Health Systems in Transition. Vol. 16 No Germany. Health system review. Reinhard Busse Miriam Blümel

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1 Health Systems in Transition Vol. 16 No Germany Health system review Reinhard Busse Miriam Blümel

2 Reinhard Busse (Series editor) was responsible for this HiT Editorial Board Series editors Reinhard Busse, Berlin University of Technology, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene & Tropical Medicine, United Kingdom Elias Mossialos, London School of Economics and Political Science, United Kingdom Sarah Thomson, European Observatory on Health Systems and Policies Ewout van Ginneken, Berlin University of Technology, Germany Series coordinator Gabriele Pastorino, European Observatory on Health Systems and Policies Editorial team Jonathan Cylus, European Observatory on Health Systems and Policies Cristina Hernández-Quevedo, European Observatory on Health Systems and Policies Marina Karanikolos, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Dimitra Panteli, Berlin University of Technology, Germany Wilm Quentin, Berlin University of Technology, Germany Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Anna Sagan, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Harvard University, United States Johan Calltorp, Nordic School of Public Health, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Allan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Soonman Kwon, Seoul National University, Republic of Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Ellen Nolte, Rand Corporation, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Federal Statutory Health Insurance Physicians Association, Germany Igor Sheiman, Higher School of Economics, Russian Federation Peter C. Smith, Imperial College, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland

3 Health Systems in Transition Reinhard Busse, European Observatory on Health Systems and Policies and Department of Health Care Management, Berlin University of Technology Miriam Blümel, Department of Health Care Management, Berlin University of Technology Germany: Health System Review 2014 The European Observatory on Health Systems and Policies is a partnership, hosted by the WHO Regional Office for Europe, which includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom and the Veneto Region of Italy; the European Commission; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine.

4 Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS organization and administration GERMANY World Health Organization 2014 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies). All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/pubrequest) The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation country or area appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Printed and bound in the United Kingdom. Suggested citation: Busse R, Blümel M. Germany: health system review. Health Systems in Transition, 2014, 16(2): ISSN Vol. 16 No. 2

5 Contents Contents Preface...v Acknowledgements...vii Glossary of terms and institutions...ix List of abbreviations... xv List of tables and figures... xvii Abstract... Executive summary... xxiii 1. Introduction Geography and sociodemography Economic context Political context Health status Organization and governance Overview of the health system Historical background Organization Decentralization and centralization Responsibilities for regulation and planning Intersectorality Health information management Regulation Patient empowerment Financing Health expenditure Sources of revenue and financial flows Overview of the statutory financing system Out-of-pocket payments xxi

6 iv Health systems in transition Germany 3.5 Private health insurance (PHI) Payment mechanisms Physical and human resources Physical resources Human resources Provision of services Public health Patient pathways Ambulatory care Hospital care Emergency care Pharmaceutical care Rehabilitation Long-term care Social care Palliative care Mental health care Dental care Complementary and alternative medicine Principal health reforms Analysis of recent reforms Future developments Assessment of the health system Stated objectives of the health system Financial protection and equity in financing User experience and equity of access to health care Health outcomes, health service outcomes and quality of care Health system efficiency Conclusions Appendices References Useful web sites HiT methodology and production process The review process About the authors...296

7 Preface Preface The Health Systems in Transition (HiT) series consists of country-based reviews that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each review is produced by country experts in collaboration with the Observatory s staff. In order to facilitate comparisons between countries, reviews are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a report. HiTs seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used: to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; to describe the institutional framework, the process, content and implementation of health-care reform programmes; to highlight challenges and areas that require more in-depth analysis; to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policymakers and analysts in different countries; and to assist other researchers in more in-depth comparative health policy analysis. Compiling the reviews poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including

8 vi Health systems in transition Germany the World Health Organization (WHO) Regional Office for Europe s European Health for All database, data from national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, data from the International Monetary Fund (IMF), the World Bank s World Development Indicators and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate review. A standardized review has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. HiTs can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to HiTs and HiT summaries are available on the Observatory s web site

9 Acknowledgements Acknowledgements The HiT on Germany was co-produced by the European Observatory on Health Systems and Policies and the Berlin University of Technology, which is a member of the Health Systems and Policy Monitor (HSPM) network. The HSPM is an international network that works with the Observatory on Country Monitoring. It is made up of national counterparts that are highly regarded at national and international level and have particular strengths in the area of health systems, health services, public health and health management research. They draw on their own extensive networks in the health field and their track record of successful collaboration with the Observatory to develop and update the HiT. This edition was written by Reinhard Busse (European Observatory on Health Systems and Policies and Department of Health Care Management at the Berlin University of Technology) and Miriam Blümel (Department of Health Care Management at the Berlin University of Technology). The basis for this edition was the previous HiT on Germany published in 2004, and written by Reinhard Busse and Annette Riesberg, as well as the 2013 published profile Das deutsche Gesundheitssystem. Akteure, Daten, Analysen by Reinhard Busse, Miriam Blümel and Diana Ognyanova. The European Observatory on Health Systems and Policies, Berlin University of Technology and the authors are grateful to a wide range of experts and officials for providing support and reviewing the report. Special thanks go to Franz Knieps (former Head of Department in the Federal Ministry of Health), Diana Ognyanova (Federal Ministry for Economic Affairs and Energy) and Annette Riesberg (Federal Association of Sickness Funds). The writing of the HiT was greatly supported by Sabine Fuchs (Berlin University of Technology), Matthew Gaskins and Armgard Hesse.

10 viii Health systems in transition Germany Thanks are also extended to the WHO Regional Office for Europe for their European Health for All database, from which data on health services were extracted; to the Organisation for Economic Co-operation and Development (OECD) for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to the German Federal Statistical Office for providing data. The HiT reflects data available in March 2014, unless otherwise indicated. The European Observatory on Health Systems and Policies is a partnership, hosted by the WHO Regional Office for Europe, which includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom, and the Veneto Region of Italy, the European Commission, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team working on HiTs is led by Josep Figueras, Director, Reinhard Busse, Martin McKee, Elias Mossialos, Sarah Thomson, Ewout van Ginneken and Suszy Lessof. The Country Monitoring Programme of the Observatory and the HiT series are coordinated by Gabriele Pastorino. The production and copy-editing process of this HiT was coordinated by Jonathan North, with the support of Caroline White, Jane Ward (copy-editing), Pat Hinsley (typesetting) and Sarah Cook (proofreading).

11 Glossary of terms and institutions Glossary of terms and institutions English name 12th Social Code Book V Amendment Act 1st Case Fees Amendment Act 1st SHI Restructuring Act 2nd Case Fees Amendment Act 2nd SHI Restructuring Act Accident funds Act to Adjust the Financing of Dentures Act to Amend SHI Physicians' Law Act to Equalize Statutory Provisions in SHI Act to Improve Efficiency in Pharmaceutical Care Act to Improve Organization Structures in SHI Act to Newly Regulate Choice of Sickness Funds Act to Reform the Risk Structure Compensation Scheme in SHI Act to Strengthen Competition in SHI Administrative board (of sickness fund) Advisory Council for the Assessment of Developments in the Health Care System (previously Advisory Council for "Concerted Action in Health Care") Alliance of Christian Nurses Associations and Nursing Organizations in Germany Alliance of Scientific Medical Societies Association of Democratic Physicians Association of German Psychologists Association of Independent Voluntary Welfare Organizations Association of Private Health Insurance Companies Association of Protestant Welfare Organizations German name 12. Sozialgesetzbuch-V-Änderungsgesetz 1. Fallpauschalen-Änderungsgesetz 1. GKV-Neuordnungsgesetz 2. Fallpauschalen-Änderungsgesetz 2. GKV-Neuordnungsgesetz Unfallkassen Gesetz zur Anpassung der Finanzierung von Zahnersatz Gesetz zur Reform des Vertragsarztrechtes und anderer Gesetze Gesetz zur Rechtsangleichung in der gesetzlichen Krankenversicherung Gesetz zur Verbesserung der Wirtschaftlichkeit in der Arzneimittelversorgung Gesetz zur Weiterentwicklung der Organisationsstrukturen in der GKV Gesetz zur Neuregelung der Krankenkassenwahlrechte Gesetz zur Reform des Risikostrukturausgleichs in der GKV GKV-Wettbewerbstärkungsgesetz Verwaltungsrat (Krankenkassen) Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen (früher: für die Konzertierte Aktion im Gesundheitswesen) Arbeitsgemeinschaft Deutscher Schwesternverbände Arbeitsgemeinschaft Wissenschaftlich-Medizinischer Fachgesellschaften Verein demokratischer Ärztinnen und Ärzte Berufsverband Deutscher Psychologen Deutscher Paritätischer Wohlfahrtsverband Verband der privaten Krankenversicherung Diakonisches Werk

12 x Health systems in transition Germany Association of Research-based Pharmaceutical Companies Basic Law (= constitution) Case fee (since 2000 in a narrower sense: diagnosis-related group) Case Fees Act Case Fees Ordinance Catalogue of Medical Aids Catalogue of Tariffs for Physicians Central Institute for SHI Physician Care Central Reallocation Pool ("Health Fund") Central Welfare Organization of the Jews in Germany Centre for Quality in Medicine Chamber of Dentists (regional) Chamber of Pharmacists (regional) Chamber of Physicians (regional) Chamber of Psychotherapists (regional) Child Bonus Act Committee for Hospital Care (the former) Committee on Hospital Payment Company-based sickness fund Conference of Health Ministers Contribution Rate Stabilization Act Convalescent Care Centre for Mothers Coordinating Committee (between Committee for Hospital Care and the Federal Committee of Physicians and Sickness Funds) (the former) Corporations under public law Diagnosis-related group (DRG) Directive (issued by the Federal Joint Committee) Düsseldorf Academy of Public Health Extended Valuation Committee Farmers sickness funds Federal Alliance of Patient Centres and Initiatives Federal Alliance for the Support of the Disabled Federal Alliance of Voluntary Welfare Organizations Federal Assembly (Lower Chamber of Parliament) Federal Association of General Regional Sickness Funds Federal Association for Medical Technology Federal Association of Pharmaceutical Manufacturers Federal Association of Pharmacists Organizations Verband forschender Arzneimittel-Hersteller Grundgesetz Fallpauschale (seit 2000 im engeren Sinn: Diagnosebezogene Fallpauschale) Fallpauschalengesetz Fallpauschalenverordnung Hilfsmittelverzeichnis Gebührenordnung für Ärzte Zentral-Institut für die kassenärztliche Versorgung Gesundheitsfonds Zentralwohlfahrtsstelle der Juden in Deutschland Ärztliches Zentrum für Qualität in der Medizin Zahnärztekammer Apothekerkammer Ärztekammer Psychotherapeutenkammer Kinder-Berücksichtigungsgesetz Ausschuss Krankenhaus (der frühere) Ausschuss Krankenhaushausentgelt Betriebskrankenkassen Gesundheitsministerkonferenz Beitragssatzsicherungsgesetz Müttergenesungswerk Koordinierungsausschuss (der frühere) Körperschaften des öffentlichen Rechts Diagnose-bezogene Fallpauschale Richtlinie (des Gemeinsamen Bundesausschusses) Akademie für öffentliches Gesundheitswesen in Düsseldorf Erweiterter Bewertungsausschuss Landwirtschaftliche Krankenkassen Bundesarbeitsgemeinschaft PatientInnenstellen Bundesarbeitsgemeinschaft Selbsthilfe von Menschen mit Behinderung und chronischer Erkrankung und ihren Angehörigen Bundesarbeitsgemeinschaft der Freien Wohlfahrtspflege Bundestag AOK Bundesverband Bundesverband Medizintechnologie Bundesfachverband der Arzneimittel-Hersteller Bundesvereinigung Deutscher Apothekerverbände

13 Health systems in transition Germany xi Federal Association for Prevention and Health Promotion Federal Association of SHI Dentists Federal Association of SHI Physicians Federal Association of Sickness Funds (until 2008: various nationwide associations of sickness funds) Federal Association of the Pharmaceutical Industry Federal Centre for Health Education Federal Chamber of Physicians (German Medical Association) Federal Commissioner for the Concerns of Disabled People Federal Commissioner for the Concerns of Patients Federal Commissioner for Narcotics Federal Committee of Physicians and Sickness Funds (the former) Federal Council (Upper Chamber of Parliament) Federal Financial Supervisory Authority Federal Framework Contract Federal Health Report Federal Institute for Pharmaceuticals and Medical Devices Federal Insurance Authority Federal Joint Committee Federal Ministry of Education and Research Federal Ministry of Health Federal Ministry of Labour and Social Affairs Federal Office for Quality Assurance Federal Republic of Germany (official name for the "old" federal states until 1990, since 1990 unified with the "new" federal states in the eastern part of Germany) Federal Statistical Office Federation of Consumer Centres Forum for the Chronically Ill and Disabled gematik (Organization for Telematics Applications of the Health Card) General regional sickness funds German Alliance of Self-Help Groups German Association of Ergotherapists German Association of Family Physicians German Association for Physiotherapy German Assocation of Psychotherapists German Caritas Association (Catholic Welfare) Bundesvereinigung Prävention und Gesundheitsförderung Kassenzahnärztliche Bundesvereinigung Kassenärztliche Bundesvereinigung GKV-Spitzenverband (bis 2008: Spitzenverbände der Krankenkassen) Bundesverband der Pharmazeutischen Industrie Bundeszentrale für gesundheitliche Aufklärung Bundesärztekammer Beauftragter der Bundesregierung für die Belange behinderter Menschen Beauftragter der Bundesregierung für die Belange der Patientinnen und Patienten Drogenbeauftragter der Bundesregierung Bundesausschuss der Ärzte und Krankenkassen (der frühere) Bundesrat Bundesanstalt für Finanzdienstleistungsaufsicht Bundesmantelvertrag Gesundheitsberichterstattung des Bundes Bundesinstitut für Arzneimittel und Medizinprodukte Bundesversicherungsamt Gemeinsamer Bundesausschuss Bundesministerium für Bildung und Forschung Bundesministerium für Gesundheit Bundesministerium für Arbeit und Soziales Bundesgeschäftsstelle für Qualitätssicherung Bundesrepublik Deutschland Statistisches Bundesamt Verbraucherzenterale Bundesverband Forum chronisch kranker und behinderter Menschen gematik (Gesellschaft für Telematikanwendungen der Gesundheitskarte) Allgemeine Ortskrankenkassen Deutsche Arbeitsgemeinschaft Selbsthilfegruppen Verband der Ergotherapeuten Deutscher Hausärzteverband (früher: Berufsverband der Allgemeinärzte Deutschlands Hausärzteverband) Deutscher Verband für Physiotherapie Zentralverband der Physiotherapeuten/ Krankengymnasten Deutscher Psychotherapeutenverband Deutscher Caritasverband

14 xii Health systems in transition Germany German Democratic Republic (the former) German Disability Council German DRG Institute (Institute for the Payment System in Hospitals) German Federal Association for Speech Therapy German Forum for Prevention and Health Promotion German Generics Association (previously: Association of Active Pharmaceutical Companies) German Hospital Federation German Industry Association for Optical, Medical and Mechatronics Technologies (Spectaris) German Institute for Medical Documentation and Information German Nursing Association German Nursing Council German Organization of Pharmacists German Procedure Classification German Red Cross Guild sickness funds Hartmann Union (Association of German Physicians; successor to the Leipzig Union) Health Care Reform Act (of 1989) Health Care Structure Act (of 1993) Health Insurance Contribution Rate Exoneration Act Health Insurance Cost-containment Act Hospital Cost-containment Act Hospital Financing Act Hospital Financing Reform Act Hospital plan Imperial Insurance Regulation Infection Protection Act Institute for Medical and Pharmaceutical Examination Questions Institute for Quality and Efficiency in Health Care Institute of the Valuation Committee Long-Term Care Improvement Act Long-term Care Quality Assurance Act Long-term Care Realignment Act Marburg Union (employed (hospital) physicians) Mediation Committee (between Federal Assembly and Federal Council) Medical Devices Act Deutsche Demokratische Republik (die ehemalige) Deutscher Behindertenrat Institut für das Entgeltsystem im Krankenhaus Deutscher Bundesverband für Logopädie Deutsches Forum Prävention und Gesundheitsförderung Deutscher Generikaverband (früher: Verband aktiver Pharmaunternehmen) Deutsche Krankenhaus-Gesellschaft Deutscher Industrieverband für optische, medizinische und mechatronische Technologien Deutsches Institut für medizinische Dokumentation und Information Deutscher Berufsverband für Pflegeberufe Deutscher Pflegerat Deutscher Apothekerverband Operationen- und Prozedurenschlüssel Deutsches Rotes Kreuz Innungskrankenkassen Hartmannbund (Verband der Ärzte Deutschlands; zuvor: Leipziger Verband) Gesundheitsreformgesetz Gesundheitsstrukturgesetz Krankenversicherungsbeitragsentlastungsgesetz Krankenversicherungskostendämpfungsgesetz Krankenhaus-Kostendämpfungsgesetz Krankenhausfinanzierungsgesetz Krankenhausfinanzierungsreformgesetz Krankenhausplan Reichsversicherungsordnung Infektionsschutzgesetz Institut für Medizinische und Pharmazeutische Prüfungsfragen Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen Institut des Bewertungsausschusses Pflege-Weiterentwicklungsgesetz Pflege-Qualitätssicherungsgesetz Pflege-Neuausrichtungsgesetz Marburger Bund Verband der angestellten und beamteten Ärztinnen und Ärzte Vermittlungsausschuss Medizinproduktegesetz

15 Health systems in transition Germany xiii Medical treatment centre Miners sickness fund Morbidity-based risk-adjustment scheme Ordinance (issued by ministries) Organization for Transparency and Quality in Health Care Patients Rights Act Paul Ehrlich Institute (Federal Institute for Vaccines and Biomedicines) Pharmaceutical Act Pharmaceutical Budget Redemption Act Pharmaceutical Expenditure Limitation Act Pharmaceutical Market Reform Act Pharmaceutical Price Ordinance Physicians Approbation Ordinance Procedure fee Psychiatric outpatient department Quality and Development in Physician Practices Reference Price Adjustment Act Regional Association of SHI Dentists Regional Association of SHI Physicians Risk Structure Reconciliation Regulation Robert Koch Institute (Federal Institute for Communicable and Non-Communicable Diseases) Round Table on Long-term Care Sailors sickness fund Scientific Institute of the General Regional Funds SHI Care Structures Act SHI Contribution Rate Exoneration Act SHI Financing Act SHI Medical Review Board SHI Modernization Act SHI Reform Act Social Code Book (V, Statutory Health Insurance; IX, Rehabilitation and Participation of Disabled People; XI, Statutory Long-term Care Insurance State(s) Statutory health insurance Statutory long-term care insurance Subcommittee on Methods Assessment (of Federal Joint Committee) Substitute funds Medizinisches Versorgungszentrum Knappschaft (früher: Bundesknappschaft) morbiditätsorientierter Risikostrukturausgleich Verordnung (von Ministerien) Kooperation für Transparenz und Qualität im Gesundheitswesen Patientenrechtegesetz Paul Ehrlich-Institut (Bundesamt für Sera und Impfstoffe) Arzneimittelgesetz Arzneimittelbudgetablösungsgesetz Arzneimittelausgaben-Begrenzungsgesetz Arzneimittelmarktneuordnungsgesetz Arzneimittelpreisverordnung Ärztliche Approbationsordnung Sonderentgelt Psychiatrische Institutsambulanzen Qualität und Entwicklung in Praxen Festbetragsanpassungsgesetz Kassenzahnärztliche Vereinigung Kassenärztliche Vereinigung Risikostruktur-Ausgleichsverordnung Robert Koch-Institut Runder Tisch Pflege Seekrankenkasse Wissenschaftliches Institut der Allgemeinen Ortskrankenkassen GKV-Versorgungsstrukturgesetz Krankenversicherungsbeitragsentlastungsgesetz GKV-Finanzierungsgesetz Medizinischer Dienst der Krankenversicherung GKV-Modernisierungsgesetz GKV-Änderungsgesetz Sozialgesetzbuch (V,Gesetzliche Krankenversicherung; IX, Rehabilitation und Teilhabe behinderter Menschen; XI, Soziale Pflegeversicherung) Land (Länder) Gesetzliche Krankenversicherung Soziale Pflegeversicherung Unterausschuss Methodenbewertung (von Gemeinsamer Bundesausschuss) Ersatzkassen

16 xiv Health systems in transition Germany Uniform Value Scale University Capital Investment Act Valuation Committee Workers' compensation funds Workers Welfare Organization Working Group of Senior State Health Officials Einheitlicher Bewertungsmaßstab Hochschulbaufördergesetz Bewertungsausschuss Berufsgenossenschaften Arbeiterwohlfahrt Arbeitsgemeinschaft der leitenden Ministerialbeamten der obersten Landesgesundheitsbehörden

17 List of abbreviations List of abbreviations AIDS AOK BKK BQS COPD DDD DMP DRG egk ENT EU EU13 Acquired immunodeficiency syndrome General regional sickness funds (Allgemeine Ortskrankenkassen) Company-based sickness fund (Betriebskrankenkassen) Federal Office for Quality Assurance (Bundesgeschäftsstelle für Qualitätssicherung) Chronic obstructive pulmonary disease Defined daily dose Disease management programme Diagnosis-related group (Diagnose-bezogene Fallpauschale) Electronic health card Ear, nose and throat European Union 13 Member States as of May 2004, January 2007 or July 2013 respectively EU15 15 EU Member States before May 2004 EU28 28 EU Member States at 1 July 2013 GDP G-DRG GP HIV IKK MRI OECD OTC PHI SGB SGB-IX SGB-V SGB-XI SHI SVR Gross domestic product German DRG General practitioner Human immunodeficiency virus guild sickness funds (Innungskrankenkassen) Magnetic resonance imaging Organisation for Economic Co-operation and Development Over the counter Private health insurance Social Code Book SGB for Rehabilitation and Participation of Disabled People SGB for Statutory Health Insurance SGB for Statutory Long-term Care Insurance Statutory health insurance (Gesetzliche Krankenversicherung) Advisory Council for the Assessment of Developments in the Health Care System (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen)

18 xvi Health systems in transition Germany VAT WHO Value-added tax World Health Organization

19 List of tables and figures List of tables and figures Tables page Table 1.1 Population/demographic indicators, Table 1.2 Macroeconomic indicators for Germany, Table 1.3 Mortality and health indicators, (selected years) 10 Table 1.4 Age-standardized death rates per population, Table 1.5 Trends in health status and health-related factors for selected indicators, (selected years) 15 Table 2.1 Trends in SHI, Table 2.2 Health care personnel and hospital capacities, Table 2.3 Number of sickness funds in Germany (as of 1 January) 46 Table 2.4 Trends in the public private mix of general hospitals, Table 2.5 Decision-making authority in the German health care system by sector, Table 2.6 Needs-based population ratios, defined as covering 100% of need per specialty, since Table 2.7 Number of patients from other EU Member States who received hospital treatment in Germany , and resulting cost (2005) 104 Table 2.8 Number of German patients who received medical treatment in another EU Member State, and resulting cost (2005) 105 Table 3.1 Trends in health care expenditure, Table 3.2 SHI and total health expenditure by institution as a percentage of GDP, Table 3.3 Sources of finance as a percentage of total finance, Table 3.4 Trends in financing SHI, Table 3.5 Out-of-pocket payments by institution and by type of service, , selected years 132 Table 3.6 Co-payment/co-insurance levels in Germany, Table 3.7 Expenditure for acute and psychiatric hospitals, Table 3.8 Number of SHI-affiliated physicians and psychotherapists, cases and remuneration, Table 3.9 Revenue of physicians according to specialist fields, Table 4.1 Hospital bed numbers and capital investment 2012 in the 16 Länder 160 Table 4.2 The inpatient care sector: capacities (number of institutions and beds) by ownership, function, contract status and reimbursement,

20 xviii Health systems in transition Germany Table 4.3 Number of beds in hospitals and homes and other operating indicators, , selected years 163 Table 4.4 High-cost medical technologies in the hospital sector per million inhabitants, Table 4.5 Health care workforce per population, Table 4.6 Students and graduates in selected health care faculties, 1990 to 2009/10, selected years 176 Table 5.1 Specialties and functions of physicians providing ambulatory care in SHI, Table 5.2 DMPs and participating insurants, Table 5.3 Inpatient structure and utilization data: hospitals in Germany, Table 5.4 Integrated care contracts: number, participants and expenditure, Table 5.5 Expenditure on pharmaceuticals by funding source and institution, Table 5.6 Trends in prescribing behaviour for SHI insured and turnover in the SHI pharmacy market, Table 5.7 Use of inpatient care in prevention and rehabilitation facilities in Germany, Table 5.8 Recipients and providers of long-term care, Table 5.9 Expenditure and revenues of statutory long-term care insurance in Table 5.10 Physicians with additional qualification in alternative examination and treatment methods, Table 6.1 Chronology of major health reform acts, Table 6.2 Development of contribution rate determination and contribution sharing 261 Figures page Fig. 1.1 Map of Germany and neighbouring countries 2 Fig. 1.2 Political map of Germany at the state (Land) level 6 Fig. 2.1 Organizational relationships of the key actors in the German health care system, Fig. 2.2 Organizational relationship between SHI and PHI, for long-term care as well as the public health service, Fig. 2.3 Number of pharmaceuticals in the German market and its segments, Fig. 3.1 Health expenditure as percentage of GDP in the WHO European Region, 2011 or latest available year 109 Fig. 3.2 Fig. 3.3 Fig. 3.4 Trends in health expenditure as a percentage of GDP in Germany and selected countries, or latest available year 110 Health expenditure in US$ purchasing power parity per capita in the WHO European Region, 2011 or latest available year 111 Public sector health expenditure as a percentage of total health expenditure in the WHO European Region, 2011 or latest available year 112 Fig. 3.5 Main sources of finance as a percentage of total health expenditure, Fig. 3.6 Financial flows in the SHI, Fig. 3.7 Financing flow chart for the German health care system (sources of finance and expenditures on providers as percentage of total), Fig. 3.8 Average annual contribution rates (%) by sickness fund associations, Fig. 3.9 Grouping process in the German DRG (G-DRG) system 144

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