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Nearly all hospital-based doctors are salaried, and those salaries are part of hospital budgets that are negotiated each year between hospitals and "sickness funds" — the 240 nonprofit insurance companies that cover nearly nine out of 10 Germans through their jobs. (About 10 percent, who are generally higher income, opt out of the main system to buy insurance from for-profit companies. A small fraction get tax-subsidized care.)
Office-based doctors in Germany operate much like U.S. physicians do. They're private entrepreneurs who get a fee from insurers for every visit and every procedure they perform. The big difference is that groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets.
Those doctor budgets get divided into quarterly amounts —
a limited pot of money for each region. Once doctors collectively use up that money, that's it — there's no more until the next quarter.
It's a powerful incentive for doctors to exercise restraint — not to provide more care than is necessary.
But often, the pot of money is exhausted before the end of the quarter.That's why Leibl is chronically angry.
"I don't get paid at the moment," he said recently, near the end of a quarter. "I haven't been paid for what I'm doing for the last two or three weeks."
He has to wait until the beginning of the next quarter before the sickness funds will start paying the bills he submits.
Some German doctors simply close their doors and take a vacation at the end of every quarter.
Keeping German Doctors On A Budget Lowers Costs : NPR