In Germany discussions of priority setting – with or without the public being involved – are carried out mainly in academia. Several attempts have been made to include decision makers – particularly physicians and politicians - without success. Indeed, all ministers of health over the last decades or so have refused to even talk about this issue. For those insured under statutory health insurance (SHI), which is about 90 % of the population, the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) makes decisions on healthcare benefits, and it defines in detail what adequate, appropriate, and economical healthcare, as defined by law, entails (https://www.g-ba.de/institution/service/publikationen/gba/).
The Federal Joint Committee (G-BA) consists of five stakeholder groups with voting rights (three impartial members; five representatives from the Central Federal Association of Health Insurance Funds, the organization representing all statutory health insurance funds; five representatives from the Central Federal Association of Health Insurance Funds, the organization representing all statutory health insurance funds; two representatives from the National Association of Statutory Health Insurance Physicians, which includes all licensed physicians and psychotherapists who treat SHI patients; two representatives from the German Hospital Federation, the interest group representing hospitals; and one representative from the National Association of Statutory Health Insurance Dentists, which includes all licensed dentists who treat SHI patients). Five patient representatives take part in all plenary sessions, subcommittee meetings, and workgroup meetings. They are entitled to submit petitions and take part in discussions, but have no right to vote. This would be the main source of information on the (sick) public’s preferences. Note, the G-BA decides which services are brought to the committee and decides what is eventually funded.
How does the public feel about this? A population survey (computer assisted personal interviews (CAPI), n = 2031) was conducted in 2009 addressing thirty-four questions with 135 items organized into ten health care and health system related themes (e.g., [4,5]). One theme was about the decision makers and their function in distributing health care benefits. The question and results (percentage of agreement) are shown in the following Fig. 1.
According to public opinion, representatives of health insurers (52 %), physicians (84 %) und patients/patient organization (55 %) should have a right of co-determination, when deciding what health care services should be paid for by the statuary health insurance. At the same time, a high percentage of the public indicate that the following should have no say: politicians (60 %), representatives of religious groups/churches (63 %) and economists (54 %). This is interesting in so far as these stakeholder groups do have considerable influence when it comes to health care services, directly (such as political programs, e.g. personal responsibility –out of pocket payment) or indirectly (like ethics committee, e.g. prenatal diagnosis). Respondents expressed the view that some stakeholders (representatives from hospitals, nurses, scientists) should rather be co-determining and advisory, whereas other stakeholders (ethicists and jurists) should have at most advisory functions. The respondents are divided when it concerns their own involvement in the decision process. The percentages in all three categories (right of co-determination; advisory function; neither nor) are similar. For no other group can we observe a dichotomy of “right of co-determination” versus “no function”. In an “Others” response category (not listed here) the “general public” and “member of the family” were mentioned. This suggests that some of the respondents assumed only selected citizens for the category “citizens” and not the general public. Obviously, also here we can observe a discrepancy between the public’s opinion and the policies employed.