Health Policy and Health Economics in Germany

Rede von Bundesgesundheitsministerin Ulla Schmidt an der Universität von Minnesota, USA

2006 +++ Ulla Schmidt +++ Quelle: Internet (05.06.2006)


Health, and of this I am firmly convinced, constitutes an indispensable basis for the wealth of a nation and for the well-being and happiness of its people.

After more than five years in office, I am now the longest-serving health minister in Europe.

In Germany, roughly 290 billion dollars are spent every year on health services in the broadest sense; about 175 billion dollars out of this total are accounted for by the statutory health care system.

Approximately 70 million out of a total population of 82 million people are covered by the social health insurance system, to which they pay a percentage of their wages and salaries as contributions.

At present, employees pay an average 7.5 per cent of their salary for health insurance coverage. Their employers contribute 6.6 per cent but will have to continue payment of wages for 6 weeks in case of illness.

Our statuary health insurance is a family insurance, meaning that children and non employed spouses are co-insured free of charge. The principle is that the rich pay for the poor, the young for the old, the healthy for the sick.

Blue and white-collar workers who earn less than 4,700 dollars a month, are insured on a mandatory basis, as are persons who are unemployed, pensioners, students, disabled persons, poor and homeless people. They are all covered in the statutory health insurance system according to the same provisions and enjoying equal access to health benefits and services.

Our funding of statutory health care and the access to it are based on the concept of solidarity. This means that contributions are made according to ability to pay and people receive benefits according to their health care needs.

Individuals with an income above 4,700 dollars per month or those who are self-employed, can either stay in the social system on a voluntary basis or opt out and purchase private health insurance. Some 10 percent of the population are privately insured and only a small number is covered by special state programmes (for example federal policemen or soldiers).

Members of a private health insurance pay premiums that reflect their health risk. Bad risks are turned down by private health insurers. However, in Germany, only a relatively small number of persons - about 300,000 - are uninsured. These are mostly people who have been unable to pay their contributions due to financial difficulties.

We worry about the fact that their number has growing. Therefore the new Federal Government has decided that, in the future, no one may lose their insurance coverage. Persons who lost their coverage because they were unable to pay their private health insurance premiums, are to be given a right to reinstatement without a new risk assessment.

I consider this as an extremely important step towards the system which I favour - one of mandatory insurance for everyone living in Germany.

Insurances in Germany offer a comprehensive package of services. They cover, for instance, outpatient and hospital treatment, all necessary medication, dental treatment, denture, as well as rehabilitation. In other words, they cover whatever is necessary.

The health care sector in Germany supplies safe and well-paid jobs for more than four million people. And both in your country and mine, the health care sector accounts for far more than ten per cent of the gross domestic product.

(…) and the advancements in medicine, pharmacology and medical technology along with demographic, social, and economic change will increase pressure for further rationalisation measures on our health care system.

The Achilles heel of Germany's social health insurance is the fact that contributions are exclusively wage-indexed. Health insurance contributions are only charged on earned income or its replacement (such as pensions).

On the whole, hospital rates in Germany are now being calculated according to the American DRG model.

The rules for providers of health care services and health products have also been changed. We liberalised sectoral and limitations, we support competition and we promote better quality.

For example, it is now possible for non-panel doctors to provide outpatient services at medical care centres – something which was not possible before.

As some of you may know Germany is the only country that has a parallel structure for specialist care. Specialist are employed in hospitals and at the same time there are well-equipped specialist clinics that provide outpatient care. Our debate on the need for changes to a duplicate, wasteful system was a hefty one! Some opponents went as far as to accuse us of planning kind of a state run, socialist medicine....

Today it is hard not to see the first achievements of the recent German reforms. Medical care centers – i.e. multidisciplinary group practices – are set up all over the country. Today there are well over 420 such centers, with some 1700 physicians, of which 1000 work as employees.

Hospitals are beginning to deliver outpatient care. It should also be mentioned that office-based physicians who see themselves as „independent single fighters“ do see the current trend towards larger practices and medical centers with growing uneasiness. Nevertheless this trend is a powerful, irreversible one that can no longer be stopped.

Now what can we learn from the US health care experiences? I must say that in Germany, we are very much impressed by your discussions around the concept of Managed Care, particularly its use in the context of integrated care, chronic care management, and disease management programs: we are carefully assessing which elements could be transferred and adapted to our setting.

We have modified a number of American approaches, adopting them in a way that DMPs now constitute a real success factor in our system. Over two million people are already enrolled in Disease Management Programs.

We are also fostering competition among all providers wishing to overcome the rigid fragmentation of the health care system.

Those who are willing to participate in the new system – which we call integrated care – receive payments from a special fund. The financial incentive towards more and better integration and coordination of care constitutes a clear proof that new ground has been broken in Germany.

(…) in Germany, we have granted patients and their advocacy groups a greater say in the health policy decision making process. Whereas in the past representatives of health insurance funds, physicians, and hospitals used to take treatment decisions and decisions on reimbursable services without the participation of those affected, today patient and consumer representatives have a place at the table. This table, a tri-partite entity called Joint Federal Committee, has contributed to considerably improving the transparency, and culture of the decision making processes.

A reasonable path means that the criteria for further reforms of the statutory health insurance must not be subjected to search of perfection:

- Fair distribution – quality improvement

- Reduction of the wage dependency of financing systems to give incentives for employment,

- Sustainability of financing

These are the guiding principles for the forthcoming reform.