Especificaciones Técnicas

Organisation and finance of health care in Germany is based on the traditional principles of social solidarity, decentralisation and self-regulation. The role of the central government is limited to providing the legislative framework in which health services are delivered while much of the executive responsibility lies with the administrations of the individual states (Länder). The Federal Ministry of Health is the key institution on the federal level, assisted by subordinate authorities with

Health Care Systems: Germany

scientific expertise. The ’Advisory Council for Concerted Action’ in health care plays an advisory role in medical and broader economic matters.

The statutory social insurance system covers nearly 88% of the German population. Workers below a certain income threshold are required to take out statutory health insurance, the unemployed are entirely covered by the State. In 1997, 75% of the population were mandatory members and 13% voluntary members of the approximately 600 sickness funds, the number of which has been constantly reduced through mergers since the early 1990s. Another 10% of Germans, mainly civil servants, are covered by their employers and high income earners are privately insured with one of the 45 private insurance companies. Less than 0.5% of the population is uninsured. Sickness funds are either organised by districts, occupation, or specific enterprises. Employees have been granted free choice of sickness funds since 1996.

The benefit package for social insurance is regulated by federal legislation, providing for the following benefits in kind: prevention of disease, screening for disease, diagnostic procedures, treatment of disease, rehabilitation, and transportation.

2. Finance

Around 60% of funding is derived from compulsory and voluntary contributions to statutory health insurance, about 21% is derived from general taxation, private insurance accounts for approximately 7% and the remaining 11% is covered by direct payments by the patient.

Contributions to sickness funds are collected from all work-related income, payroll taxes being divided equally between employer and employee. Additionally, there has been a significant variation of contribution rates between the different funds, depending on the risk structure of the fund’s members, i.e. the different health risks of their insured (e.g. as a result of age and gender profile). This led in 1994 to the introduction of a financial compensation system between the sickness funds. This risk structure mechanism provides for a financial balancing-out between the sickness funds. Payment into and out of the pool is based on a complex calculation primarily based on the age, gender and geographical factors of the insured. The average contribution rate was 13.5% of gross income in 1997.

There is a strict separation of purchasers (sickness funds) and health care services in the German system. Service fees are subject to a highly decentralised process of bargaining between the major health care institutions.

Hospitals, whether public or private, listed on plans established by the Länder, are financed by a

dual system involving coverage of capital costs by the Länder and payment of operating costs by the sickness funds. Since 1996, operating costs under statutory insurance have been financed on the basis of a complex calculation combining case-fees related to a specific diagnosis (according to Diagnosis Related Groups), procedure fees and departmental charges per diem. The new payment system replaced a system in which hospital services were financed on a per-diem basis regardless of the care required and aims to reduce the average length of stay in acute hospital care. Hospital services for privately-insured patients are reimbursed according to separate fee-schedules.

Health Care Systems: Germany

Before German unification in 1990, data on total expenditure on health care refer to the former Federal Republic 19

of Germany. Data from 1991 onwards are those for the unified country.

Ambulatory care is financed throughout a complex formal negotiation process between

representatives of the sickness funds and physician and dental associations. To provide services to members of statutory insurance funds, practitioners are required to join the respective associations.

The principal mechanism of reimbursement is fee-for-service for general practitioner, specialist services and dental care. There is a federal fee schedule, the Uniform Evaluation Standard. The actual monetary value is negotiated regionally, adjusted to the overall income of physicians. There are no direct charges for patients for ambulatory medical care. In contrast, dental care requires up to 100% co-payments especially for prosthetic services.

There are uniform prices for drugs in Germany. The majority of pharmaceuticals are reimbursed on the basis of a reference-price system. The physician is free to prescribe a more expensive product but the patient has to pay extra when the price of the prescribed drug exceeds its reference price. The budget for pharmaceutical and for ambulatory expenditure was abolished in 1997. In spite of a gradual increase, the co-payment rate for drugs is still one of the lowest in the European Union.

3. Health Care Expenditure19

Figure 10 illustrates the growth of health care expenditure in Germany between 1960 and 1995. Health care expenditure in West Germany grew rapidly from 4.1% of GDP in 1960 to 8.1% in 1980 and rose again to 8.4% in 1981, but following the Health Reform Law of 1989, came down slightly to 8.2% in 1990 {7.2%}. German reunification caused a sharp increase in health care expenditure to 9.6% of Gross Domestic Product in 1991. This was caused by the low level of national resources in the East while health care expenditure rapidly grew towards the level of the West. The latest figures demonstrate a further upward trend between 1992 and 1995. In 1995, the proportion of German GDP devoted to health care reached the highest level in the EU at 10.4% {7.7}, this is equivalent to 2,362 ECU per head {1,412.7}.

Distribution of sickness fund expenditure following German reunification differed somewhat between the new and the old Länder, with expenditure on dental care and pharmaceuticals contributing a higher share in the new compared to the old Länder. Hospital and ambulatory care had a higher expenditure share in the sickness funds of the old Länder.

Health Care Systems: Germany

Figure 10: Total expenditure on health care 1960 to 1995 in the Federal Republic of Germany until 1990 and unified Germany thereafter, distribution of expenditure in 1995