The German health system: basics and some comparisons with other countries

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1 The German health system: basics and some comparisons with other countries Prof. Dr. med. Reinhard Busse, MPH Department ofhealthcare Management/ WHO Collaborating Centre for Health Systems, Research and Management, Berlin University oftechnology & European Observatory on Health Systems and Policies

2 How we look at health systems Collector of resources Third-party payers Regulator Population Providers

3 The German system at a glance Uniform wage-related contribution + possibly additional premium (set by sickness fund), Choice of fund/ insurer Risk-structure compensation Collector of resources Health fund Risk-related premium Strong delegation (Federal Joint Committee) & limited governmental control Third-party payers Ca. 130 sickness funds Ca. 45 private insurers Contracts, mostly collective No contracts Population Universal coverage: Statutory Health Insurance 86%, Private HI 11% Choice Providers Public-private mix, organised in associations ambulatory care/ hospitals

4 German health system overview Key characteristics (I): a) Sharing of decision-making powers between the sixteen Länder (states), the federal government and statutory civil society organizations i.e. important competencies are legally delegated to membership-based, self-regulated organisations of payers and providers b) German health care [almost] = Statutory health insurance (SHI) SHI Cornerstone of health service provision is the Fifth Book of the German Social Law (SGB V) i.e. it organizes and defines the self-regulated corporatist structures and give them the duty and power to develop benefits, prices and standards c) Existence of substitutive private health insurance alongside SHI

5 German health system overview Key characteristics (I): a) Sharing of decision-making powers between the sixteen Länder (states), the federal government and statutory civil society organizations i.e. important competencies are legally delegated to membership-based, self-regulated organisations of payers and providers b) German health care [almost] = Statutory health insurance (SHI) SHI Cornerstone of health service provision is the Fifth Book of the German Social Law (SGB V) i.e. it organizes and defines the self-regulated corporatist structures and give them the duty and power to develop benefits, prices and standards c) Existence of substitutive private health insurance alongside SHI

6 SHI Private health insurance

7 Third-party Payers Taxes 9% 77% public Social Health Insurance contributions 68% Voluntary insurance 9% Population Germany 2011 Out-of-pocket 12% Providers 11.3% of GDP

8 Financial flows in SHI (2011) allocations Source: Göppfarth & Henke, Health Policy 2013

9 German health system overview Key characteristics: d) Sectoral borders Provision of ambulatory and inpatient services. Planning, resource allocation, provision and financing are separate for ambulatory (office-based physicians) and inpatient (hospitals) sector. Complicates the provision of health care delivery (problematic especially for chronically ill answers: Disease Management Programmes and selective integrated care contracts) Increases the amount of specialists Increases the health care expenditure Various reforms have tried to lessen sectoral borders (last in 2012 by creating a new in-between sector for highly specialized ambulatory care)

10 Decision-making in German SHI Legislation Parliament Federal Ministry of Health Supervision Patient 150,000 ambulatory care physicians and psychotherapists Federal Association of SHI Physicians (KBV) 130 sickness funds German Hospital Federation (DKG) 2,000 hospitals Federal Association of Sickness Funds Federal Joint Commitee (G-BA) Members: 13 voting 3 neutral + 5 sickness funds + 5 providers (+ up to 5 patient representatives) Statutory Health Insurance

11 Objectives of Federal Joint Committee Main functions: to regulate SHI-wide issues of access, benefits and quality(and not primarily of costs or expenditure) Normative function of the G-BA by legally binding directives ( sub-law ) toguarantee equal excess to necessary and appropriate services for all SHI insured Benefit package decisions must be justified by an evidencebased process to determine whether services, pharmaceuticals or technologies are medically effective in terms of morbidity, mortality and quality of life By law, evidence based assessments can only be used to select the most appropriate (efficient) service etc. from others not to prioritize among service areas: if a costly innovation has a significant additional benefit, the sickness funds must pay for it

12 The hospital sector: (too) many beds, Acute care hospital beds per % % Austria Belgium Denmark France Germany Italy Netherlands Norway Spain Sweden Switzerland United Kingdom EU members before May

13 The hospital sector: (too) many cases 28 Acute care hospital discharges per % -2% -32% Austria Belgium Denmark France Germany Italy Netherlands Norway Spain Sweden Switzerland EU members before May

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15 Average annual growth of total health expenditure before crisis: (OECD 2013) +3.4% +3.9% +3.3% +7.0% +5.3% +5.5% +3.7% +2.1% +2.1% +2.2% +1.8% +4.1% +1.6% +5.3%

16 Rating of overall quality of healthcare in country (autumn 2009): good (Eurobarometer 327) 90% 94% 87% 53% 86% 91% 97% 88% 91% 86% 95% 42% 81% 54% 25%

17 Health policy rating 2008 (Mackenbach& McKee 2013)

18 An example quality indicator: prescription of antibiotics (in DDD/ capita),

19 Average annual growth of total health expenditure in crisis: (OECD 2013) +1.8% +1.6% -6.6% -1.8% +1.0% -1.8% +0.6% +0.7% +2.1% +0.2% -2.2% -0.5% -0.4% -11.1%

20 Average annual growth of total health expenditure: vs (OECD 2013) +7.0% -6.6% +2.1% +2.1% -11.1% +5.3%

21 Performance assessment Avoidable mortality Deaths per 100,000 population* FR AUS ITA JPN SWE NOR NETH AUT FIN GER GRE IRL NZ DEN UK US

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