Healthcare in Germany

The University Medical Center Freiburg

Germany has a universal^[1] multi-payer health care system with two main types of health insurance: "Law-enforced health insurance" (Gesetzliche Krankenversicherung) known as sickness funds and "Private" (Private Krankenversicherung).^[2][3][4]

Compulsory insurance applies to those below a set income level and is provided through private non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. Provider compensation rates are negotiated in complex corporatist social bargaining among specified autonomously organized interest groups (e.g. physicians' associations) at the level of federal states (Länder). The sickness funds are mandated to provide a wide range of coverages and cannot refuse membership or otherwise discriminate on an actuarial basis. Small numbers of persons are covered by tax-funded government employee insurance or social welfare insurance. Persons with incomes above the prescribed compulsory insurance level may opt into the sickness fund system, which a majority do, or purchase private insurance. Private supplementary insurance to the sickness funds of various sorts is available.

The segment health economics of Germany was about US$368.78 billion (€287.3 billion) in 2010, equivalent to 11.6 percent of gross domestic product (GDP) this year and about US$4,505 (€3,510) per capita.^[5] According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004.^[6] In 2004 Germany ranked thirtieth in the world in life expectancy (78 years for men). It had a very low infant mortality rate (4.7 per 1,000 live births), and it was tied for eighth place in the number of practicing physicians, at 3.3 per 1,000 persons. In 2001 total spending on health amounted to 10.8 percent of gross domestic product.^[7]

History

Germany has the world's oldest national social health insurance system,^[1] with origins dating back to Otto von Bismarck's social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889. As mandatory health insurance, it originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population.^[8] The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1,100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.^[9] Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds.

1970–Present

Siemens CT Scanner

Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.^[10] The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.^[11]

Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).^[12][13] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).^[14]

Regulation

The healthcare system is regulated by the Federal Joint Committee (Gemeinsamer Bundesausschuss), a public health organization authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine decisions regarding healthcare in Germany.^[15]

Health insurance

German health care spending (red) as a percentage of GDP for 1970 to 2007 compared with other nations

Health insurance in Germany is split in several parts. The largest part of 85% of the population is covered by a basic health insurance plan provided by statute, formally insured under the legislation set with the Sozialgesetzbuch V (SGB V), which provides a standard level of coverage. The remainder of 15% opt for private health insurance, which frequently offers additional benefits.

The government partially reimburses the costs for low-wage workers, whose premiums are capped at a predetermined value. Higher wage workers pay a premium based on their salary. They may also opt for private insurance. This may result in substantial savings for younger individuals in good health. With age and illness, private premiums will rise and the insured will usually cancel their private insurance, turning to the government option.,^[9] however, this is not always possible, nor is it simple to accomplish

Reimbursement is on a fee-for-service basis, but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional medical societies. Co-payments were introduced in the 1980s in an attempt to prevent over-utilization.

Insurance systems

Total health spending per capita, in US$ PPP-adjusted, of Germany compared amongst various other first world nations.

Germany has a universal multi-payer system with two main types of health insurance. Germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.

Accident insurance for working accidents (Arbeitsunfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.

Long-term care (Pflegeversicherung) is covered half and half by employer and employee and covers cases in which a person is not able to manage his or her daily routine (provision of food, cleaning of apartment, personal hygiene, etc.). It is about 2% of a yearly salaried income or pension, with employers matching the contribution of the employee.

There are two separate types of health insurance: public health insurance (Gesetzliche Krankenversicherung) and private insurance (Private Krankenversicherung). Both systems struggle with the increasing cost of medical treatment and the changing demography. About 87.5% of the persons with health insurance are members of the public system, while 12.5% are covered by private insurance (as of 2006).^[16]

Public insurance

Emergency vehicle in Hannover

All salaried employees must have public health insurance. Only public officers, self-employed people and employees with a large income, above c. €50,000.00 (adjusted yearly), may join the private system.

In the Public system the premium

• is set by the Federal Ministry of Health based on a fixed set of covered services as described in the German Social Law (Sozialgesetzbuch – SGB), which limits those services to "economically viable, sufficient, necessary and meaningful services"
• is not dependent on an individual's health condition, but a percentage (currently 15.5%) of salaried income.
• includes family members of any family members, or "registered member" ( Familienversicherung – i.e., husband/wife and children are free)
• is a "pay as you go" system – there is no saving for an individual's higher health costs with rising age or existing conditions.

With an aging population, there is an intrinsic risk that, in the long run, the burden to be carried by the young and working generations for the higher share of elderly will run the public system into a huge deficit or result in high premiums.

Private insurance

In the Private system the premium

• is based on an individual agreement between the insurance company and the insured person defining the set of covered services and the percentage of coverage
• depends on the amount of services chosen and the person's risk and age of entry into the private system
• is used to build up savings for the rising health costs at higher age (required by law)

For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance, the higher premiums must then be paid out of a lower income. During the last twenty years private health insurance became more and more expensive and less efficient compared with the public insurance.^[17]

Statistics

The reduction in infant mortality between 1960 to 2008 for Germany (green) in comparison with Australia, France, the Netherlands, the United Kingdom, and the United States.

Germany ranked 20th in the world in life expectancy with 76.5 years for men and 82.1 years for woman. It had a very low infant mortality rate (4.3 per 1,000 live births), and it was eighth place in the number of practicing physicians, at per 1,000 people (3.3).

Major diagnosis

In 2002 the top diagnosis for male patients released from the hospital was heart disease, followed by alcohol-related disorders and hernias. For women, the top diagnoses related to pregnancies, breast cancer, and heart weakness.

At the end of 2004, some 449,000 Germans, or less than 0.1 percent of the population, were infected with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). In the first half of 2005, German health authorities registered 1,164 new infections; about 60 percent of the cases involved homosexual men. Since the beginning of the HIV/AIDS epidemic, about 24,000 Germans have died from the disease.^{[citation needed]}

Widespread smoking also has a deleterious impact on health. According to a 2003 survey, 37 percent of adult males and 28 percent of adult females in Germany are smokers.^[7]

Obesity in Germany has been increasingly cited as a major health issue in recent years. A 2007 study shows Germany has the highest number of overweight people in Europe.^[18][19] However, the United Kingdom, Greece and certain countries in Eastern Europe have a higher rate of "truly obese" people.^[20] Forbes.com ranks Germany as the 43rd fattest country in the World with a rate of 60.1%.^[21]

Hospitals

The Charité (Hospital) in Berlin

The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days).^[22][23] Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).^[24]

• Universitätsklinikum Freiburg, Freiburg
• Universitätsklinikum Heidelberg, Heidelberg
• Rechts der Isar Hospital, Munich
• Charité – Universitätsmedizin Berlin, Berlin
• University Medical Center Hamburg-Eppendorf, Hamburg
• Universitätsklinikum Gießen und Marburg
• Universitätsklinikum Aachen, Aachen
• Universitätsklinikum Bonn, Bonn

See also

• Health care compared
• Universal health care
• GERAC

References