Prospects of gatekeeping in German social health insurance

From 2004, German social health insurers are bound by law to offer their insured a gatekeeping option. In return for renouncing direct access to specialist care, the insured can be granted bonus payments by their social health insurer. So far, experience with gatekeeping is very limited in Germany. In social health insurance, sickness funds are very reluctant to offer gatekeeping, although this was already legally possible before 2004. In the private health insurance sector, cost savings in gatekeeping tariffs are probably the result of self-selection of the insured rather than more cost-efficient provision of health care services. International experience does not prove that gatekeeping results in cost savings or a better patient–physician relationship. Although in countries with a strong primary care system there is a higher life expectancy, gatekeeping is not the only factor to bring about this effect. It is not to be expected that the new legislation will result in a major proliferation of gatekeeping options in German social health insurance. Either the gatekeeping options will not be attractive for the insured or sickness funds will use gatekeeping options as an instrument for risk selection.