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The German healthcare system Strong. Reliable. Proven.
Foreword
Dear Readers,
Across the world, healthcare systems are at the heart of efforts to cope with the current
COVID-19 pandemic. Because a political response to mitigate the economic and social
consequences of the pandemic will not be possible unless the spread of the coronavirus
is stopped. A crisis like this reveals whether the existing structures and processes can stand
up to extraordinary pressures, and whether the actors involved have sufficient capacities
and resources to provide the population with medical care and effectively fight infec-
tions for which neither a vaccine nor a treatment are immediately available. We must all
use this crisis to strengthen our resources where deficits have been exposed. Because
there is certain to be another pandemic or a similar medical emergency in the future!
At the same time, the COVID-19 pandemic has made it very clear that the challenges we
face are not just a national matter. The virus does not stop at borders. The European and
global dimensions of the crisis have especially been highlighted by the supply of medicines
and medical supplies and equipment.
From 1 July to 31 December 2020 Germany holds the Presidency of the Council of the European Union and so will assume key responsibilities within the EU framework. For the health portfolio, this primarily means considering questions relating to the ongoing pandemic in their European perspective and learning the lessons that have to be learnt to ensure that we in Europe are even better prepared in future. But there are also other urgent healthcare topics that are of great importance for the future of Europe and its ability to withstand crises. So during Germany’s Presidency of the Council of the European Union, we want to drive forward digitalisation and the use of big data and artificial intelligence in the health system, and we want to safeguard and improve the supply of pharmaceutical products and medical devices in the EU. Joint European solutions always work particularly well when they take national specifi- cities into account. These specificities often go back a long way and mean that in many areas the structures and processes in the member states differ from one another. Health systems in Europe have also adapted to the different national circumstances and condi- tions and so are different in themselves. This publication provides an overview of the German health system and explains its main institutions and regulatory mechanisms. We hope that it contributes to an understanding of the different healthcare systems in Europe. Because it is only with understanding for one another – especially in a medical emergency like the COVID-19 pandemic – that we and our partners in the EU and worldwide can ensure the medical treatment of citizens, improve our systems and create genuine added value in the context of the EU. Jens Spahn, Federal Minister of Health
Contents
A long history: the basic principles of the healthcare system 6 Multiple networks: the actors in the healthcare system 14 Dependable protection: statutory health insurance (SHI) 22 All-round support: medical and nursing care 28 Structurally dynamic: challenges and opportunities 40 German healthcare facts and figures 48 The Federal Ministers of Health from 1961 to today 50 Glossary 51 Reference sources 54 Information from the Federal Ministry of Health 56 Imprint 61
A long history: the basic principles of the healthcare system
Providing Germany’s population of 83 mil-
lion with medical care is a massive task.
Delivering this healthcare draws on a net-
work of around 1,900 hospitals1, 150,000
doctors2, 28,000 psychotherapists3 offering
outpatient care and almost 19,500 pharma-
cies4. The costs of this healthcare system are Healthcare in
high – more than €391 billion5 was spent on
healthcare in Germany in 2018 according to
Germany is based on
the latest figures from the Federal Statistical five principles
Office. That is more than a billion euros a
day. In other words, over one in ten euros Mandatory insurance
of Germany’s GDP goes on healthcare. Statutory health insurance (SHI) and private
health insurance (PHI) were made manda-
The healthcare system is financed by statu tory on 1 April 2007, and as of 1 January 2009
tory and private health insurance. Today’s everyone registered or usually resident in
system has a long history. The first precur- Germany is required to take out health in-
sors of a mutual health insurance system surance. Employees are required to make
can be found in the Middle Ages. Guilds SHI contributions if their income is below
and some companies assumed responsi- a certain level (in 2020 the threshold was
bility for financing medical and nursing €5,212.50 per month). If their monthly in-
care for their members and employees. come exceeds this level, employees can
The different forms of social safety net retain membership of the SHI on a voluntary
that evolved over the centuries were har- basis or elect to take out private health in-
monised in the course of the 19th century. surance. Some groups are also exempt
One milestone was the world’s first system from mandatory contributions to the SHI
of social insurance introduced in 1883 by regardless of their income level. They in-
the German chancellor at the time, Otto clude civil servants and the self-employed,
von Bismarck. It laid the foundations for for example.
the statutory health insurance system in
Germany, which today covers most of the
country’s residents.
A network
including some 1,900 hospitals, 150,000 doctors
and 28,000 psychotherapists offering outpatient
care, as well as almost 19,500 pharmacies, provides
healthcare services to roughly 83 million people
in Germany
8also charge an additional premium, which
currently averages around one percent and
of which the employer also pays half.
People insured privately may also be sub-
sidised by their employer or pension fund.
In the SHI, in contrast to the PHI, coverage
is extended at no extra cost to the children
Financed by contributions and the spouse of the insured if they have
Both SHI and PHI are funded by contribu- little or no income. Health insurance con-
tions or premiums from their members. tributions for those receiving unemploy-
Whereas contributions to PHI depend on ment or social security benefits are gener-
a person’s health, the age at which they ally paid by the relevant benefits agency.
take out the insurance, their individual
risk, the type of coverage and any excess,
contributions to the SHI are based on a
person’s salary. With the SHI, all the in-
sured receive the same level of services.
Those who earn more pay higher contri-
butions. This is what is meant by solidarity
in the statutory health insurance system.
The general contribution rate in the SHI is
14.6 percent of salary, of which the em-
ployer pays half. Each insurance fund can 83.3 years
is currently the
life expectancy for
newborn girls.6
78.5 years
is currently the
life expectancy for
newborn boys.6
9 The basic principles of the healthcare system30%
of people in Germany go to the Self-administration
doctor three to five times a year.7 The health system is complex. It is charac-
terised by conflicting interests, which have
to be aligned with one another: patients
want optimal treatment, doctors want
modern technology and the health insur-
Solidarity ance funds have to ensure that they can
The German healthcare system is financed finance it all with the contributions they
on the principle of solidarity. This means receive from the insured. Who has to coord
that all those with statutory health insur- inate it all? The state? The market? Or the
ance bear the costs for the treatment of in- individuals involved?
dividual members. Everyone covered by
SHI is entitled to medical care, regardless Germany has chosen the latter and applies
of their income and therefore their health the principle of self-administration. This
insurance contributions. So the healthy means that the state defines the frame-
pay for the sick, the rich for the poor and work for medical care and its responsibil
singles for families. Another aspect of this ities. It enacts legislation and regulations
solidarity is that those in work continue to for this purpose. But how the system is
receive their salary if they become ill. Em- organised and structured in detail and
ployers pay them their full salary for the above all what medical treatments, oper
first six weeks. Anyone who is off work ations, therapies and medicines are financed
for longer receives an allowance of 70 per- by the health insurance funds and those
cent of their gross pay from their health that are not are decided within the health-
insurance fund. care system. This self-administration of
the healthcare system is carried out jointly
No direct payment by patients by representatives of doctors, dentists,
Those covered by SHI receive medical treat- psychotherapists, hospitals, health insur-
ment without having to outlay the costs ance funds and the insured. Its supreme
themselves. Doctors, hospitals and phar- decision-making body is the Federal Joint
macies charge the cost of treatment and Committee (G-BA). Representatives of pa-
medicines directly to the health insurance tient organisations have the right to table
funds. The insured are entitled to free motions in and take part in G-BA sessions.
treatment, apart from any individual extra The G-BA defines in binding guidelines
charges defined by law. the healthcare services to which those
covered by statutory health insurance are
entitled, e.g. what treatments are covered
by the statutory health insurance. As a rule,
new medicines are covered.
The basic principles of the healthcare system 10Classification of the
German health system
Comparing the health systems of various Finally, there are market-based systems,
countries, they can be roughly divided in which the state plays a subordinate
into three categories: role. The organisation and management
of the healthcare sector are functions of
There are national health services organ- private operators. Funding is also organ-
ised by the state and funded from tax ised privately: there are private-sector
revenue. This is the case in the UK and insurance companies or people pay for
Sweden, for instance. In these countries, their medical treatment themselves.
all operations, therapies and medicines They also have to cover their own cost of
are paid for from the government living if they cannot work for a longer
budget. There may be extra charges for period due to illness – there is no sick
some treatments. In these countries, it is pay in this case. This is how it works in
the state that organises the provision of the USA for example.
hospitals and healthcare centres too.
In other countries, there are social insur-
ance systems. Here, it is largely social
security funds, i.e. health insurance funds,
which finance medical care. They are fi-
nanced by contributions from compan
ies and employees, as is the case in Ger-
many. Private and public providers operate
side by side, in contrast to national health
services. They regulate their interrelation-
ships themselves, within a defined statu-
tory framework. This is known as the
principle of self-administration.
Approximately 5.7
million people work in the healthcare sector –
ranging from doctor’s practices, to administrative
functions to the pharmaceutical industry.8
11 The basic principles of the healthcare systemThe basic principles of the healthcare system 12
Germany’s federal
system
When the coronavirus reached Germany, To continue with the example of the
steps to combat the pathogen were taken COVID-19 pandemic: the federal legislature
on two levels: the Federal Government defined the framework for protecting the
recommended a policy of social distan population in Germany. What authorities
cing for everyone in the country. The indi- take action and how the regulations are
vidual states then decided whether and implemented in detail are then decided by
when to close schools, museums and res- the states for their respective territories.
taurants to protect people from infection. The idea behind this is that politics should
be as devolved and as local as possible. For
This was an example of the federal system this reason, state responsibilities in Germany
on which the Federal Republic of Germany are divided according to the principle of
and as a result its healthcare system are subsidiarity: first, the municipalities are
based. Close cooperation between the responsible for their local residents, then the
Federal Government and the individual states, or Länder. The Federal Government
states forms the core of the federal system. sets out the policy framework in certain areas.
The states participate in the legislative
process, including via the Bundesrat, and
implement federal laws.
13 The basic principles of the healthcare systemMultiple networks: the actors in the healthcare system
Everyone should get medical assistance
quickly if they become ill. This requires
many different actors, including doctors,
therapists, nurses, carers, hospitals, re- 1. A framework defined by the state – at
habilitation centres and pharmacies. And federal, state (Land) and municipal level –
their services have to be paid for. This in in line with Germany’s political structure
turn is the responsibility of the health in-
surance funds. But what treatments exact- 2. A healthcare structure as defined by
ly? All this has to be decided, codified and the system of self-administration, with
coordinated. The healthcare system is its bodies and associations
complex. It can be divided into three levels:
3. Provision of care by health insurers,
doctors, many different healthcare pro-
fessionals, hospitals and pharmacies,
whose interests are represented by as-
sociations
Evolving
responsibilities
Even though the Federal Ministry of Health (BMG)
has been the senior federal authority in matters
of health since 1961 its remit has been altered
repeatedly over the decades. Between 1969 and
1991 the BMG was merged with what is now the
Federal Ministry for Family Affairs, Senior Citizens,
Women and Youth. Having regained its independ
ence in 1991 it was briefly responsible for social
affairs (and therefore for pensions) between 2002
and 2005 before this portfolio was moved back
to what is today the Federal Ministry of Labour and
Social Affairs.
The actors in the healthcare system 16The first level: the legislative framework Federal Ministry of Health Within the Federal Government, the Federal Alongside the German Bundestag and the Ministry of Health (BMG) has primary re- Federal Government, the Bundesrat is the sponsibility for health policy. This means third key driver of health policy at the fed- it is in charge of drawing up the corres eral level. As the “second chamber of par- ponding legislative proposals, ordinances liament”, it is the institution where the and administrative regulations. The Fed governments of the individual German eral Ministry of Health supervises a number states can debate matters of health policy. of institutions that deal with overarching aspects of health policy: the Federal Insti- The legislature and state health policy de- tute for Drugs and Medical Devices fine the framework in which the various (BfArM), the Paul-Ehrlich-Institut, Federal partners in the healthcare sector can make Institute for Vaccines and Biomedicines their decisions. The aim is to align the pri- (PEI), the Robert Koch Institute (RKI) and orities of health policy with the effective the Federal Centre for Health Education use of available funding. (BZgA). The Federal Minister of Health is also supported by the Federal Govern- ment’s Delegate for Long-term Care, the Federal Government’s Commissioner for Drugs and the Federal Government’s Commissioner for Patients’ Affairs. 17 The actors in the healthcare system
The states Municipalities
The individual states or Länder have their People who go to a doctor or a physiother-
own legislative powers. They are responsible apist generally choose someone in their
for implementing federal legislation as well own city, town or village. This is their
as for planning and financing inpatient familiar environment and it is where they
care. Furthermore, they exercise functional want to receive their medical care. This is
and disciplinary supervision over the why municipalities as the smallest polit
municipal public health services. ical units are so important – they are close
to their residents and therefore have re-
Responsibility for statutory health insur- sponsibility for the provision of local
ance is largely a federal matter. However, healthcare. Preventive healthcare also falls
the Länder are in charge of supervising the within their remit, and the municipalities
regional health insurance funds. They also offer many easily accessible medical and
supervise the regional medical associ care services, such as psychosocial coun-
ations (for doctors, dentists, pharmacists selling in crises. In this way, they ensure
and psychotherapists) and the associ equality of opportunity in the German
ations of doctors and dentists treating health system.
patients with statutory health insurance.
The municipal health authorities are an-
other important part of the German
healthcare system. They are close to the
local residents. In the ongoing coronavirus
pandemic, for instance, they document all
new infections and trace chains of infec-
tion, in order to monitor the spread of the
virus in their municipality. They also agree
with the local hospitals on the extent to
which beds have to be made available for
COVID-19 patients and other treatments,
Healthcare policy such as elective surgery, have to be post-
poned as a result. The municipalities often
at the Länder level run the hospitals themselves.
In institutional terms, the Länder generally
have a health ministry to administer their
healthcare policies. The regional health
ministers meet regularly at the Gesundheits
ministerkonferenz (Conference of Health
Ministers, GMK) of the Länder.
Municipalities
In most cases, the consultation services offered
by German municipalities are free of charge
for all, as is the case for consultations and coun
selling on pregnancy, HIV prevention, addiction
and psychological and psychiatric support.
18The second level:
Social security
self-administration elections
One important element of the German What many people in Germany do not know is
health system is that the actors themselves that the “social security elections” held every
decide which medical treatments are de- six years enable everyone covered by statutory
livered by service providers at the expense health and pension insurance to elect repre
of the community, i.e. are financed by the sentatives to the self-administration bodies of
statutory health insurance funds. In mak- the agencies concerned.
ing their decisions, they are guided by the
principle of cost-effectiveness. This means
that treatment has to be sufficient, expedi-
ent and cost-effective; it may not go be-
yond what is necessary. Patients generally
Two scientific insti
have to pay for any treatment going be-
yond this limit. With many available treat-
tutes support the
ments, it goes without saying that they
will be paid for by the statutory health in-
work of the G-BA
surance: if someone has a heart attack, The Institute for Quality and Efficiency in
they will be treated by an emergency doc- Health Care (IQWiG) primarily evaluates the
tor immediately. And the statutory health benefits and costs of pharmaceutical products
insurance covers the bill. So too with and treatment methods in the SHI system.
sports – if someone twists their ankle, they The Institut für Qualität und Transparenz im
show their health insurance card to the Gesundheitswesen (Institute for Quality and
orthopaedic surgeon, are X-rayed and get Transparency in the Healthcare System, IQTIG)
their foot bandaged as necessary. is the central institute for the quality assurance
required by law for the healthcare sector.
But there are grey areas too. What if a pa-
tient with an orthopaedic injury wants to be
treated by an osteopath rather than a physio
therapist? What if they do not want to take The G-BA is made up of members of the
painkillers, but would rather have homoeo- National Association of Statutory Health
pathic medicine? Then someone has to de- Insurance Funds, the National Association
cide whether the health insurance fund will of Statutory Health Insurance Physicians,
also pay for these treatments. This is the job the National Association of Statutory
of the Federal Joint Committee. Health Insurance Dentists and the Ger-
man Hospital Federation. Patients are also
Federal Joint Committee entitled to make their interests heard, so
The Federal Joint Committee (G-BA) is organisations representing patients and
based in Berlin and is the most important people with disabilities have the right to
body in the joint self-administration of take part in and table motions in G-BA ses-
healthcare. Representatives of statutory sions. They can contribute to all the topics
health insurance funds, doctors and hos- being discussed, for example whether the
pitals meet to discuss whether the health insurance funds should pay for dietary ad-
insurers should pay for new methods of vice for patients with diabetes, what new
treatment, modern medical technology, treatment methods are covered or the
new medicines or alternative therapies. The type of dental replacement financed by
benefits of new medicines are evaluated. the insurance funds.
As a rule, new medicines are covered.
19 The actors in the healthcare systemThe statutory health insurance funds
and their federal association
In Germany, there is a wide range of op-
tions for obtaining health insurance. Statu
tory health insurance, currently made up The national associations of
of 1059 insurance funds, covers the largest SHI doctors and dentists
number of people. People with statutory The local associations of SHI doctors and
health insurance can be members of a local dentists and their umbrella associations at
health insurance fund, a company or guild the federal level are responsible for ensur-
health insurance fund, a substitute insurance ing the delivery of outpatient medical,
fund or are insured through the agricultural psychotherapeutic and dental care to peo-
health insurance fund or the miners’ in- ple with statutory health insurance in Ger-
surance fund. In addition, there are private many. In addition to this mandate to ensure
health insurance companies. provison of care, they represent the interests
of doctors, psychotherapists and dentists
The statutory health insurance funds are who provide care to patients with statutory
represented at the federal level by an um- health insurance.
brella organisation, the National Associ
ation of Statutory Health Insurance Funds
(GKV-Spitzenverband). Via this or its re-
gional branches, they sign contracts with
medical associations, hospitals and phar-
macies and agree on how much they will
pay for individual medical treatments.
The German Hospital Federation
Individual hospitals do not represent their
interests individually but rather via their
associations. At the regional level, hos
pitals are organised in associations for their
specific Land or state. The regional associ-
ations in turn send delegates to the federal
body, the German Hospital Federation
(DKG). This has a number of duties assigned
to it by law in line with the self-administra-
tion system in the healthcare sector.
The actors in the healthcare system 20The third level: individual actors and their lobby groups And now, where are people actually treat- ed, where do patients receive care? This takes place at the third level, which is made up of doctors, therapists, hospitals and rehabilitation centres. To ensure that those involved in providing treatment dir ectly to patients also have a voice and can make themselves heard by policymakers, they have formed professional organisa- tions and trade associations. These include the federal and regional associations of various medical professions, as well as the Federal Union of German Associations of Pharmacists (ABDA). In addition, there are patients’ organisations, the medical asso- ciations, the associations of other health- care professionals, the association of private health insurance funds and the associations of pharmaceutical companies. 21 The actors in the healthcare system
Dependable protection: statutory health insurance
Statutory health insurance (SHI) is a core The German system of health insurance
component of the German healthcare system. has a great heritage. As mentioned earlier,
Its role extends from promoting healthy the SHI can trace its roots back to Bis-
living and preventive healthcare through marck’s social security legislation in the
to the treatment of concrete illnesses and 19th century. Initially, the self-adminis-
subsequent rehabilitation. Its responsibil tered insurance, financed by contributions,
ities are defined by law as being to keep was intended solely for industrial workers.
the insured in good health, to restore them SHI was extended to salaried employees in
to health if they fall ill and generally to im- 1911. Today, some 90 percent of the public
prove their standard of health. are covered by SHI.
Health insurance cover in Germany10
in percent and millions, 2018
SHI
87.7%
approx. 72.8 m
Residents:
83,019,200
Insured:
SHI **: 72,781,399
PHI***: 8,736,300
Other: 1,501,501
Other* PHI
1.8% 10.5%
approx. 1.5 m approx. 8.7 m
* Other: entitlement to healthcare provision as recipients of social security benefits, disabled veterans, recipients of support resulting from the
equalisation of burdens, free medical or therapeutic care for police and Germany’s armed forces, people without health insurance, existence
of health insurance not stated
** Statutory health insurance (SHI) *** Private health insurance (PHI)
Statutory health insurance 24Since 1996 most people have been able to This also means that the SHI funds can
choose their health insurance fund freely. sign discount agreements with pharma-
Risk structure compensation was intro- ceutical companies. These entail a pharma-
duced to ensure fair competition between ceutical manufacturer giving a health
the insurance funds. This equalises the insurance fund a discount on the drugs it
35,000
structural risks resulting from different produces. In exchange, the insurance
insured groups and prevents an uneven funds provide their members with medi-
distribution of higher and lower earning cines from their contracted suppliers on
members, young and old, healthy and sick, an exclusive basis via the pharmacies. The At the end of the 19th century,
singles and families from having an ad- intention of the legislation was to cut drug Germany had around 35,000
verse effect on the financial situation of spending by the SHI funds and so reduce health insurance funds; 11
individual insurance funds. the contributions payable by employees nowadays, there are 105.12
and employers.
The structure of the SHI has been reformed
repeatedly over the past 25 years. The aim
was for the health system to become more
efficient and deliver higher quality out-
comes. The health insurance funds were
gradually enabled to sign individual agree-
ments (known as selective agreements) for
specific treatments with doctors, medical
associations and hospitals.
25 Statutory health insuranceThe healthcare fund
Statutory health insurance has been fi-
nanced via the healthcare fund since 2009.
This is funded by contributions from em-
Federal Employment Deutsche
ployers, other social security agencies, Agency Rentenversicherung
members of the SHI funds and a grant (German Pension
State
from the Federal Government. The fund Insurance)
provides the SHI funds with the resources Contributions
they need – by means of the risk structure for the un
compensation mentioned above – to finance employed and
treatments for their insured members. In
pensioners
addition to the standard rate contribution
paid to the healthcare fund (currently 14.6
percent of gross pay), individual insurance Contribution from
Healthcare
funds can levy an additional contribution,
which they receive directly and is intended
to ensure an element of competition.
tax revenues
fund15
Total volume approx.
€222.2 bn
Payment
Basic flat rate
per insured individual
Contributions
Additional forwarded
+ extra charges
+ administrative costs
contributions and
refunds possible
Around 4.34 percent
of the employed were unfit for work on an
average day in 2019.13
Health insurance funds
Approx. 4.9 bn Contributions Payment for
medicines,
In 2019 the SHI funds were able to cut their
consistent at 14.6%
Employees 7.3% treatments, etc.
spending on medicines by a total of approx. Insured Employers 7.3% Doctors,
€4.9 billion thanks to discount agreements.14
hospitals, etc.
26 27 Statutory health insuranceAll-round support: medical and nursing care
You might think it were perfectly simple: All treatments, rehabilitation activities and
when people fall ill, they go to see a doctor. therapies provided outside hospitals belong
If someone is more seriously ill, they are to the category of outpatient care. Hospitals
treated in hospital. But thanks to progress can also provide outpatient care, however,
112
in medical science, the range of treatment in specialist outpatient departments, for
options available is now much more di- example. At times, some independent phy-
verse. Nowadays, there are people with sicians also work in hospitals, where they
In life-threatening cases, chronic illnesses who can lead a normal look after a certain number of patients.
the number to call life with virtually no adverse effects.
is 112, for emergency
medical services. The German healthcare system is divided
into inpatient and outpatient treatment.
Both medical and nursing care are provid-
ed on an inpatient and outpatient basis.
Treatments that combine the two tend to be
the exception.
Healthcare in Germany16
Selected treatment types as a percentage of overall spending for treatment covered by SHI in 2018
amounting to €226.22 bn
Treatment by doctors
17.4% Hospital treatment
34.1%
Medicines
17.1%
Medical products and aids
7.1%
Dental treatment Other
6.4% 17.9%
Medical and nursing care 30Outpatient care Inpatient care
Outpatient care is provided by general There are around 1,900 hospitals17 in Ger-
practitioners, specialists, dentists and psy- many providing inpatient treatment. Most
chotherapists, as well as other healthcare of these hospitals treat everyone, regard-
professionals, such as physiotherapists and less of whether they have statutory or pri-
speech therapists. vate health insurance. Patients only have
to be referred to the hospital by a doctor –
Most independent physicians, dentists and except in emergencies, of course, when the
psychotherapists treat patients with statu- hospital provides treatment straight away.
tory health insurance, i.e. they have been Patients can choose which hospital they
116 117
approved by the SHI funds. This means wish to go to. The SHI covers the expenses,
they have been approved for the provision as long as the hospital is approved for the
of treatment on the basis of contracts with provision of treatment to SHI patients.
the SHI funds and are members of the cor- The vast majority of hospitals are approved. Patients can receive medical
responding association of SHI doctors or At present, hospitals are run in roughly equal treatment, even in acute cases,
dentists. Furthermore, it means that their proportions by private companies, not-for- by calling 116 117. They can use
approval is tied to the location of their profit organisations and municipalities. this service to ask for advice and
practice and so depends on the require- to make medical appointments.
ments of the respective regional associ People with statutory health insurance
ations for SHI doctors and dentists. have to pay a supplementary charge for
their accommodation and meals when they
Outside normal appointment times, the receive inpatient treatment. This is defined
independent doctors and dentists provide before the treatment is given in a contract
an on-call service for treatment. between the patient and the hospital.
Free choice of
medical practitioner
When someone falls ill, their first point of contact
with the healthcare system is usually their family
doctor or general practitioner. In principle, however,
the insured can see any doctor who is approved by
the SHI funds. Patients are thus free to choose the
medical practitioner they wish to see.
31 Medical and nursing careAlmost 19,500
pharmacies in Germany supply 3.5 million people
with medicines every day.18
Provision of medicines
If someone is given a prescription for It is important to know that patients can
medication by a doctor, they take it to a take their prescription to any pharmacy.
pharmacy. The health insurance fund pays Medicines cost the same in all of them,
most of the costs of prescription medi- thanks to a regulation. It stipulates that
cines. SHI patients have to pay a supple- there is a uniform sales price for prescrip-
mentary charge of 10 percent of the sales tion medicines everywhere.
price, with a minimum charge of €5 and a
maximum of €10. So if a patient were, for However, the fact that the same active in-
example, prescribed a drug manufactur- gredient can be more or less expensive has
er’s thyroid hormone that costs €17.80 at a different reason. Pharmaceutical com
the pharmacy, they would pay the min panies generally decide themselves on the
imum charge of €5. If they need a rheuma- pricing of their medicines. There are drugs
tism medicine that costs €70, they pay for which the patent has expired (off-pa
10 percent, so €7, themselves. tent), and there are generic drugs. These are
medicines with the same active ingredient
Children and young people up to the age as the original, but which are not the ori
of 18 do not have to pay the supplemen ginal, and so are often much cheaper. In
tary charge. Moreover, there are caps on the order to reduce their spending on medicines,
total amount the insured have to pay. Sup- the SHI funds often define which pharma-
plementary charges are capped at two ceutical products may be prescribed to
percent (and one percent for people with their members, unless the doctor writing
chronic illnesses) of a person’s annual gross the prescription has ruled this out. So it
income. The statutory health insurance sometimes happens that after many years,
fund concerned determines whether the the pharmacist suddenly starts supplying
cap has been reached. Patients must apply a medicine from a different manufacturer.
to their SHI fund if they wish to have their These generic drugs are just as effective, how-
charges reviewed. ever, and they can even be advantageous
for patients because the supplementary
charge they have to pay is lower.
Medical and nursing care 32New medicines not only have to be tested
thoroughly and officially authorised. Their
benefits must also be evaluated before the
SHI pays for them. Since the act reforming
the pharmaceuticals market came into ef-
fect in 2011 the G-BA has therefore com-
pared the benefits of a new medicine with
other drugs for the same disorder. On the
basis of this evaluation, the respective
pharmaceutical company and the Nation-
78%
al Association of Statutory Health Insur-
ance Funds agree on an adequate price for
the new medicine.
Generic drugs accounted
for 78% by volume of all
medicines prescribed in
the statutory health in
surance system in 2018.
It is easier for SHI funds
to obtain discount agree
ments for generic drugs.19
33 Medical and nursing careThe care grades Nursing care
1 If someone is physically or psychologically
Slight loss of independence incapable of taking care of themselves on
an everyday basis, they are entitled to
2 nursing care. It is not an easy decision to
Considerable loss of independence take, but good nursing care should help
people to live as independently and autono-
3 mously as possible, in dignity, despite their
Severe loss of independence limitations. Long-term care insurance was
made mandatory from 1 January 1995 for
4 everyone with statutory and private health
Very severe loss of independence insurance, in order to provide the best
possible support to those in need of care
5 and to their family members.
Very severe loss of independence
with an exceptionally pronounced Statutory long-term care insurance is
need for nursing care financed equally by employers and em-
ployees. Since 1 January 2019 the contri-
bution rate has been 3.05 percent of gross
income, rising to 3.3 percent for those with-
out children. People with private health
insurance must take out private long-term
care insurance.
Long-term care insurance does not cover
all the costs of nursing care, however. The
remainder is paid by the people being cared
for or their relatives, or by social security
benefits if necessary. Long-term care insur-
ance is therefore known as “partial cover-
age insurance”.
Since it was introduced, the law on long-
term care insurance has been revised several
times to reflect new demands. One important
step was to redefine the need for long-
term care, taking a differentiated view of
independence as the basis for the assess-
Long-term care ment (rather than the amount of time
needed for physical assistance).
insurance
is an independent pillar of the social
insurance system (Social Code XI, SGB XI)
Medical and nursing care 34need support to structure and cope with
This more holistic assessment of individ their everyday lives. Since 2017, in addition
uals in need of long-term care now enables to physical limitations, a loss of emotional
the type of care provided for all those in and psychological independence, such as
need of nursing care to be divided into that seen in those with Alzheimer’s and
five levels. Previously, the needs of people other forms of dementia, is now taken
with dementia were not taken sufficiently into account. The situation for people with
into account for access to nursing care. dementia will be further improved by the
Although they often have no serious physical implementation of the National Dementia
disabilities, many people with dementia Strategy from 2020 onwards.
Around 3.92 million
people every month receive nursing care paid for from
their long-term care fund. Most of them, around
2.9 million, are cared for on an outpatient basis, i.e. in
their home. Some 780,000 people received inpatient
or residential nursing care in 2018 according to figures
from the long-term care funds and private insurers.20
35 Medical and nursing careSome €5.7 billion SHI spending on all preventive healthcare treatments, especially vaccinations and the early detection of illnesses, came to some €5.7 billion in 2018. The SHI funds invested approximately €544 million of this total in primary prevention and health promotion.21 Medical and nursing care 36
Prevention and promo
tion of healthy living
We all wish for good health, for ourselves at work and in residential care homes.
and our relatives. And we can do things to Dietary advice, exercise programmes,
make that happen by, for instance, eating a relaxation exercises, stopping smoking,
balanced diet, exercising and trying to find reducing alcohol consumption – all this
a healthy balance between work and leis helps people to stay healthy and avoid
ure time. illnesses in the first place. Many SHI funds
offer preventive healthcare courses for
The health system and other areas of social their insured, to motivate them and to
security provision also dedicate resources empower them to make the most of their
to the prevention of illnesses and the pro- opportunities in living a healthy life.
motion of healthy living. In 2015 the um-
brella organisations of the statutory insur- They also promote the health of their
ance agencies for health, accident, pensions insured with services provided in their
and long-term care and the association of everyday environments, so where people
private health insurance companies met live, learn and grow up. They also offer
at the Nationale Präventionskonferenz advice and support to small and medium-
(National Prevention Conference) and sized enterprises at the Land level and
agreed a national preventive healthcare have particularly developed hospitals and
strategy. They decided jointly to direct care homes for company-based health
their treatments towards a common goal: promotion. The Präventionsgesetz (Preven-
that people should grow up, live and work tion Act, PrävG) also boosted health checks
in good health and stay healthy in old age. and screening programmes for children,
In short, they agreed to promote good young people and adults. It also gives
health in all stages of life. To achieve this, greater priority to individual burdens and
they defined a number of action areas in risk factors for the development of diseases.
which the statutory and private insurers Doctors were given the opportunity to
can encourage and support citizens to be make preventive recommendations and
healthy in the environments in which they so to help preserve and improve the health
live, such as in nursery schools, in schools, of their patients.
37 Medical and nursing careOutpatient and Mixed and special
inpatient rehabilitation forms of medical
centres treatment
A severe illness, a long period of therapy The German healthcare system is multifa
or an operation mark a rupture in a per- ceted, with inpatient and outpatient care,
son’s life. These can often result in long- general practitioners and specialists, acute
term effects. To help patients resume their medicine and rehabilitation, prevention
normal lives as quickly as possible, there and long-term therapies. At the same time,
is a wide range of rehabilitation activities there is increasing recognition that the
on offer, both on an outpatient and in treatment of patients is a team perform
patient basis: physiotherapy, psychological ance. Someone with age-related hip pain,
support and assistance with learning for example, is given an orthopaedic exam-
how to use aids. In addition, the German ination as an outpatient, possibly followed
healthcare system provides rehabilitation by surgery in hospital, before staying at a
centres for special indications, such as rehabilitation centre and later going to a
eating disorders or addictions. local physiotherapist. This is just one ex-
ample of many, which shows that medical
treatment often goes beyond the context
of specific sectors. People with chronic
illnesses benefit particularly from services
that put together elements of outpatient
and inpatient care to form an individually
optimised package of treatment. Completely
new treatment models have been devel-
oped for this purpose in recent years.
Book IX of the
Social Code
Outpatient and inpatient rehabilitation is largely
covered by Book IX of the Social Code and so is also
a separate pillar of German social security law.
Medical and nursing care 38Examples from
everyday practice
1. 3.
The SHI funds offer structured treatment General practitioner contracts make GPs
programmes for certain chronic diseases, guides for their patients. They coordinate
including diabetes (type 1 and 2), breast the whole treatment process. This side-
cancer, coronary artery disease, asthma and steps the free choice of medical practition-
chronic obstructive pulmonary disease er which is actually a principle of the Ger-
(COPD). And under those programmes, the man system. On the other hand, the entire
entire course of treatment or treatments treatment is coordinated by someone the
needed is coordinated by a single agency. patient knows and trusts. SHI funds sign
People with chronic illnesses can participate such GP contracts for the benefit of their
in these disease management programmes members. The aim is to improve the coord
(DMP) on a voluntary basis. Hospitals may ination of specialists, hospitals and others.
also be entitled to provide outpatient care Around 7.4 million22 people with statutory
as part of such programmes. health insurance are currently taking part
in such programmes.
2.
Integrated care enables doctors and hos- 4.
pitals to devise joint treatment concepts Outpatient specialist medical treatment
that transcend the distinction between in- is a service for patients with rare or severe
patient and outpatient care. They sign con- illnesses with a particular course and progres
tracts with the SHI funds so that the funds sion (e.g. tuberculosis, cystic fibrosis or
can offer these treatments to their members. Wilson’s disease). They are treated by
interdisciplinary teams of doctors from hos-
pitals along with independent specialists.
One of the latest developments intended
to enable structural innovations in the
German healthcare system is the Innovation
Fund that was set up in 2015. The fund is
financed by the SHI funds and the health-
care fund and sponsors care research pro-
jects and novel forms of inpatient/out
patient treatment.
39 Medical and nursing careStructurally dynamic: challenges and opportunities
The corona pandemic:
a challenge like no other
The year 2020 has confronted us with an a certain amount of income – for instance
unprecedented challenge, the COVID-19 from operations planned far in advance,
pandemic. rehabilitation work or new residents in
care. To compensate them for this, the Ger-
The Federal Ministry of Health (BMG) re- man Bundestag adopted the Covid-19-
sponded promptly with legislation and Krankenhausentlastungsgesetz (Act to Re-
measures to slow the spread of the new lieve Pressures on Hospitals due to COVID-
coronavirus SARS-CoV-2. 19) in March 2020. It ensures that health-
care providers will receive financial sup-
As early as in March 2020, so immediately port during the COVID-19 pandemic.
after the first cases of COVID-19 occurred
in Germany, the Federal Government re- People with chronic illnesses were subject
stricted international travel and banned to particular strains. They include more
incoming flights from certain countries. than eight million adults with addictions23
and their family members. At the initiative
At that time, it became clear that the BMG of the Federal Government’s Commission-
had to have the capacity itself to organise er for Drugs, the rules for replacement
supplies of personal protective equipment, therapy were made more flexible by means
disinfectant, medical products and medi- of the SARS-CoV-2 medicines regulation
cines in Germany. The Protection against issued on 20 April 2020 which means that
Infection Act (IfSG) was amended accord- treatment can be maintained even during
ingly on 27 March 2020. Since then, the the pandemic. In parallel, the German
Federal Government has been able to regu Bundestag passed the Gesetz zum Schutz
late the import of protective equipment der Bevölkerung bei einer epidemischen
independently. Lage von nationaler Tragweite (Act to Pro-
tect the Population against a Nationwide
To gain an overview of the number of hos- Epidemic). For the duration of the pan-
pital beds with ventilators, the BMG took demic, the Federal Government was given
action in April 2020 and issued a regula- the power to issue regulations to protect
tion requiring all hospitals nationwide to the population. These include travel re-
report their free beds in intensive care. It strictions and a duty to report and undergo
intervened as necessary to ensure sufficient tests for suspected COVID-19 infection.
capacities, by postponing elective surgery
for example. On 29 April 2020 the Zweites Gesetz zum
Schutz der Bevölkerung bei einer epidemi
These measures have so far ensured the schen Lage von nationaler Tragweite (Sec-
medical treatment of all patients. However, ond Act to Protect the Population against
the hospitals, rehabilitation centres, doc- a Nationwide Epidemic) was adopted.
tors and nursing homes did have to forego
Challenges and opportunities 42This was primarily intended to ensure fast- Government has set up a “coronavirus
er identification and treatment of COVID- cabinet”, which meets regularly and can
19 infections. Its main provisions were the adjust policy at short notice.
reinforcement of the public health services,
better use of existing testing capacities, The COVID-19 pandemic is certain to be
particularly for areas at risk, such as senior with us for some time to come. As part of
citizens’ residences and nursing homes, an ongoing process, new administrative
and the extension of reporting obligations. measures and legislation are being put in
Another important aspect was to give place. The Federal Ministry of Health will
nurses and carers a bonus for their good continue to inform the public on its website,
work at such a difficult time and to ensure as well as on its YouTube channel and the
they receive more flexible support. social networks Facebook, Twitter, Instagram
and TikTok. Information from the BMG
Until there is a vaccine against SARS- about COVID-19 is also communicated via
CoV-2, it will be necessary to continuously TV, radio, press advertisements and posters.
re-evaluate the situation. The Federal
Together against
Coronavirus
On the website “Zusammen gegen Corona” (Together
against Coronavirus, www.zusammengegencorona.de),
the BMG has compiled reliable answers and concrete
information about how people can protect themselves
and help others.
43 Challenges and opportunitiesStructural change and
digitalisation
The intelligent advancement of healthcare Secure healthcare infrastructure
and how it is delivered in future is an area The telematics infrastructure (TI) and the
of high priority for the Federal Ministry of electronic health card provide a nation-
Health. Ultimately, the aim is to maintain wide technological basis for secure infor-
for future generations the comprehensive mation exchange. Electronic patient files
healthcare that is available to everybody will also be available from 2021 at the
in our country – regardless of where they latest. To speed up the process, the BMG
live, their bank balance, age or gender – acquired a majority stake in the company
and to improve it wherever possible. Here, responsible for developing this infra-
we have high expectations of digitalisation structure (gematik GmbH) in autumn
in the health system. Because innovation 2019. Originally, the company only re-
and the use of the latest information tech- ported to the self-administration entity
nology will bring significant improve- of the healthcare system. With an interest
ments in many respects to how people re- of 51 percent, the BMG is now the majority
2021
ceive medical treatment in future. shareholder of gematik GmbH and so the
driving force behind the digitalisation of
Groundbreaking models already exist. For the German health system.
is when electronic example, there are apps that remind people
patient files will with chronic illnesses to take their tab- Further digitalisation
be available at the lets or help them to manage their diabetes The Terminservice- und Versorgungsgesetz
latest. better. There are also heart rate monitors (Act on Medical Appointments and Health-
that patients wear all the time and which care, TSVG) that took effect on 11 May 2019
send an alarm to their doctor if the pulse is also intended to make greater use of the
rate worsens dramatically. Those are just opportunities offered by digitalisation. The
two examples of how digitalisation can SHI funds were required to provide their
make these people more independent and members with an electronic patient file.
so improve their quality of life. Doctors Those that wish to do so will also be able to
can offer online consultations to save pa- access their electronic patient file in future
tients having to travel to and wait in their via a smartphone or tablet.
practice. Telemedicine can made a key
contribution to overcoming physical dis- The Gesetz für mehr Sicherheit in der
tances and so to providing better health- Arzneimittelversorgung (Act on Greater
care to people who do not live in a big city Security in the Supply of Medicines, GSAV)
like Berlin, Hamburg or Munich. defines the necessary regulations for using
electronic prescriptions.
These are just some examples that demon-
strate how the digital age has also arrived At the same time, the industry is preparing
in the healthcare sector. tools for managing emergency data and
Challenges and opportunities 44medication plans in electronic form and Artificial intelligence
for secure communications, between GPs When it comes to the healthcare of the fu-
and specialists for example. The aim is to ture, artificial intelligence (AI) and big data
introduce these applications gradually play an important role. They provide op-
from 2020. Legislation is intended to drive portunities to keep improving healthcare.
the secure digitalisation of the health sys- AI can help doctors to reach a diagnosis
tem, particularly concerning details of the faster, for example, particularly in the case
electronic patient file, and to strengthen of rare diseases. AI therapies can also be
the rights of the insured, as well as to de- adapted for patients on a more individual
fine data protection standards for the tele- basis. This is already the case for cancer
matics infrastructure. From 2022 the elec- treatment today. In future, sensible AI will
tronic patient file should also be able to be another instrument in a doctor’s bag,
include electronic versions of the vaccin just like a stethoscope or an X-ray. The idea
ation record, the maternity record, chil- is not to replace medical personnel, but to
dren’s medical check-ups and the dental help them to treat their patients faster and
treatment record. more precisely. Because then they have
more time for a personal talk with the
Digital health applications patient. The BMG is funding various
In addition to building the telematics infra- research projects to find out more about
structure, the BMG is working to facilitate the concrete benefits of AI in healthcare.
the roll-out and use of digital healthcare
technologies. One important component in BMG funding forms part of the Federal
this respect is the Digitale-Versorgung-Ge- Government’s AI strategy.
setz (Digital Healthcare Act, DVG), which
from 2020 makes digital healthcare apps
in Germany eligible for coverage by the
SHI funds – “apps on prescription”. The
important thing is that the apps can
Apps on
demonstrate a positive impact on health
and that they meet the security and data
prescription
protection standards. Successful digital Secure and effective digital
solutions are developed from the perspec- healthcare apps will be
tive of the patient and focus on individual eligible for coverage by the
needs and everyday actions. The approval SHI funds.
and evaluation of these digital offerings
that are eligible for prescription is organ-
ised by the Federal Institute for Drugs and
Medical Devices (BfArM), which published
guidelines concerning this in April 2020.
45 Challenges and opportunitiesDigital healthcare competence
It is important to educate people and con- But for one in two people, the increasing
vey an understanding of digital healthcare volume of information is a problem when
solutions. Acceptance and trust are pre- it comes to navigating the healthcare uni-
requisites for the advancement of digital verse, evaluating information and making
healthcare. This not only applies to the the right decisions. The development of a
doctors, psychotherapists and other ser- national health portal is intended to
vice providers; developing and strength- strengthen the role of the self-determined
ening the (digital) healthcare competence patient. The portal is to pool knowledge
of the patients is equally important. Be- about diagnoses and therapies as well as
cause increasing the competence of the generally to do with the health system
general public in terms of health can con- while offering neutral and understand
tribute to greater sustainability in health- able explanations with the help of evi-
care. More and more people are looking dence-based information.
online for information about health topics.
Challenges and opportunities 46You can also read
