Key Aspects of a Sustainable Health Insurance System in Germany

Abstract

Background

The main goals of health-care systems are to improve the health of the population they serve, respond to people’s legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design.

Objective

This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges.

Methods

We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire.

Results

We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance.

Conclusion

We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.

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Notes

  1. 1.

    The basic coverage of private insurance funds is similar to regulated SHI coverage. However, it significantly differs with respect to the possible deductibles. While a deductible of up to EUR5000 is possible for private insurance funds, the highest possible deductible for SHI coverage is EUR600/900 [9].

  2. 2.

    The Federal Republic of Germany is a federal parliamentary republic and consists of 16 constituent states, called the Länder.

  3. 3.

    The German Bundestag is the constitutional and legislative body at the federal level in Germany.

  4. 4.

    The “Grundgesetz” is the German constitution.

  5. 5.

    Effect size: partial eta squared (0.02 small, 0.13 medium, 0.26 large).

  6. 6.

    Note that although the number of hospital beds is decreasing, the capacity of hospital beds is actually increasing because the average hospital stay is decreasing significantly.

  7. 7.

    Although medical coverage exceeds the need on average (108.6 % coverage rate), approximately one-third of the planning areas feature a coverage rate below 100 % [31].

  8. 8.

    In praxis, the German system does not incorporate physicians as gate-keepers. In 2004, gate-keeping models were partially implemented in order to reduce non-coordinated or unnecessary visits, but these models offered limited success.

  9. 9.

    Note that the German Bundestag passed a law in May 2015 to allow for more thorough retention of sickness data on the “Gesundheitskarte”, a smart card specifically designed for SHIs.

  10. 10.

    At the same time, interviewee I4 argued that rising costs do not pose a challenge to the German health-care system: “No, definitively not [does the overall increase of health care costs pose a challenge].”

  11. 11.

    Pensioners are normally aged 65 and over. However, due to a few exemptions, the group of pensioners may include a small number of individuals under 65.

  12. 12.

    Note that the formula from Schmitz and Ziebarth reads 0.5 × 15.5 % instead. However, this formula is not entirely correct because the distribution between employers and employees was not equally shared between 2009 and 2014. Instead, apart from a period from July 1, 2009 to December 2010, employers paid 7.3 % and employees 8.2 %.

  13. 13.

    Statutory health care consists of 123 statutory health insurance companies in 2014, which is a significant decrease from 1815 companies in 1970, and 420 companies in 2000 [62].

  14. 14.

    Within the German system, physicians are able to charge a fee approximately twice as high when treating private patients rather than patients with social health insurance. Specifically, depending on the particularities of the treatment, physicians can charge between 2.3 and 3.5 times the regular rate.

  15. 15.

    Moral hazard issues also come into play. The service recipient might not have the motivation to verify the additional benefits or costs of a proposed treatment because he does not have to cover the costs personally. Furthermore, asymmetric information between service recipients and insurance companies might lead to adverse selection issues. Interviewee I2 suggested increased offering of medical service telephones by insurance companies to allow patients to obtain a second opinion more easily.

  16. 16.

    We thank one anonymous reviewer for bringing our attention to this issue.

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Acknowledgments

We thank the two anonymous reviewers and the editor for their thorough review. We greatly appreciate their comments and suggestions, which significantly contributed to improving the quality of the publication.

Financial support by the Mercator Research Center Ruhr is gratefully acknowledged.

Author contributions

The manuscript was prepared by MP, with contributions from VH and FLU. Interviews were conducted by MP and FLU, with contributions from VH. The online survey was conducted by VH, with contributions from MP and FLU. MP, VH, and FLU acted as guarantors for the overall content.

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Corresponding author

Correspondence to Matthias Pelster.

Ethics declarations

This study was funded by the Mercator Research Center Ruhr. MP, VH, and FLU have no conflicts of interest.

Appendix: Interview Guideline for the Semi-Structured Expert Interviews

Appendix: Interview Guideline for the Semi-Structured Expert Interviews

  1. 1.

    Introduction

    1. (a)

      Introduction of the interviewer and the context of the research.

    2. (b)

      Introduction of the interviewee.

  2. 2.

    Challenges

    1. (a)

      We are especially interested in your appraisal of the challenges for the German health insurance system.

      1. 1.

        Which aspects pose major challenges?

      2. 2.

        Which aspects are from your point of view of high relevance?

      3. 3.

        Where do you see the need for changes or reforms?

  3. 3.

    Causes

    1. (a)

      Wherein lay the fundamental causes for those processes/challenges from your point of view?

    2. (b)

      Which role do faulty incentives have in this?

  4. 4.

    Solutions

    1. (a)

      From your point of view, what are possible solutions or first steps towards a solution to successfully face these challenges?

    2. (b)

      We are also interested in aspects of health insurance systems from around the world.

      1. 1.

        Are there countries that would be of interest to us in terms of their health insurance systems?

      2. 2.

        What would we need to consider when applying such ideas to the German health-care system?

      3. 3.

        How about the transferability of such ideas to Germany?

  5. 5.

    Conclusion/End of interview

    1. (a)

      Is there an aspect upon which you would like to elaborate?

    2. (b)

      Is there anything else you would like to add?

Generic follow-up questions:

  • Could you give me some examples?

  • What examples do you have in mind?

  • What is the reason for that?

  • What has changed since then?

Items questionnaire

P1 The dualism of statutory and private health insurance funds is a problem in the German health-care system
P2 The reason for the dualism of statutory and private health insurance funds becoming a problem lies within the increasing privatization of statutory insurance funds and the growing socialization of private health insurance funds
P3 The reason for the dualism of statutory and private health insurance funds becoming a problem lies within the scale of fees for medical treatment separating between the scale of fees for physicians (GOÄ) and the Doctors’ Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM)
P4 The German health-care system offers too few options (e.g. lack of degrees of freedom) for health insurance providers to create innovations and process innovations
P5 The German health-care system offers too few incentives (e.g. profit gain) for health insurance funds to create innovations and process innovations
P6 A missing “protection of patents” reduces the incentive for health insurance funds to aim for innovations
P7 The German health insurance funds system offers no opportunities for competition
P8 The German health insurance funds system offers no opportunities for competition on pricing
P9 The German health insurance funds system offers no opportunities for competition on quality
P10 The German health-care system is not patient centered
P11 The German health-care system lacks working, quality measurement systems
P12 In the German health-care system, there is insufficient hospital planning taking place (e.g. it is possible that unprofitable but structurally relevant hospitals are being closed)
P13 One of the fundamental problems of the German health-care system is rising health-care costs
P14 The process of demographic change is an essential cost factor for the German health-care system
P15 Medical and technological advances are an essential cost factor for the German health-care system
P16 Changing patient needs are an essential cost factor for the German health-care system
P17 Please indicate here which other causes/challenges the German health-care system is currently facing from your point of view
L1 Creating clear structures with regard to competition within the health insurance funds system is a necessity
L2 Opportunities for competition on pricing between health insurance funds have to be provided more frequently
L3 Opportunities for competition on quality between health insurance funds have to be provided more frequently
L4 To meet the challenges the health-care system is facing, only collective agreements should be provided without exception
L5 To meet the challenges the health-care system is facing, selective agreements should be encouraged
L6 The scale of fees for physicians (GOÄ) and the Doctors’ Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) should be combined to create one unified scale of fees
L7 The dualism of statutory and private health insurance funds should be dis-established
L8 A reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the quality of health care
L9 A reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the efficiency of health care
L10 The creation of networks adds to improved health care in rural areas
L11 Integrated care as an example for effective networks helps to ensure a more efficient functioning of the health-care system in urban regions
L12 The segmentation between outpatient and inpatient care has to be overcome
L13 Creating networks also on a patient level (e.g. using relief funds, using company welfare schemes, or on a regional level) will result in reinforced health consciousness and prevention
L14 Centralizing patient data (using, for example, an electronic health card) to create a database (“data mining”) can be an important factor towards increasing quality and reducing costs
L15 Patient-centered care should become more prominent in the health-care system
L16 There is a need for consistent standards to build and run specialized medical centers
L17 Using consistent standards for specialized medical centers can reduce costs
L18 Using consistent standards for specialized medical centers can increase the quality of patient care
L19 It is essential to create a unified (government-regulated) institution to control the quality standards set within the German health-care system and thereby increase the quality of patient care
L20 A more active role within the health-care system should be attributed to patients and policyholders (insured persons)
L21 There is a need for increased integration of measures aimed at health prevention in schools
L22 Possible solutions to meet the various challenges the German health-care system is facing are…
1. … the creation of new professional fields
2. … improved education of all health-related professions
3. … increased academic training and professionalization of nursing professions
4. … increased delegation of medical care and treatment provided by physicians to specialized and trained medical personnel
Area of expertise Where do you work?
0 = research
1 = private health insurance fund
2 = statutory health insurance fund
3 = policies
4 = medical field
5 = administration
Age Please provide details of your age in natural numbers, e.g. 43
Sex Which gender are you?

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Pelster, M., Hagemann, V. & Laporte Uribe, F. Key Aspects of a Sustainable Health Insurance System in Germany. Appl Health Econ Health Policy 14, 293–312 (2016). https://doi.org/10.1007/s40258-016-0223-8

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Keywords

  • Private Insurance
  • Private Health Insurance
  • Incentive System
  • Sickness Fund
  • Statutory Health Insurance