Possibilities and limitations in priority setting in German ambulatory health care

Ambulatory health services provided by physicians in Germany get reimbursed by the statutory health insurance when benefits and costs of a proposed technology compared to alternatives are favourable. This decision has to be made by a joint committee of physicians and sickness funds which has far-reaching autonomy in health issues (the so-called "Bundesausschuss"). In order to offer a comprehensive basket of health benefits it is necessary to develop an explicit, transparent, and reproducible prioritization process which allows the evaluation of new technologies as well as the evaluation of already introduced technologies. The existing approach tends to be uncomprehensive and neglects the potentials of steering health care towards defined health goals. However, it reflects a bottom up procedure which meets with physicians' as well as patients' needs. For existing technologies a framework specific for Germany is proposed which allows the evaluation of health technologies in a context with health goals. Already implemented technologies should be evaluated in a conceptual framework which allows the implementation of mid- and long term health goals for German ambulatory health care. To achieve this goal a "procedural" consent of participating stakeholders is necessary.