the redistribution of some of
the tasks that today are the sole responsibility of phy-
sicians. If implemented on a larger scale, this would
have a rather fundamental impact on German health
care structures. However, the open question of how
to include the new profession into nancing structures
in ambulatory care is still a major obstacle to a large-
scale implementation.
The main goal of the AGNES project is not to improve
care coordination but to establish a new structure of
support for primary care physicians in rural areas. Still,
the introduction of nurse practitioners into the German
health care system and the current discussion about
the delegation of clinical tasks to non-physician staff
might over time turn out to be a step towards inte-
grated primary care in Germany. To deliver continu-
ing, person-focused, comprehensive care and full a
coordinating role, a multidisciplinary primary care team
is better tted than a physician in solo practice with
little support [36, 37]. The discussion around AGNES
nurse practitioners might open the door for new forms
of cooperation within primary care practices.
Conclusion: towards integrated
primary care in Germany—drivers
and future challenges
The reforms described in the previous section can be
considered as the rst careful steps towards a better
integrated care system in which primary care takes on
a stronger role as coordinator and navigator. Reforms
since 2000 have activated a number of drivers. The
government, assuming a leading role throughout a
year-long reform process, negotiated with all stake-
holders in the system, introduced legal changes,
making possible selective contracting between health
insurance funds and providers. Health insurance funds
are obliged by law to offer gatekeeping programmes
to their insured, thus strengthening the role of general
practitioners in the system. The role of primary care is
also strengthened through DMPs, the majority of which
is coordinated by general practitioners. To increase
uptake of the new schemes, nancial incentives for
providers and patients were introduced.
For patients, the rather complex developments of sev-
eral new forms of care in Germany are hard to com-
prehend as a general trend towards more coordination
and more competition in health care. However, patients
participating in the new primary care arrangements
most often approve of the more patient-oriented care
delivery. The increasing number of integrated care
contracts, DMPs, gatekeeping programmes and medi-
cal care centres as well as the increasing number of
enrolled patients indicate that these new forms of care
slowly gain acceptance in the German system.
Nevertheless, the reforms have also met with con-
siderable resistance and implementation of primary
care-focused care has not yet been achieved on a
large scale. One reason is that it is difcult to change
long-established traditions, expectations of providers
and patients, practice habits and structures. German
physicians feel threatened in many ways by the struc-
tural changes that policy makers have initiated. Their
complaints are about increased reporting and docu-
mentation requirements associated with DMPs. Tools
for transparency and benchmarking are by some phy-
sicians seen as an attack on their independence and
professionalism, as are new forms of care and care
management, such as larger medical care centres, or
the staff physician status in ambulatory care. However,
younger physicians and female doctors are more likely
to consider the advantages in new workplace and con-
tractual arrangements in more professionally managed
settings, and of (peer) evaluation and feedback.
Future reforms—and a constant dialogue between
policy makers and health professionals—will have to
address the following challenges:
– Primary care as the foundation of the health care
system and as a public good needs continuing reg-
ulatory endorsement and political protection;
– Shared leadership: interdisciplinary and horizon-
tal cooperation between providers from different
specialties and sectors needs support and SHI-
endorsed incentives, particularly in regional nego-
tiations about budgetary redistribution with SHI
physician associations where primary care provid-
ers are often outweighed by specialists;

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This article is published in a peer reviewed section of the International Journal of Integrated Care 9
– Population orientation: DMPs and most integrated
care contracts still are predominantly single disease-
oriented and lack a broader population-centred
approach that embraces both prevention and multi-
morbidity.
In short, in Germany the debate about granting a stron-
ger role to primary care as a lever for better care coordi-
nation and integration has only just begun. Continuing
political support, a rare window of opportunity in the form
of prolonged personal continuity at the head of the Fed-
eral Ministry of Health, and a visionary leadership willing
to learn from primary care experiences elsewhere have
been instrumental throughout the reform years. Or as
Marc Danzon has put it more broadly when commenting
on similar developments across Europe: “These types
of fundamental organizational adjustments are, by their
very nature, long-term endeavours. Progress must be
counted in years and requires focused and persistent
efforts from key actors” [38, p. XVII].
Reviewers
Mark Harris, Prof., Executive Director Centre for
Primary Health Care and Equity, Faculty of Medicine,
University of New South Wales, Sydney, Australia
Geoff Meads, Hon. Professor of International Health
Studies, Warwick Medical School, University of
Warwick, UK
Petra Riemer-Hommel, Prof., PhD, HTW des
Saarlandes, School of Social Sciences, Saarbrücken,
Germany
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