Health in Germany
Encyclopedia
According to the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

, Germany's health care system
Health care system
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations....

 was 77% government-funded and 23% privately funded as of 2004. In 2004 Germany ranked thirtieth in the world in life expectancy
Life expectancy
Life expectancy is the expected number of years of life remaining at a given age. It is denoted by ex, which means the average number of subsequent years of life for someone now aged x, according to a particular mortality experience...

 (78 years for men). It had a very low infant mortality rate (4.7 per 1,000 live births), and it was tied for eighth place in the number of practicing physicians, at per 1,000 people (3.3). In 2001 total spending on health amounted to 10.8 percent of gross domestic product.

Health care insurance history

Germany has Europe's oldest universal health care
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...

 insurance system, with origins dating back to Otto von Bismarck
Otto von Bismarck
Otto Eduard Leopold, Prince of Bismarck, Duke of Lauenburg , simply known as Otto von Bismarck, was a Prussian-German statesman whose actions unified Germany, made it a major player in world affairs, and created a balance of power that kept Europe at peace after 1871.As Minister President of...

's Social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889. As mandatory health insurance, these bills originally applied only to low-income workers and certain government employees; their coverage, and that of subsequent legislation gradually expanded to cover virtually the entire population.

Health care insurance today

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

The government partially reimburses the costs for low-wage workers, whose premiums are capped at a predetermined value. Higher wage workers pay a premium based on their salary. They may also opt for private insurance. This may result in substantial savings for younger individuals in good health. With age and illness, private premiums will rise and the insured will usually cancel their private insurance, turning to the government option.

Reimbursement is on a fee-for-service
Fee-for-service
Fee-for-service is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care...

 basis, but the number of physicians allowed to accept Statutory Health Insurance in a given locale is regulated by the government and professional medical societies.

Co-payments were introduced in the 1980s in an attempt to prevent overutilization
Overutilization
Overutilization refers to medical services that are provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overutilization is the predominant factor in its expense...

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

Reforms

Health reform (Gesundheitsreform) is an ongoing topic in German federal politics. However, all attempts primarily focus a friction free distribution of the available budget. The effort to improve the processing of medical services mainly covers medical subject, hence organisational aspects are ranking much below impact. As the majority of the clinics is in public ownership, the strategy to escape the overburding of services with administrational requirements is not addressed with other reformatory approaches but administrational regulations.

The health care reform law that took effect on 1 January 2004, aimed at reducing health insurance costs and required payroll deductions. Costs were to be reduced by introducing more competition into the health care system and requiring higher co-payments by the insured. Related savings were estimated at US$12 billion in 2004 and US$26 billion in 2005. In conjunction with the cost reductions, payroll contributions were expected to decline below 14 percent in 2004 and below 13 percent in 2005.. Till today and equivalent to the stated results in international comparison, there is no evidence that the concept of lump sum billing based on Diagnosis related grouping (DRG) has contributed anything to
  • more efficient service organisation,
  • higher outcome,
  • higher quality,
  • lower complication rates, beyond a reduction of days spent per in-patient cure.

Insurance systems

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

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

Long-term care
Long-term care
Long-term care is a variety of services which help meet both the medical and non-medical need of people with a chronic illness or disability who cannot care for themselves for long periods of time....

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

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

Public insurance

All salaried employees must have public health insurance. Only public officers, self-employed people and employees with a large income, above c. €50,000 (adjusted yearly), may join the private system.

In the Public system the premium
  • is set by the Federal Ministry of Health
    Federal Ministry of Health (Germany)
    The Federal Ministry of Health, is a ministry of the German federal government...

     based on a fixed set of covered services as described in the German Social Law (Sozialgesetzbuch – SGB), which limits those services to "economically viable, sufficient, necessary and meaningful services"
  • is not dependent on an individual's health condition, but a percentage (actually 15,5%) of salaried income.
  • includes family members of any family members, or "registered member" ( Familienversicherung – i.e. husband/wife and children are free)
  • is a "pay as you go" system – there is no saving for an individual's higher health costs with rising age or existing conditions.


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

Private insurance

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


A person who opts out of the public health insurance system and gets private health insurance cannot go back later to the public system, even if income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance, the higher premiums must be paid out of a lower income.

Major diagnosis and health trends

In 2002 the top diagnosis for male patients released from the hospital was heart disease
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...

, followed by alcohol-related disorders
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...

 and hernias. For women, the top diagnoses related to pregnancies, breast cancer, and heart weakness
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...

. At the end of 2004, some 449,000 Germans, or less than 0.1 percent of the population, were infected with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). In the first half of 2005, German health authorities registered 1,164 new infections; about 60 percent of the cases involved homosexual men. Since the beginning of the HIV/AIDS epidemic, about 24,000 Germans have died from the disease. Widespread smoking also has a deleterious impact on health. According to a 2003 survey, 37 percent of adult males and 28 percent of adult females in Germany are smokers.

Obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...

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