Healthcare in Germany

The Federal Republic of Germany lies in the middle of Europe. Reunification in 1990 transformed Germany into the largest country in Europe, with 16 states (Länder) that cover an area of 356,970 square kilometers (137,827 square miles). This densely populated country has more than 83 million people. Despite the heavy financial strain imposed by reunification, Germany has continued to invest 10.5% of GDP on healthcare (which compares with 13.7% in the USA, 9.5% in Canada, and 7.0% in England).

Q: What kind of healthcare system does Germany have?

A: The German health service is highly decentralized. Each of the 16 states share responsibility with the central government for the building and upkeep of hospitals, while the state-regulated health insurance providers exert some control over running costs. Of Germany's 2,030 hospitals, 790 are publicly owned, 820 are private non-profit, and 420 are private for-profit. The Catholic and Protestant churches run many of the hospitals with federal or state subsidies. The hospitals, in general, are packed with technological sophistication and a high level of accommodation comfort. According to World Health Organization (WHO) statistics, Germany has an average of 358.40 physicians per 100,000 inhabitants (the USA has 279.0 and Canada has 229.1).

Q: How is the healthcare system funded?

A: Until they reach the retirement age of 65, people must, by law, pay into health insurance plans (and, since 1994, an additional long-term care plan). The health insurance plans are either state-regulated or private. After retirement, contribution payments for the state-regulated plans stop (although private patients continue payments), but coverage is continued until death.

Only certain groups are allowed to take out private health insurance. The vast majority of people are obliged to use state-regulated plans and, depending on their individual circumstances, choose from one of about 400 options. The government regulates the fees of state-regulated plans. Although some doctors take only private patients, normally every doctor has a sign that says s/he is accredited by all insurance providers.

There are several types of state-regulated plans. Some large companies and guilds offer their employees in-house plans. Other groups – notably people working in technical and scientific environments, employees in medium-sized and small firms, or blue-collar workers – often prefer the so-called self-governing substitute plan (Ersatzkassen). The state covers health insurance contributions for the unemployed and those with low income.

Contributions to the state-regulated health plans (currently around 14% of the employee's gross income and shouldered equally by the employee and the employer) cover up to 68% of overall healthcare costs. Income taxes, funds derived from those with private health insurance, and out-of-pocket payments (e.g., for prescriptions where the insurance covers only 90% of the charges) attempt to cover the remainder.

The government regulates the use of private insurance. There are three main types of people who use private insurance plans. Persons with a monthly income exceeding US$3,825 may legally opt out of state-regulated plans and switch to private insurance. The self-employed are excluded from the state-regulated plans and so must take private insurance. Public sector employees (e.g., police, teachers) are reimbursed for part of their health costs by the state but have to be privately insured to cover the rest. (The government is now trying to make it difficult to opt for private insurance because the state-regulated insurance loses the 14% contribution from these high-income earners.)

Currently, the seven million patients insured by the 52 private health insurance providers are billed directly by physicians, dentists, and hospitals, and are reimbursed by the insurance companies. Doctors may charge higher fees for private patients and it is at the insurer's discretion to refuse to cover unreasonable amounts.

Both types of insurance cover physician fees, hospital fees, chronic care, and part of dental care. Patients within the state-regulated insurance plans may consult any general practitioner or specialist officially contracted and recognized by their insurance provider. The doctor then settles the fees directly through the insurance provider. Hospital bills for diagnostic tests, treatment, and drugs are settled directly between the insurance providers and the hospitals. In order to keep costs down, the government is forcing the powerful pharmaceutical firms to give insurance providers a higher discount on medicines.

Q: What is the quality of care in each system?

A: In the WHO's year 2000 report for global healthcare, Germany ranked 25th out of 191 countries based on a cost/effectiveness ratio (the USA came 37th and Canada 30th). Although some hospitals have certain wards designated solely for the use of private patients, people in state-regulated insurance plans and those with private insurance use the same hospitals. On the whole, patients who are not privately insured are at no medical disadvantage and receive the same standard of care as the private patients.

Generally, doctors work either in hospitals or in private practice. Those working in hospitals are employed by the hospitals. Those working outside the hospitals have their own offices and are self-employed (these include general practitioners and specialists, e.g., gynecologists, internists, homeopaths), but they all refer patients to a hospital if necessary. Some of the specialists – notably gynecologists and ENT surgeons – have "reserved" beds in a hospital, where they perform operations and visit their patients, leaving the rest of the care to the hospital staff.

Apart from relatively minor delays for non-emergency surgery (e.g., three to four months for hip replacements), waiting times are virtually non-existent.

Q: What are the current concerns among healthcare workers in the country?

A: To keep costs down, the government has frozen hospital workers' salaries for the year 2003. Also, government legislation imposing strict limits on hospital expenditure and the number and type of medication practitioners are allowed to prescribe, has fuelled fears that healthcare workers will leave the country, resulting in generally lower standards at home. Recently, there have been scandals involving doctors who bill insurance companies for treatments that they never performed, and there has been an increase in malpractice (especially in the ORs). In eastern Germany, many new practices have high debts and face insolvency, which undermines provision of healthcare.

Q: What are the current concerns among patients?

A: A lack of screening facilities for the early detection of breast cancer makes Germany fall well behind European standards. Also, Germany's underdeveloped palliative care system provides only 12 beds per one million inhabitants. Other weak points of the system include a lack of co-ordination between inpatient and ambulatory care and, at best, fragmented support from the social services departments.

Patients currently perceive healthcare in Germany – despite its generally excellent results – as being in a crisis and fear that it is turning into a "two-class system" whereby the rich would be able to buy private, comprehensive, quality healthcare but those legally bound to the state-regulated schemes would receive only basic healthcare.

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