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The German Health Care System

by Miriam Blümel and Reinhard Busse, Berlin University of Technology

What is the role of government?

Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by competing, not-for-profit, nongovernmental health insurance funds (“sickness funds”; there were 124 as of January 2015) in the statutory health insurance (SHI) system, or by substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities, and own about half of hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. A large degree of regulation is delegated to self-governing associations of the sickness funds and the provider associations, which together constitute the most important body, the Federal Joint Committee.

Who is covered and how is insurance financed?

Publicly financed health insurance: In 2013, total health expenditure was 11.5 percent of GDP, of which 73 percent was public and 58 percent was SHI spending (Federal Statistical Office, 2015). General tax–financed federal spending on “insurance-extraneous” benefits provided by SHI (e.g., coverage for children) amounted to about 4.4 percent of total expenditure in 2014 and 2015. Sickness funds are funded by compulsory contributions levied as a percentage of gross wages up to a ceiling. Coverage is universal for all legal residents. All employed citizens (and other groups such as pensioners) earning less than EUR54,900 (USD69,760) per year as of 2015 are mandatorily covered by SHI, and their nonearning dependents are covered free of charge. Individuals whose gross wages exceed the threshold and the previously SHI-insured self-employed can remain in the publicly financed scheme on a voluntary basis (and 75% do) or purchase substitutive PHI, which also covers civil servants. About 86 percent of the population receive their primary coverage through SHI and 11 percent through substitutive PHI. The remainder (e.g., soldiers and policemen) are covered under special programs. Visitors are not covered through German SHI. Undocumented immigrants are covered by social security in case of acute illness and pain, as well as pregnancy and childbirth.

As of 2015, the legally set uniform contribution rate is 14.6 percent of gross wages. Both the legal contribution rate for employees (0.9%) and the supplementary premiums set by sickness funds have been abolished and replaced by a supplementary income-dependent contribution rate determined by each sickness fund individually (Busse and Blümel, 2014). As of 2015, the supplementary contribution rate is, on average, 0.9 percent—that is, most of the SHI-insured pay the same as previously, but rates range between 0 percent and 1.3 percent (Federal Association of Sickness Funds, 2015).

This contribution also covers dependents (nonearning spouses and children). Earnings above EUR49,500 (USD63,360) per year (as of 2015) are exempt from contribution. Sickness funds’ contributions are centrally pooled and then reallocated to individual sickness funds using a risk-adjusted capitation formula, taking into account age, sex, and morbidity from 80 chronic and/or serious illnesses.

Private health insurance: In 2014, 8.8 million people were covered through substitutive private health insurance (Association of Private Health Insurance Companies, 2015). PHI is especially attractive for young people with a good income, as insurers may offer them contracts with more extensive ranges of services and lower premiums.

There were 42 substitutive PHI companies in June 2015 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the self-employed) and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

PHI also plays a mixed complementary and supplementary role, covering minor benefits not covered by SHI, access to better amenities, and some copayments (e.g., for dental care). Federal government determines provider fees in substitutive, complementary, and supplementary PHI through a specific fee schedule. There are no government subsidies for complementary and supplementary PHI. In 2013, all forms of PHI accounted for 9.2 percent of total health expenditure (Federal Statistical Office, 2015).

What is covered?

Services: SHI covers preventive services, inpatient and outpatient hospital care, physician services, mental health care, dental care, optometry, physical therapy, prescription drugs, medical aids, rehabilitation, hospice and palliative care, and sick leave compensation. Home care is covered by long-term care insurance (LTCI). SHI preventive services include regular dental checkups, child checkups, basic immunizations, checkups for chronic diseases, and cancer screening at certain ages. All prescription drugs are covered unless explicitly excluded by law (mainly so-called lifestyle drugs) or disallowed following evaluation. While the broader framework of the benefits package is legally defined, specifics are decided upon by the Federal Joint Committee (see below). Long-term care services are covered separately by the LTCI scheme (see below).

Cost-sharing and out-of-pocket spending: Out-of-pocket (OOP) spending accounted for 13.6 percent of total health spending in 2013, mostly on nursing homes, pharmaceuticals, and medical aids (Federal Statistical Office, 2015).

Copayments include EUR5.00 (USD6.40) to EUR10.00 (USD12.70) per outpatient prescription, EUR10.00 per inpatient day for hospital and rehabilitation stays (for the first 28 days per year), and EUR5.00 to EUR10.00 for prescribed medical devices. Sickness funds offer selectable tariffs with a range of deductibles and no-claims bonuses. Preventive services do not count toward the deductible. SHI-contracted physicians are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a list of “individual health services” outside the comprehensive range of SHI coverage may be offered to patients paying OOP.

Safety nets: Children under 18 years of age are exempt from cost-sharing. For adults, there is an annual cap on cost-sharing equal to 2 percent of household income; part of a household’s income is excluded from this calculation for additional family members. About 0.4 million SHI insureds exceeded the 2 percent cap in 2013 and were exempted from further cost-sharing. The cap is lowered to 1 percent of annual gross income for qualifying chronically ill people; to qualify, those people have to demonstrate that they attended recommended counseling or screening procedures prior to becoming ill. Nearly 6.5 million people, or around 9 percent of all the SHI-insured, have benefited from this regulation in 2013 (Federal Statistical Office, 2015). Unemployed people contribute to SHI in proportion to their unemployment entitlements. For the long-term unemployed, government contributes on their behalf.

How is the delivery system organized and financed?

Physicians: General practitioners (GPs) and specialists in ambulatory care who get reimbursed by SHI are by law mandatory members of regional associations that negotiate contracts with sickness funds. Regional associations of SHI-accredited physicians are responsible for coordinating care requirements within their region, and act as financial intermediaries to the sickness funds and the physicians in ambulatory care. However, ambulatory physicians typically work in their own private practices—around 60 percent in solo practice and 25 percent in dual practices. Most physicians employ doctors’ assistants, while other nonphysicians (e.g., physiotherapists) have their own premises. In 2014, of the roughly 109,600 self-employed SHI-accredited physicians in ambulatory care, 52,800 (48%) were practicing as family physicians (including GPs, internists, and pediatricians) and 56,800 (52%) as specialists. There were about 2,000 multispecialty clinics with more than 13,000 physicians (10% of ambulatory care physicians) in 2014. Around 11,000 physicians working in multispecialty clinics are salaried employees, while 12,000 are employed in practices of self-employed physicians. The total number of ambulatory care physicians is more than 130,000 (Federal Association of SHI Physicians, 2015). Some specialized outpatient care is provided by hospital specialists, including treatment of rare diseases and of severe progressive forms of disease, as well as highly specialized procedures.

Individuals have free choice among GPs, specialists, and, if referred to inpatient care, hospitals. Registration with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds are required to offer their members the option to enroll in a “family physician care model,” which has been shown to provide better services and often also provides incentives for complying with gatekeeping rules.

SHI-accredited physicians in ambulatory care (GPs and specialists) are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule negotiated between sickness funds and physicians (see below). Payments are limited to predefined maximum numbers of patients per practice and reimbursement points per patient, setting thresholds on the number of patients and treatments per patient for which a physician can be reimbursed. For the treatment of private patients, GPs and specialists also get an FFS, but the private tariffs are usually higher than the tariffs in the SHI uniform fee schedule. Pay-for-performance has not been established yet. The average reimbursement of a family physician is above EUR200,000 (USD254,000) per year, covering costs for personnel, etc., but excluding income from private patients, which varies substantially (Federal Association of SHI Physicians, 2015).

Financial incentives for care coordination can be part of integrated care contracts, but are not routinely implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD152, in 2015) for patients enrolled in a Disease Management Program (DMP), in which physicians provide patient training and document patient data. Bundled payments are not common in primary care, but a regional initiative, “Healthy Kinzigtal” (Kinzigtal is a valley in southeast Germany), provides an example of a shared savings model offering primary care doctors and other providers financial incentives for integrating care across providers and services.

Administrative mechanisms for direct patient payments to providers: SHI physicians in ambulatory care bill their regional associations according to a uniform fee schedule; the associations are in turn reimbursed by sickness funds. Copayments or payments for services not included in the benefit catalogue are paid directly to the provider. In cases of private health insurance, patients pay up front and submit claims to the insurance company for reimbursement.

After-hours care: After-hours care is organized by the regional associations of SHI-accredited physicians to ensure access to ambulatory care around the clock. Physicians are obliged to provide after-hours care in their practice, with differing regional regulations. In some areas (e.g., Berlin), after-hours care has been delegated to hospitals. The patient is given a report of the visit afterwards to hand to his or her GP. There is also a tight network of emergency care providers (the responsibility of the municipalities). After-hours care assistance is also available via a nationwide telephone hotline (116 117-Ärztlicher Bereitschaftsdienst). Payment for ambulatory after-hours care is based on the above-mentioned fee schedules, again with differences in the amount of reimbursement for SHI and PHI.

Hospitals: Public hospitals make up about half of all beds, while private not-for-profits account for about a third. The number of private, for-profit hospitals has been growing in recent years (now around one-sixth of all beds). All hospitals are staffed principally by salaried doctors. Doctors in hospitals are typically not allowed to treat outpatients (similar to hospitalists in the U.S.), but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also provide certain highly specialized services on an outpatient basis.

The 16 state governments determine hospital capacity, while ambulatory care capacity is subject to rules set by the Federal Joint Committee. Inpatient care is paid per admission through a system of diagnosis-related groups (DRGs) revised annually, currently based on around 1,200 DRG categories. DRGs also cover all physician costs. Other payment systems like pay-for-performance or bundled payments have yet to be implemented in hospitals.

Mental health care: Acute psychiatric inpatient care is largely provided by psychiatric wards in general (acute) hospitals, while the number of hospitals providing care only for patients with psychiatric and/or neurological illness is low. In 2014, there were a total of 32,872 office-based psychiatrists, neurologists, and psychotherapists working in the ambulatory care sector (paid FFS) (Federal Association of SHI Physicians, 2015). Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists are also coordinators of a set of SHI-financed benefits called “sociotherapeutic care” (which requires referral by a GP), to encourage the chronically mentally ill to use necessary care and to avoid unnecessary hospitalizations. To further promote outpatient care for psychiatric patients (particularly in rural areas with a low density of psychiatrists in ambulatory care), hospitals can be authorized to offer treatment in outpatient psychiatric departments.

Long-term care and social supports: LTCI is mandatory and usually provided by the same insurer as health insurance, and therefore comprises a similar public–private insurance mix. The contribution rate of 2.35 percent of gross salary is shared between employers and employees; people without children pay an additional 0.25 percent. The contribution rate will increase further by 0.2 percentage points in early 2017. Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for benefits, which are: 1) dependent on an evaluation of individual care needs by the SHI Medical Review Board (leading either to a denial or to a grouping into currently one of three levels of care); and 2) limited to certain maximum amounts, depending on the level of care. Beneficiaries can choose between in-kind benefits and cash payments (around a quarter of LTCI expenditure goes to these cash payments). Both home care and institutional care are provided almost exclusively by private not-for-profit and for-profit providers. As benefits usually cover approximately 50 percent of institutional care costs only, people are advised to buy supplementary private LTCI. Since 2013, family caregivers get financial support through continuing payment of up to 50 percent of care payments if they provide care.

Hospice care is partly covered by LTCI if the SHI Medical Review Board has evaluated a care level. Medical services or palliative care in a hospice are covered by SHI. The number of inpatient facilities in hospice care has grown significantly over the last 15 years, to 200 hospices and 250 palliative care wards nationwide in 2014 (German Hospice and Palliative Association, 2015). Legislation has recently been discussed to improve hospice and palliative care with the aim of guaranteeing care in underserved rural areas and linking long-term care facilities more strongly to ambulatory palliative and hospice care.

What are the key entities for health system governance?

The German health care system is notable for two essential characteristics: 1) the sharing of decision-making powers between states, federal government, and self-regulated organizations of payers and providers; and 2) the separation of SHI (including the social LTCI) and PHI (including the private LTCI). SHI and PHI (as well as the two long-term care insurance systems) use the same providers—that is, hospitals and physicians treat both statutorily and privately insured patients, unlike many other countries.

Within the legal framework set by the Ministry of Health, the Federal Joint Committee has wide-ranging regulatory power to determine the services to be covered by sickness funds and to set quality measures for providers (see below). To the extent possible, coverage decisions are based on evidence from health technology assessments and comparative-effectiveness reviews. The Federal Joint Committee is supported by the Institute for Quality and Efficiency (IQWiG), a foundation legally charged with evaluating the cost-effectiveness of drugs with added therapeutic benefits, and the newly formed Institute for Quality and Transparency (IQTiG). The Federal Joint Committee has had 13 voting members: five from the Federal Association of Sickness Funds, two each from the Federal Association of SHI Physicians and the German Hospital Federation, one from the Federal Association of SHI Dentists, and three who are unaffiliated. Five patient representatives have an advisory role but no vote in the committee. Representatives of patient organizations have the right to participate in different decision-making bodies, e.g., the subcommittees of the Federal Joint Committee.

The Federal Association of Sickness Funds works with the Federal Association of SHI Physicians and the German Hospital Federation to develop the SHI ambulatory care fee schedule and the DRG catalogue, which are then adopted by bilateral joint committees.

What are the major strategies to ensure quality of care?

Quality of care is addressed through a range of measures broadly defined by law, and in more detail by the Federal Joint Committee. Structural quality is assured by the requirement that providers have a quality management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. However, there is no revalidation requirement for physicians. Hospital accreditation is voluntary.

All new diagnostic and therapeutic procedures applied in ambulatory care must be positively evaluated in terms of benefits and efficiency before they can be reimbursed by sickness funds. Volume thresholds have been introduced for a number of complex procedures (e.g., transplantations), requiring a minimum number of such procedures for hospitals to be reimbursed. Process and (partly) outcome quality are addressed through the mandatory quality reporting system for the roughly 2,000 acute-care hospitals. The recently passed Hospital Care Structure Reform Act will provide a focus on quality-related hospital accreditation and payment, beginning in 2016 (see section on reforms).

Disease management programs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance. Nonbinding clinical guidelines are produced by the Physicians’ Agency for Quality in Medicine and by professional societies.

All hospitals are required to publish results on selected indicators defined by the Federal Office for Quality Assurance and, until 2015, the AQUA Institute, allowing for hospital comparisons.

Many institutions and health service providers include complaint management systems as part of their quality management programs; in 2013, such systems were made obligatory for hospitals. At the state level, professional providers’ organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims.

To strengthen quality by law, in addition to the above, government commissioned the Federal Joint Committee in 2015 to establish the Institute for Quality and Transparency in Health Care, replacing the AQUA Institute. The institute will be operational from January 2016, with the task of developing further indicators for quality assurance, which might provide an additional criterion for decisions on hospital planning and payment.

The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. In August 2013, as part of the National Cancer Plan, the federal government passed a bill that proposes the implementation of a nationwide standardized cancer registry in 2018 to improve the quality of cancer care.

What is being done to reduce disparities?

Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ between states. Health disparities are implicitly mentioned in the national health targets. A network of 53 health-related institutions (e.g., sickness funds and their associations) promotes the health of the socially deprived (Cooperative Alliance National Health Targets, 2015). Primary prevention is mandatory by law for sickness funds; detailed regulations are delegated to the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds support 22,000 health-related programs, e.g., in nurseries and schools (Federal Association of Sickness Funds, 2015). With the Act to Strengthen Health Promotion and Prevention, these programs will be further developed and financially supported (see below).

The Health Monitor (Gesundheitsmonitor) is a national association of nonprofit organizations and sickness funds. To assess access to health care, it regularly conducts studies from the patient perspective, for example, on the level of information, experiences with health care, or evaluation of health system reforms.

What is being done to promote delivery system integration and care coordination?

Many efforts to improve care coordination have been implemented, e.g., sickness funds offer integrated-care contracts and disease management programs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2014, 9,917 registered disease management programs for six indications had enrolled about 6.5 million patients (more than 8% of all the SHI-insured). There is no pooling of funding streams between the health and social care sectors.

From 2016, the Innovation Fund will promote new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD381 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds will be awarded through an application process overseen by an Innovation Committee based at the Federal Joint Committee.

What is the status of electronic health records?

About 90 percent of physicians in private practice use electronic health records (EHRs) to help with billing, documentation, tracking of laboratory data, and quality assurance. The use of online services to transmit billing information and documentation from disease management programs is obligatory. Hospitals have implemented EHRs to varying degrees. Unique patient identifiers do not exist and interoperability is limited, as data safety concerns represent a significant obstacle.

As of 2015, electronic medical chip cards are used nationwide by all the SHI-insured; they encode information as to the person’s name, address, date of birth, and sickness fund, along with details of insurance coverage and the person's status regarding supplementary charges (Company for Telematics Applications for the Electronic Health Card, 2015). In 2015, the Federal Cabinet proposed a bill for secure digital communication and health care applications (E-Health Act), which provides concrete deadlines for implementing infrastructure and electronic applications, and introduces incentives and sanctions if schedules are not adhered to. SHI physicians will receive additional fees for transmitting electronic medical reports (2016–17), collecting and documenting emergency records (from 2018), and managing and reviewing basic insurance claims data online. From July 2018, SHI physicians who do not participate in the online review of the basic insurance claims data will receive reduced remuneration. Furthermore, in order to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan, starting in October 2016. In the medium term, this medication plan will be included in the electronic medical record (Federal Ministry of Health, 2015).

How are costs contained?

All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added medical benefit. Drug companies are required to produce scientific dossiers for all new drugs demonstrating added medical benefit, which is then evaluated by IQWiG, followed by a Federal Joint Committee decision within a six-month period. For drugs with added benefit, the Federal Association of Sickness Funds negotiates a rebate on the manufacturer’s price that is applied to all patients. In addition, rebates are negotiated between individual sickness funds and pharmaceutical manufacturers to lower prices below the reference price.

Recently, reliance on overall budgets for ambulatory physicians and hospitals and on collective regional prescription caps for physicians has been replaced by an emphasis on quality and efficiency. The Hospital Care Structure Reform Act aims not only to link hospital payments to good service quality, but also to reduce payments in the case of “low value.”

To extend competition, some purchasing powers have been handed over to the sickness funds, e.g., to contract providers selectively within an integrated care contract or to negotiate rebates with pharmaceutical companies.

What major innovations and reforms have been introduced?

In June 2015, parliament passed the Act to Strengthen SHI Health Care Provision. This act is based on the 2011 SHI Care Structures Act, and takes measures to further strengthen service provision structures for SHI patients, particularly in underserved rural areas. These measures include a right for municipalities to establish medical treatment centers, a ban on transferring SHI-accredited practices to successors in overserved areas, the establishment of appointment service centers that would guarantee a specialist appointment within four weeks, and the promotion of innovative forms of care, especially through the establishment of an Innovation Fund at the Federal Joint Committee endowed with EUR300 million (USD381 million) annually from 2016 to 2019 (Health Systems and Policy Monitor, 2015).

The Act to Strengthen Health Promotion and Prevention passed parliament in July 2015. In an upcoming National Prevention Conference, the social security schemes, in collaboration with federal, state, and local governments, as well as the Federal Employment Agency, will agree on common goals and approaches. Furthermore, the act aims to improve prevention and health promotion by regulating vaccination policy and by expanding health checkups. Sickness funds and long-term care funds invest EUR500 million (USD635 million) annually, of which about EUR300 million is earmarked for health promotion in children’s day-care facilities, schools, the work environment, and long-term care facilities (Federal Ministry of Health, 2015).

The Hospital Care Structure Reform Act comes into force in January 2016. The law provides for the introduction of quality aspects in hospital planning (legally defined minimum volumes) and payment (quality-related supplements and reductions), as well as a more patient-friendly design for hospital reports. In order to strengthen nursing care of patients and to create new nursing jobs, a subsidy program will provide up to EUR660 million (USD839 million) in 2016–2018, and, starting in 2019, EUR330 million (USD419 million) per year. Hospital financing will be developed further and the reallocation pool will earmark EUR500 million to support measures to improve hospital care structures (Federal Ministry of Health, 2015).

Several other bills are pending in the legislative process, e.g., the E-Health Act (see section on EHR) and the Hospice and Palliative Care Act (see section on long-term care and social supports).

Acknowledgements

The authors would like to acknowledge Stephanie Stock as a contributing author to earlier versions of this profile.

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