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https://www.expatica.com/de/healthcare/healthcare-basics/the-german-healthcare-system-a-guide-to-healthcare-in-germany-103359/

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The German Health Ca
The German Health Care System (GHCS) faces many challenges among which an aging population and economic problems are just a few. The GHCS traditionally emphasised equity, universal coverage, ready access, free choice, high numbers of providers and technological equipment; however, real competition among health-care providers and insurance companies is lacking. Mainly in response to demographic changes and economic challenges, health-care reforms have focused on cost containment and to a lesser degree also quality issues. In contrast, generational accounting, priorisation and rationing issues have thus far been completely neglected. The paper discusses three important areas of health care in Germany, namely the funding process, hospital management and ambulatory care, with a focus on cost control mechanisms and quality improving measures as the variables of interest. Health Information Technology (HIT) has been identified as an important quality improvement tool. Health Indicators have been introduced as possible instruments for the priorisation debate.

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elijah
elijah
German health benefits are very generous. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the world's best health care systems, visible in little ways that most Germans take for granted
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Nurdiana
Health insurance is compulsory for the whole population in Germany; in 2009, coverage was expanded from nearly all the population to everyone.[22] Salaried workers and employees below the relatively high income threshold of 60,750 Euros per year (2019)[23] are automatically enrolled into one of currently around 130 public non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. The employer pays half of the contribution, and the employee pays the other half.[23]
Regular salaried employees must have public health insurance, unless their income exceeds 60,750€ per year (2019). If their income exceeds that amount, they can have private health insurance instead. Freelancers can have public or private insurance, regardless of their income.[23]
For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance[citation

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The German Health Care System (GHCS) faces many challenges among which an aging population and economic problems are just a few. The GHCS traditionally emphasised equity, universal coverage, ready access, free choice, high numbers of providers and technological equipment; however, real competition among health-care providers and insurance companies is lacking. Mainly in response to demographic changes and economic challenges, health-care reforms have focused on cost containment and to a lesser degree also quality issues. In contrast, generational accounting, priorisation and rationing issues have thus far been completely neglected. The paper discusses three important areas of health care in Germany, namely the funding process, hospital management and ambulatory care, with a focus on cost control mechanisms and quality improving measures as the variables of interest. Health Information Technology (HIT) has been identified as an important quality improvement tool. Health Indicators have been introduced as possible instruments for the priorisation debate.

https://www.researchgate.net/publication/225097938_Challenges_for_the_German_Health_Care_System

- Janissa

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Health insurance is compulsory for the whole population in Germany; in 2009, coverage was expanded from nearly all the population to everyone.[22] Salaried workers and employees below the relatively high income threshold of 60,750 Euros per year (2019)[23] are automatically enrolled into one of currently around 130 public non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. The employer pays half of the contribution, and the employee pays the other half.[23]
Regular salaried employees must have public health insurance, unless their income exceeds 60,750€ per year (2019). If their income exceeds that amount, they can have private health insurance instead. Freelancers can have public or private insurance, regardless of their income.[23]

For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance[citation needed], the higher premiums must then be paid out of a lower income. During the last twenty years[when?] private health insurance became more and more expensive and less efficient compared with the public insurance.[citation needed]For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance[citation needed], the higher premiums must then be paid out of a lower income. During the last twenty years[when?] private health insurance became more and more expensive and less efficient compared with the public insurance.[citation needed]

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German health benefits are very generous. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the world's best health care systems, visible in little ways that most Germans take for granted

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Mention European health care to an American, and it probably conjures up a negative stereotype - high taxes, long waiting lines, rationed care.

It's not that way in Germany. Very little tax money goes into the system. The lion's share comes, as in America, from premiums paid by workers and employers to insurance companies.

German health benefits are very generous. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the world's best health care systems, visible in little ways that most Germans take for granted.
Checking In With An Old Friend
Juergen in der Schmitten was a medical student when I first met him 17 years ago. Now, he's a 42-year-old general practitioner in a suburb of Dusseldorf.

On one particular night, Juergen was the doctor on call for the region. Any German who needs after-hours care can call a central number and get connected to a doctor.

Around 11 p.m., a woman with a fever called Juergen. She wanted him to make a house call. They talked for maybe five minutes, in the end agreeing that she would come into his office in the morning.

A situation like this would be unlikely in the United States. Americans might not get through to a doctor at all, let alone have a discussion about whether the physician should make a house call in the middle of the night to treat a case of flu.
The Patients' Perspective
Sabina and Jan Casagrandes say they've had really good care from the German health system. And they've used it a lot.

Sabina is American, Jan is German. They live in a fourth-floor walkup with their two little girls in Cologne, an ancient city on the Rhine in western Germany.

"I've probably been very expensive for the health insurance system here," Sabina says. "When I was 33 years old, I had a giant lump on my neck all of a sudden, where your thyroid is. And it was a big tumor."

It took two operations to remove her cancer. Luckily it was curable with surgery and radiation. Sabina says she had the best care she could imagine.

"Then I came home to my little daughter, who I couldn't really lift up because of my neck having been cut open," Sabina says. "So I asked my doctor, 'What can I do?' And she said, 'Well, your health insurance will pay for someone to come help you in the house.'"

Sabina's health insurer paid a friend to shop, cook and even help care for the baby until Sabina was back on her feet. That's not unusual in Germany. In fact, under the country's system for long-term care, family members can choose to be paid for taking care of a frail elder at home if they want to avoid nursing home care.
Coverage For All
The health care system that took such good care of Sabina is not funded by government taxes. But it is compulsory. All German workers pay about 8 percent of their gross income to a nonprofit insurance company called a sickness fund. Their employers pay about the same amount. Workers can choose among 240 sickness funds.

Basing premiums on a percentage-of-salary means that the less people make, the less they have to pay. The more money they make, the more they pay. This principle is at the heart of the system. Germans call it "solidarity." The idea is that everybody's in it together, and nobody should be without health insurance.

"If I don't make a lot of money, I don't have to pay a lot of money for health insurance," Sabina says. "But I have the same access to health care that someone who makes more money has."

But she acknowledges that nearly 8 percent of her salary is a sizable bite.

"Yes, it's expensive. You know, it's a big chunk of your monthly income," Sabina says. "But considering what you can get for it, it's worth it."

Actually, it's about the same proportion of income that American workers pay, on average, if they get their health insurance through their job. The big difference is that U.S. employers pay far more, on average, than German employers do - 18 percent of each employee's gross income versus around 8 percent in Germany.
More Added Benefits In Germany
Moreover, German health insurance has more generous benefits than U.S. policies cover. There are never any deductibles, for instance, before coverage kicks in. And all Germans get the same coverage.

For instance, the Casagrandes' insurance covers an expensive medicine Jan needs for a chronic intestinal problem. He says if they moved to America, they might not be able to buy insurance at all because of their pre-existing conditions - a nonproblem in Germany.

"He says for himself - or for us - the health care system in the United States is the major reason why we have never moved there, and never will move there. Because both of us have chronic illnesses that have to have a lot of medical attention, and we would go broke," Sabina says, translating for Jan.

Jan adds something else. "It's also the No. 1 reason in the United States that people personally go bankrupt," Sabina translates, "which would never happen here ... never!"
Coverage For The Family
On the other side of Germany, in Berlin, we meet another couple who know both the American and German health systems.

Nicole and Chris Ertl own Tip Toe Shoes, a children's shoe shop in a well-off area of the German capital. The Ertls sell high-quality European shoes - tiny Italian sandals, French and Danish boots and clogs in wonderful colors.

Chris is from San Diego, Nicole is German. She also works part time as a physician therapist and gets her health care through her job like the great majority of Germans. Like the Casagrandes, she's happy with her coverage.

"It's a good deal!" she says. "It's really good because it's a package."

It's a package many Americans might envy. Nicole pays a premium of $270 a month for insurance that covers her children, too. Nicole pays a single $15 copayment once every three months to see her primary-care doctor - and another $15 a quarter to see each specialist, as often as she wants. She pays no copayments for her children's care ---and her insurance even covers her daughter's orthodontia bill.

"They always have good care," Nicole says, "because for kids, everything is free. The drugs, it's always free" until they turn 18.
Different Rules For The Self-Employed
But even though her insurance covers the kids, it doesn't cover her husband. Because Chris Ertl is self-employed, he has to buy insurance on his own, from a for-profit insurance company.

About one in 10 Germans buy this so-called "private" coverage. It's not just for people who are self-employed. Civil servants and anyone who makes more than $72,000 a year can opt out of the main system. It's a kind of safety valve for people who want more and can pay for it.

But most people don't opt out. Chris says that's because there's a fundamental difference in the way Germans view health care and the government's role - which, in Germany, means refereeing the system and making sure it's fair and affordable.

"The general opinion in Germany is always that the government will do it for us, everything will be OK," Chris says. "In the States, I think you grow up knowing that no one's going to help you do anything. If you want health care, go get it."

It's important to remember that the German government doesn't provide health care or finance it directly. It does regulate insurance companies closely - the nonprofits in the main system and the for-profits where Chris gets his coverage. So Chris' insurer can't raise his rates if he gets sick or jack up his premiums too much as he gets older. The government also requires insurers to keep costs down so things don't get too expensive.

"Where am I better off medically?" Chris says. "I would probably say Germany."

In some ways, Chis Ertl's coverage is better than his wife's. He gets his choice of top doctors - the chief of medicine, if he wants. If he goes into the hospital, he gets a private room. When he goes to the doctor, he gets a free cup of coffee and goes to the head of the line. All this embarrasses him - and annoys Nicole.

"When he goes to the doctor, he has a lot more service," she complains.

Germans really hate any hint of unfairness in health care. The fundamental idea is that everybody must be covered and, preferably, everybody should get equal treatment. So the fact that 10 percent or so can buy some perks is an irritant - something Germans complain about but manage to put up with.

But it's unthinkable that 48 million people wouldn't have health insurance at all - the situation in America. As an American, Chris thinks that's shameful. "It's terrible," he says. "It's unbelievable. It shouldn't happen."

Germans, he says, would never tolerate that. And their system has been working pretty well for 125 years.
Radio piece produced by Jane Greenhalgh.

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Most Patients Happy With German Health Care

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German health benefits are very generous, and there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the best health care systems in the world. It's visible in little ways that most Germans take for granted.

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Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance (Private Krankenversicherung or PKV) to replace or top up state cover (gesetzliche Krankenkasse or GKV). -kari

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Health insurance is compulsory for the whole population in Germany; in 2009, coverage was expanded from nearly all the population to everyone. - Yong Shen

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Health insurance is compulsory for the whole population in Germany; in 2009, coverage was expanded from nearly all the population to everyone. - Yong Shen

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I take from wikipedia one

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Germany has a universal multi-payer health care system paid for by a combination of statutory health insurance (Gesetzliche Krankenversicherung) and "Private Krankenversicherung" (private health insurance).

The turnover of the health sector was about US$368.78 billion (€287.3 billion) in 2010, equivalent to 11.6 percent of gross domestic product (GDP) and about US$4,505 (€3,510) per capita. According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004. In 2004 Germany ranked thirtieth in the world in life expectancy (78 years for men). It had a very low infant mortality rate (4.7 per 1,000 live births), and it was tied for eighth place in the number of practicing physicians, at 3.3 per 1,000 persons. In 2001 total spending on health amounted to 10.8 percent of gross domestic product.

According to the Euro health consumer index, which placed it in seventh position in its 2015 survey, Germany has long had the most restriction-free and consumer-oriented healthcare system in Europe. Patients are allowed to seek almost any type of care they wish whenever they want it. The governmental health system in Germany is currently keeping a record reserve of more than €18 billion which makes it one of the healthiest healthcare systems in the world.

Germany has the world's oldest national social health insurance system, with origins dating back to Otto von Bismarck's social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889. Bismarck stressed the importance of three key principles; solidarity, the government is responsible for ensuring access by those who need it, subsidiarity, policies are implemented with the smallest political and administrative influence, and corporatism, the government representative bodies in health care professions set out procedures they deem feasible. Mandatory health insurance originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population. The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population are covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1,100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher-income workers sometimes choose to pay a tax and opt-out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status. Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physicians' associations and sickness funds.

1970-Present

Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries. The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost-containment mechanism but would require consent of regional medical associations, and has not materialized.

Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days). The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).

This section needs expansion. You can help by adding to it.

The healthcare system is regulated by the Federal Joint Committee ( Gemeinsamer Bundesausschuss), a public health organization authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine decisions regarding healthcare in Germany. The Federal Joint Committee consists of 13 members, who are entitled to vote on these binding regulations. The members composed of legal representatives of the public health insurances, the hospitals, the doctors and dentists and three impartial members. Also, there are five representatives of the patients with an advisory role who are not allowed to vote.

The German law about the public health insurance (Fünftes Sozialgesetzbuch) sets the framework agreement for the committee. One of the most important tasks is to decide which treatments and performances the insurances have to pay for by law. The principle about these decisions is that every treatment and performance has to be required, economic, sufficient and appropriate.

Health insurance is compulsory for the whole population in Germany; in 2009, coverage was expanded from nearly all the population to everyone.

Salaried workers and employees below the relatively high income threshold of 60,750 Euros per year (2019) are automatically enrolled into one of currently around 130 public non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. The employer pays half of the contribution, and the employee pays the other half. Self-employed workers and unemployed workers with no unemployment benefits must pay the entire contribution themselves. Provider payment is negotiated in complex corporatist social bargaining among specified self-governed bodies (e.g. physicians' associations) at the level of federal states (Länder). The sickness funds are mandated to provide a unique and broad benefit package and cannot refuse membership or otherwise discriminate on an actuarial basis. Social welfare beneficiaries are also enrolled in statutory health insurance, and municipalities pay contributions on behalf of them.

Besides the "Statutory Health Insurance" (Gesetzliche Krankenversicherung) covering the vast majority of residents, those with a yearly income above 60,750 Euros (2019), students and civil servants for complementary coverage can opt for private health insurance (about 11% of the population have private health insurance). Most civil servants benefit from a tax-funded government employee benefit scheme covering a percentage of the costs, and cover the rest of the costs with a private insurance contract. Recently, private insurers provide various types of supplementary coverage as an add upon of the SHI benefit package (e.g. for glasses, coverage abroad and additional dental care or more sophisticated dentures). Health insurance in Germany is split in several parts. The largest part of 89% of the population is covered by a comprehensive health insurance plan provided by statutory public health insurance funds regulated under specific the legislation set with the Sozialgesetzbuch V (SGB V), which defines the general criteria of coverage, which are translated into benefit packages by the Federal Joint Committee. The remaining 11% opt for private health insurance, including government employees.

Public health insurance contributions are based on the worker's salary. Private insurers charge risk-related contributions. This may result in substantial savings for younger individuals in good health. With age, private contributions tend to rise and a number of insurees formerly cancelled their private insurance plan in order to return to statutory health insurance; this option is now only possible for beneficiaries under 55 years.

Reimbursement for outpatient care was on a fee-for-service basis but has changed into basic capitation according to the number of patients seen during one quarter, with a capped overall spending for outpatient treatments and region. Moreover, regional panel physician associations regulate number of physicians allowed to accept Statutory Health Insurance in a given area. Co-payments, which exist for medicines and other items are relatively low compared to other countries.

Germany has a universal system with two main types of health insurance. Germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.

Accident insurance for working accidents ( Arbeitsunfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.

Long-term care ( Pflegeversicherung) is covered half and half by employer and employee and covers cases in which a person is not able to manage his or her daily routine (provision of food, cleaning of apartment, personal hygiene, etc.). It is about 2% of a yearly salaried income or pension, with employers matching the contribution of the employee.

There are two separate types of health insurance: public health insurance ( Gesetzliche Krankenversicherung) and private insurance ( Private Krankenversicherung). Both systems struggle with the increasing cost of medical treatment and the changing demography. About 87.5% of the persons with health insurance are members of the public system, while 12.5% are covered by private insurance (as of 2006).

In 2013 a state funded private care insurance was introduced ("Private Pflegeversicherung"). Insurance contracts that fit certain criteria are subsidised with 60 Euro per year. It is expected that the number of contracts will grow from 400,000 by end of 2013 to over a million within the next few years. These contracts have been criticized by consumer rights foundations.

The German legislature has reduced the number of public health insurance organisations from 1209 in 1991 down to 123 in 2015.

The public health insurance organisations (Krankenkassen) are the Ersatzkassen (EK), Allgemeine Ortskrankenkassen (AOK), Betriebskrankenkassen (BKK), Innungskrankenkassen (IKK), Knappschaft (KBS), and Landwirtschaftliche Krankenkasse (LKK).

As long as a person has the right to choose his or her health insurance, he or she can join any insurance that is willing to include the individual.

public health insurance organisations in January 2019

Numbers

number of members including retired persons

open on federal level

open on state level

not open

Regular salaried employees must have public health insurance, unless their income exceeds 60,750€ per year (2019). If their income exceeds that amount, they can have private health insurance instead. Freelancers can have public or private insurance, regardless of their income.

In the Public system the premium

is set by the Federal Ministry of Health based on a fixed set of covered services as described in the German Social Law (Sozialgesetzbuch - SGB), which limits those services to "economically viable, sufficient, necessary and meaningful services"

is not dependent on an individual's health condition, but a percentage (currently 15.5%, 7.3% of which is covered by the employer) of salaried income under €54,450 per year (in 2019).

includes family members of any family members, or "registered member" ( Familienversicherung - i.e., husband/wife and children are free)

is a "pay as you go" system - there is no saving for an individual's higher health costs with rising age or existing conditions.

In the Private system the premium

is based on an individual agreement between the insurance company and the insured person defining the set of covered services and the percentage of coverage

depends on the amount of services chosen and the person's risk and age of entry into the private system

is used to build up savings for the rising health costs at higher age (required by law)

For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance, the higher premiums must then be paid out of a lower income. During the last twenty years private health insurance became more and more expensive and less efficient compared with the public insurance.

In Germany, all privately financed products and services for health are assigned as part of the 'second health market'. Unlike the 'first health market' they are usually not paid by a public or private health insurance. Patients with public health insurance paid privately about 1.5 Billion Euro in this market segment in 2011, while already 82% of physicians offered their patients in their practices individual services being not covered by the patient's insurances; the benefits of these services are controversial discussed. Private investments in fitness, for wellness, assisted living, and health tourism are not included in this amount. The 'second health market' in Germany is compared to the United States still relatively small, but is growing continuously.

Self-payment (International patients without any national insurance coverage)

Besides the primary governmental health insurance and the secondary private health insurance mentioned above, all governmental and private clinics generally work in an inpatient setting with a prepayment-system, requiring a cost-estimate that needs to be covered before the perspective therapy can be planned. Several university hospitals in Germany have therefore country-specific quotes for pre-payments that can differ from 100% to the estimated costs and the likelihood of unexpected additional costs, i.e. due to risks for medical complications.

Health economics in Germany can be considered as a collective term for all activities that have anything to do with health in this country. This interpretation done by Andreas Goldschmidt in 2002 seems, however, very generous due to several overlaps with other economic sectors. A simple outline of the health sector in three areas provides an " onion model of health care economics" by Elke Dahlbeck and Josef Hilbert from "Institut Arbeit und Technik (IAT)" at the University of applied sciences Gelsenkirchen: Core area is the ambulatory and inpatient acute care and geriatric care, and health administration. Around it is located wholesale and supplier sector with pharmaceutical industry, medical technology, healthcare, and wholesale trade of medical products. Health-related margins are the fitness and spa facilities, assisted living, and health tourism.

According to this basic idea, an almost totally regulated health care market like in the UK were not very productive, but also a largely deregulated market in the United States would not be optimal. Both systems would suffer concerning sustainable and comprehensive patient care. Only a hybrid of social well-balanced and competitive market conditions created a relevant optimum. Nevertheless, forces of the healthcare market in Germany are often regulated by a variety of amendments and health care reforms at the legislative level, especially by the "Social Security Code" (Sozialgesetzbuch- SGB) in the past 30 years.

Health care in Germany, including its industry and all services, is one of the largest sectors of the German economy. Direct inpatient and outpatient care equivalent to just about a quarter of the entire 'market' - depending on the perspective. A total of 4.4 million people working in this, that means about one in ten employees in 2007 and 2008. The total expenditure in health economics was about 287.3 billion Euro in Germany in 2010, equivalent to 11.6 percent of gross domestic product (GDP) this year and about 3.510 Euro per capita.

The pharmaceutical industry plays a major role in Germany within and beyond direct health care. Expenditure on pharmaceutical drugs is almost half of those for the entire hospital sector. Pharmaceutical drug expenditure grew by an annual average of 4.1% between 2004 and 2010. Such developments caused numerous health care reforms since the 1980s. An actual example of 2010 and 2011: First time since 2004 the drug expenditure fell from 30.2 billion Euro in 2010 to 29.1 billion Euro in 2011, i. e. minus 1.1 billion Euro or minus 3.6%. That was caused by restructuring the Social Security Code: manufacturer discount 16% instead of 6%, price moratorium, increasing discount contracts, increasing discount by wholesale trade and pharmacies.

As of 2010, Germany has used reference pricing and incorporates cost sharing to charge patients more when a drug is newer and more effective than generic drugs. However, as of 2013 total out-of-costs for medications are capped at 2% of income, and 1% of income for people with chronic diseases.

In a sample of 13 developed countries Germany was seventh in its population weighted usage of medication in 14 classes in 2009 and tenth in 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use. It has the highest number of dentists in Europe - 64,287 in 2015.

In 2002 the top diagnosis for male patients released from the hospital was heart disease, followed by alcohol-related disorders and hernias. For women, the top diagnoses related to pregnancies, breast cancer, and heart disease.

The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days). Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).

In 2017 the BBC reported that compared with the United Kingdom the Caesarean rate, the use of MRI for diagnosis and the length of hospital stay are all higher in Germany.

According to several sources from the past decade, waiting times in Germany remain low for appointments and surgery, although a minority of elective surgery patients face longer waits. In 1992, a study by Fleming et al. (cited in Siciliani & Hurst, 2003, p. 8), 19.4% of German respondents said they'd waited more than 12 weeks for their surgery.

In the Commonwealth Fund 2010 Health Policy Survey in 11 Countries, Germany reported some of the lowest waiting times. Germans had the highest percentage of patients reporting their last specialist appointment took less than 4 weeks (83%, v. 80% for the U. S.), and the second-lowest reporting it took 2 months or more (7%, vs. 5% for Switzerland and 9% for the U. S.). 70% of Germans reported that they waited less than 1 month for elective surgery, the highest percentage, and the lowest percentage (0%) reporting it took 4 months or more.

Both Social Health Insurance (SHI) and privately insured patient experienced low waits, but privately insured patients' waits were even lower. According to the Kassenärztliche Bundesvereinigung (KBV), the body representing contract physicians and contract psychotherapists at federal level, 56% of Social Health Insurance patients waited 1 week or less, while only 13% waited longer than 3 weeks for a doctor's appointment. 67% of privately insured patients waited 1 week or less, while 7% waited longer than 3 weeks. Waits can also vary somewhat by region. Waits were longer in eastern Germany according to the KBV (KBV, 2010), as cited in "Health at a Glance 2011: OECD Indicators".

Germany has a large hospital sector capacity measured in beds. High capacity on top of significant day surgery outside of hospitals (especially for ophthalmology and othopaedic surgery) with doctors paid fee-for-service for activity performed are likely factors preventing long waits, despite hospital budget limitations. Activity-based payment for hospitals also is linked to low waiting times (Siciliani & Hurst, 2003, 33-34, 70). Germany introduced Diagnosis-Related Group activity-based payment for hospitals (with a soft cap budget limit).

1. ^ Bump, Jesse B. (October 19, 2010). "The long road to universal health coverage. A century of lessons for development strategy" (PDF). Seattle: PATH. Carrin and James have identified 1988-105 years after Bismarck's first sickness fund laws-as the date Germany achieved universal health coverage through this series of extensions to growing benefit packages and expansions of the enrolled population. Bärnighausen and Sauerborn have quantified this long-term progressive increase in the proportion of the German population covered mainly by public and to a smaller extent by private insurance. Their graph is reproduced below as Figure 1: German Population Enrolled in Health Insurance (%) 1885-1995.
Carrin, Guy; James, Chris (January 2005). "Social health insurance: Key factors affecting the transition towards universal coverage" (PDF). International Social Security Review. 58 (1): 45-64. doi:10.1111/j.1468-246X.2005.00209.x. Initially the health insurance law of 1883 covered blue-collar workers in selected industries, craftspeople and other selected professionals.⁶ It is estimated that this law brought health insurance coverage up from 5 to 10 per cent of the total population.
Bärnighausen, Till; Sauerborn, Rainer (May 2002). "One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low income countries?" (PDF). Social Science & Medicine. 54 (10): 1559-1587. doi:10.1016/S0277-9536(01)00137-X. PMID 12061488. As Germany has the world's oldest SHI [social health insurance] system, it naturally lends itself to historical analyses

2. ^ DiPiero, Albert (2004). "Universal Problems & Universal Healthcare: 6 COUNTRIES - 6 SYSTEMS" (PDF). Archived from the original (PDF) on 21 February 2006.

3. ^ A. J. W. Goldschmidt: Der 'Markt' Gesundheitswesen. In: M. Beck, A. J. W. Goldschmidt, A. Greulich, M. Kalbitzer, R. Schmidt, G. Thiele (Hrsg.): Management Handbuch DRGs, Hüthig / Economica, Heidelberg, 1. Auflage 2003 (ISBN 3-87081-300-8): S. C3720/1-24, with 3 revisions / additional deliveries until 2012

4. ^ Germany country profile. Library of Congress Federal Research Division (December 2005). This article incorporates text from this source, which is in the public domain.

5. ^ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Archived from the original (PDF) on 2017-06-06.

6. ^ E. REINHARDT, UWE. "A German Import That Could Help U.S. Health Reform". The New York Times. Germany's joint committee was established in 2004 and authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine coverage decisions. The ministry of health reserves the right to review the regulations for final approval or modification. The joint committee has a permanent staff and an independent chairman.

7. ^ "An education handbook about the federal joint committee and its tasks, published by the federal medical association in germany" (PDF). website of the German federal medical association. 2009.

8. ^ Busse, Reinhard; Blümel, Miriam; Knieps, Franz; Bärnighausen, Till (August 2017). "Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition". The Lancet. 390 (10097): 882-897. doi:10.1016/S0140-6736(17)31280-1. ISSN 0140-6736. PMID 28684025.

9. ^ David Squires; Robin Osborn; Sarah Thomson; Miraya Jun (November 14, 2013). International Profiles of Health Care Systems, 2013 (PDF) (Report).

10. ^ Schmitt, Thomas (21 May 2012). "Wie Privatpatienten in die Krankenkasse schlüpfen" (in German). Handelsblatt.

11. ^ "Vorsicht Pflege-Bahr: Stiftung Warentest rät von staatlich geförderten Pflege-Tarifen ab". 16 April 2013 - via FAZ.NET.

12. National Association of Statutory Health Insurance Funds: ^ List of German Public Health Insurance Companies Archived 7 June 2015 at the Wayback Machine

13. ^ J. Kartte, K. Neumann: Der zweite Gesundheitsmarkt. Die Kunden verstehen, Geschäftschancen nutzen, o.O.: Roland Berger Strategy Consultants, München, 2007

14. ^ Pfeiffer D, Spitzenverband der Gesetzlichen Krankenkassen GKV →Mitteilung im Nachrichtendienst dapd vom 4. February 2012

15. ^ A. J. W. Goldschmidt: Paragraph „Unternehmensbedeutung" in: Krankenhausmanagement mit Zukunft?. In: A. J. W. Goldschmidt, J. Hilbert (Hrsg.): Krankenhausmanagement mit Zukunft - Orientierungswissen und Anregungen von Experten. kma Medien in Georg Thieme Verlag KG, Stuttgart, 2011, (ISBN 978-3-13- 161231-1): p. 4.

16. A. J. W. Goldschmidt, J. Hilbert: Von der Last zur Chance - Der Paradigmenwechsel vom Gesundheitswesen zur Gesundheitswirtschaft. In: A. J. W. Goldschmidt, J. Hilbert (Hrsg.): Gesundheitswirtschaft in Deutschland. Die Zukunftsbranche. Band 1 der Schriftenreihe: Gesundheitswirtschaft und Management. kma-Reader - Die Bibliothek für Manager. Wikom-Verlag (Thieme), Wegscheid, 2009 (^ ISBN 978-3-9812646-0-9): p. 20-40

17. ^ Statistisches Bundesamt: Beschäftigung in der Gesundheitswirtschaft steigt weiter an. Pressemitteilung Nr. 490, Berlin, 17.12.2008

18. ^ B. Häusler, A. Höer, E. Hempel: Arzneimittel-Atlas 2012. Springer, Berlin u. a. 2012 (ISBN 978-3-642-32586-1) Archived 2013-01-01 at the Wayback Machine

19. ^ Hossein, Zare; Gerard, Anderson (2013-09-01). "Trends in cost sharing among selected high income countries-2000-2010". Health Policy. Health System Performance Comparison: New Directions in Research and Policy. 112 (1): 35-44. doi:10.1016/j.healthpol.2013.05.020. ISSN 0168-8510. PMID 23809913.

20. ^ Office of health Economics. "International Comparison of Medicines Usage: Quantitative Analysis" (PDF). Association of the British Pharmaceutical Industry. Archived from the original (PDF) on 2015-11-11.

21. ^ Ballas, Dimitris; Dorling, Danny; Hennig, Benjamin (2017). The Human Atlas of Europe. Bristol: Policy Press. p. 79. ISBN 9781447313540.

22. ^ Length of hospital stay, Germany Archived 2011-06-12 at the Wayback Machine group-economics.allianz.com, undated

23. ^ Siciliani, S., & Hurst, J. (2003). Explaining Waiting Times Variations for Elective Surgery across OECD Countries. OECD Health Working Papers, 7, 8, 33-34, 70. https://dx.doi.org/10.1787/40674618616

24. The Commonwealth Fund. (2010). ^ Commonwealth Fund 2010 Health Policy Survey in 11 Countries (pp. 19-20). New York, NY: Author. Accessed from http://www.commonwealthfund.org/~/media/files/publications/chartbook/2010/pdf_2010_ihp_survey_chartpack_full_12022010.pdf

25. Kassenärztliche Bundesvereinigung. (2016). ^ Health data: Die Wartezeit ist für die meisten kurz The wait is short for most. Retrieved from Google Translate

26. Busse R., & Blümel, M. (2014). Germany: health system review. ^ Health Systems in Transition, 16(2), 142-148. Available from http://www.euro.who.int/__data/assets/pdf_file/0008/255932/HiT-Germany.pdf?ua=

# data[].attributes.attachment_link.description
Germany has a universal multi-payer health care system paid for by a combination of statutory health insurance (Gesetzliche Krankenversicherung ) and "Private Krankenversicherung " (private health insurance). The turnover of the health sector was about US$368.78 billion (€287.3 billion) in 2010, equivalent to 11.6 percent of gross domestic product (GDP) and about US$4,505 (€3,510) per capita.

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Germany invests a substantial amount of its resources on health care: 11.4% of gross domestic product in 2012, which is one of the highest levels in the European Union. In international terms, the German health care system has a generous benefit basket, one of the highest levels of capacity as well as relatively low cost-sharing. However, the German health care system still needs improvement in some areas, such as the quality of care. In addition, the division into statutory and private health insurance remains one of the largest challenges for the German health care system, as it leads to inequalities. 

# data[].attributes.subject
Germany invests a substantial amount of its resources on health care: 11.4% of gross domestic product in 2012, which is one of the highest levels in the European Union. In international terms, the German health care system has a generous benefit basket, one of the highest levels of capacity as well as relatively low cost-sharing. However, the German health care system still needs improvement in some areas, such as the quality of care. In addition, the division into statutory and private health insurance remains one of the largest challenges for the German health care system, as it leads to inequalities. 

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https://apps.who.int/iris/handle/10665/130246
-Evans

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https://www.nbcnews.com/now/video/is-germany-s-healthcare-a-model-for-the-u-s-62591045742

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ZH

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How Germany's Universal Health-Care System Works

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Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance (Private Krankenversicherung or PKV) to replace or top up state cover (gesetzliche Krankenkasse or GKV). -kari

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https://www.youtube.com/watch?v=CY2jFh55Ztw

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The German healthcare system is rated as one of the best in the world. It offers a flexible range of choices and extensive coverage. Residents who want to get insurance have many options to choose from and a wide variety of health insurance packages to meet their financial capacities and medical needs. Different health insurance plans vary in terms of coverage, costs and specific conditions.
https://www.germanyhis.com/

sano

# data[].attributes.headline
The vast majority of residents in Germany are part of the statuary public healthcare insurance system (Gesetzliche Krankenversicherung, GKV) whereby contributions from employers and employees are paid via social security payments. This is paid to one of the main public healthcare insurers, such as Techniker Krankenkasse (TK), which hospitals and doctors make claims to whenever their services are used. The public healthcare system is heavily subsidized by the German government.

# data[].attributes.subject
The vast majority of residents in Germany are part of the statuary public healthcare insurance system (Gesetzliche Krankenversicherung, GKV) whereby contributions from employers and employees are paid via social security payments. This is paid to one of the main public healthcare insurers, such as Techniker Krankenkasse (TK), which hospitals and doctors make claims to whenever their services are used. The public healthcare system is heavily subsidized by the German government.

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https://www.expatrio.com/living-germany/health-insurance-germany
Xavier

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German health benefits are very generous. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the world's best health care systems, visible in little ways that most Germans take for granted - pc

# data[].attributes.headline
Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance (Private Krankenversicherung or PKV) to replace or top up state cover (gesetzliche Krankenkasse or GKV).

# data[].attributes.subject
Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance (Private Krankenversicherung or PKV) to replace or top up state cover (gesetzliche Krankenkasse or GKV).

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https://www.klinikkompass.com/en/the-german-healthcare-system/

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-lucas

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Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by two systems, namely: 1) competing, not-for-profit, nongovernmental health insurance funds ("sickness funds"-there were 118 as of January 2016 ¹) in the statutory health insurance (SHI) system; and 2) substitutive private health insurance (PHI). States own most university hospitals, while municipalities play a role in public health activities and own about half of all hospital beds. However, the various levels of government have virtually no role in the direct financing or delivery of health care. To a large degree, regulation is delegated to self-governing associations within sickness funds and provider associations, which are together represented by the most important body, the Federal Joint Committee.

Publicly financed health insurance: In 2014, total health expenditure was 11.2 percent of GDP, of which 74 percent was public, mainly SHI spending (58% of total). General tax-financed federal spending on "extraneous benefits" provided by SHI, such as coverage for children, amounted to about 4.5 percent of total expenditure in 2014. ² Sickness funds are financed by compulsory contributions levied as a percentage of gross wages up to a ceiling. Coverage is universal for all legal residents. All employed citizens (and other groups such as pensioners) earning less than EUR56,250 (USD71,564) per year as of 2016 are mandatorily covered by SHI, and their nonearning dependents are covered free of charge. ³ Individuals whose gross wages exceed the threshold and the previously SHI-insured self-employed can remain in the publicly financed scheme on a voluntary basis (as 75% do) or purchase substitutive PHI, which also covers civil servants. About 86 percent of the population receive their primary coverage through SHI and 11 percent through substitutive PHI. Military members, police, and other public-sector employees are covered under special programs. Visitors are not covered through German SHI. Refugees and undocumented immigrants are covered by social security in case of acute illness and pain, as well as pregnancy and childbirth.

As of 2016, the legally set uniform contribution rate is 14.6 percent of gross wages, shared equally by the employer and employees. A previous legally fixed additional contribution rate for employees (0.9%) and supplementary per capita premiums set by sickness funds have been abolished and replaced by a supplementary income-dependent contribution rate determined individually by each sickness fund. ⁴ In 2015, the supplementary contribution rate was, on average, 0.83 percent-that is, most of the SHI-insured paid less than previously, with rates ranging between 0 and 1.3 percent. For 2016, the average supplementary contribution rate is estimated at 1.1 percent. ⁵

This contribution also covers dependents (nonearning spouses and children). Earnings above EUR50,850 (USD64,994) per year (as of 2016) are exempt from contribution. The sickness funds' contributions are centrally pooled and then reallocated to individual sickness funds using a risk-adjusted capitation formula, taking into account age, sex, and morbidity from 80 chronic and/or serious illnesses.

Private health insurance: In 2015, 8.8 million people were covered through substitutive private health insurance. ⁶ PHI is especially attractive for young people with a good income, as insurers may offer them contracts with more extensive ranges of services and lower premiums.

There were 42 substitutive PHI companies in April 2016 (of which 24 were for-profit) covering the two groups exempt from SHI (civil servants, whose health care costs are partly refunded by their employer, and the self-employed) ⁷ and those who have chosen to opt out of SHI. All of the PHI-insured pay a risk-related premium, with separate premiums for dependents; risk is assessed only upon entry, and contracts are based on lifetime underwriting. Government regulates PHI to ensure that the insured do not face large premium increases as they age and are not overburdened by premiums if their income decreases.

PHI also plays a mixed complementary and supplementary role, covering minor benefits not covered by SHI, access to better amenities, and some copayments (e.g., for dental care). The federal government determines provider fees under substitutive, complementary, and supplementary PHI through a specific fee schedule. There are no government subsidies for complementary and supplementary PHI. In 2014, all forms of PHI accounted for 8.9 percent of total health expenditure. ⁸

Services: SHI covers preventive services, inpatient and outpatient hospital care, physician services, mental health care, dental care, optometry, physical therapy, prescription drugs, medical aids, rehabilitation, hospice and palliative care, and sick leave compensation. Home care is covered by long-term care insurance (LTCI). Preventive services under SHI include regular dental checkups, child checkups, basic immunizations, checkups for chronic diseases, and cancer screening at certain ages. All prescription drugs are covered except for those explicitly excluded by law (mainly so-called lifestyle drugs) and those excluded following benefits assessment. While the broader framework of the benefit package is legally defined, specifics are determined by the Federal Joint Committee (see below). Long-term care services are covered separately by the LTCI scheme (see below).

Cost-sharing and out-of-pocket spending: Out-of-pocket spending accounted for 13.2 percent of total health spending in 2014, mostly on nursing homes, pharmaceuticals, and medical aids. ⁹

Copayments include EUR5.00 to EUR10.00 (USD6.36 to USD12.72) per outpatient prescription, EUR10.00 per inpatient day for hospital and rehabilitation stays (for the first 28 days per year), and EUR5.00 to EUR10.00 for prescribed medical devices. Sickness funds offer selectable tariffs with a range of deductibles and no-claims bonuses. Preventive services do not count toward the deductible. SHI-contracted physicians are not allowed to charge above the fee schedule for services in the SHI benefit catalogue. However, a list of "individual health services" outside the comprehensive range of SHI coverage may be offered to patients paying out of pocket.

Safety nets: Children under 18 years of age are exempt from cost-sharing. For adults, there is an annual cap on cost-sharing equal to 2 percent of household income; part of a household's income is excluded from this calculation for additional family members. About 0.3 million of those insured under SHI exceeded the 2 percent cap in 2014 and were exempted from further cost-sharing. The cap is lowered to 1 percent of annual gross income for qualifying chronically ill people; to qualify, those people have to demonstrate that they attended recommended counseling or screening procedures prior to becoming ill. Nearly 6.3 million people, or around 9 percent of all the SHI-insured, benefited from this regulation in 2014. ¹⁰ Unemployed people contribute to SHI in proportion to their unemployment entitlements. For the long-term unemployed, government contributes on their behalf.

Physicians: General practitioners (GPs) and specialists in ambulatory care who get reimbursed by SHI are by law mandatory members of regional associations that negotiate contracts with sickness funds. Regional associations of SHI-accredited physicians are responsible for coordinating care requirements within their region and act as financial intermediaries between the sickness funds and the physicians in ambulatory care. However, ambulatory physicians typically work in their own private practices-around 60 percent in solo practice and 25 percent in dual practices. Most physicians employ doctors' assistants, while other nonphysicians (e.g., physiotherapists) have their own premises. In 2015, of the roughly 108,500 self-employed SHI-accredited physicians in ambulatory care, 51,900 (48%) were practicing as family physicians (including GPs, internists, and pediatricians) and 56,600 (52%) as specialists. There were about 2,000 multispecialty clinics, with more than 13,000 physicians (10% of ambulatory care physicians), in 2015. Around 11,000 physicians working in multispecialty clinics are salaried employees, while 12,000 are employed in practices of self-employed physicians. The total number of ambulatory-care physicians and psychotherapists is more than 140,000. ¹¹ Some specialized outpatient care is provided by hospital specialists, including treatment of rare diseases and of severe progressive forms of disease, as well as highly specialized procedures.

Individuals have free choice among GPs, specialists, and, if referred to inpatient care, hospitals. Registration with a family physician is not required, and GPs have no formal gatekeeping function. However, sickness funds are required to offer their members the option to enroll in a "family physician care model," which has been shown to provide better services and also often provides incentives for complying with gatekeeping rules.

SHI-accredited physicians in ambulatory care (GPs and specialists) are generally reimbursed on a fee-for-service (FFS) basis according to a uniform fee schedule negotiated between sickness funds and physicians (see below). Payments are limited to covering a predefined maximum number of patients per practice and reimbursement points per patient, setting thresholds on the number of patients and of treatments per patient for which a physician can be reimbursed. For the treatment of private patients, GPs and specialists also get an FFS, but the private tariffs are usually higher than the tariffs in the SHI uniform fee schedule. Pay-for-performance has not been established yet. The average reimbursement of a family physician is above EUR200,000 (USD254,452) per year, covering costs for personnel, etc., but excluding income from private patients, which varies substantially. ¹²

Financial incentives for care coordination can be part of integrated care contracts, but are not routinely implemented. The only regular financial incentive that GPs receive is a fixed annual bonus (EUR120, or USD153, in 2016) for patients enrolled in a Disease Management Program (DMP), in which physicians provide patient training and document patient data. Bundled payments are not common in primary care, but a regional initiative, "Healthy Kinzigtal" (Kinzigtal is a valley in southeast Germany), provides an example of a shared savings model offering primary care doctors and other providers financial incentives for integrating care across providers and services.

Administrative mechanisms for direct patient payments to providers: SHI physicians in ambulatory care bill their regional associations according to a uniform fee schedule; the associations receive the money from the sickness funds in the form of annual capitations. Copayments or payments for services not included in the benefit catalogue are paid directly to the provider. In cases of private health insurance, patients pay up front and submit claims to the insurance company for reimbursement.

After-hours care: After-hours care is organized by the regional associations of SHI-accredited physicians to ensure access to ambulatory care around the clock. Physicians are obliged to provide after-hours care in their practices, with differing regional regulations. In some areas (e.g., Berlin), after-hours care has been delegated to hospitals. The patient is given a report of the visit afterward to hand to his or her GP. There is also a tight network of emergency care providers (the responsibility of the municipalities). After-hours care assistance is also available via a nationwide telephone hotline (116 117-Ärztlicher Bereitschaftsdienst). Payment for ambulatory after-hours care is based on the above-mentioned fee schedules, again with differences in the amount of reimbursement by SHI and PHI.

Hospitals: Public hospitals make up about half of all beds, while private not-for-profits account for about a third. The number of private, for-profit hospitals has been growing in recent years (now around one-sixth of all beds). All hospitals are staffed principally by salaried doctors. Doctors in hospitals are typically not allowed to treat outpatients (similar to hospitalists in the U.S.), but exceptions are made if necessary care cannot be provided by office-based specialists. Senior doctors can treat privately insured patients on an FFS basis. Hospitals can also provide certain highly specialized services on an outpatient basis.

The 16 state governments determine hospital capacity, while ambulatory care capacity is subject to rules set by the Federal Joint Committee. Inpatient care is paid per admission through a system of diagnosis-related groups (DRGs) revised annually, currently based on around 1,200 DRG categories. DRGs also cover all physician costs. Other payment systems like pay-for-performance or bundled payments have yet to be implemented in hospitals.

Mental health care: Acute psychiatric inpatient care is largely provided by psychiatric wards in general (acute) hospitals, while the number of hospitals providing care only for patients with psychiatric and/or neurological illness is low. In 2015, there were a total of 35,368 office-based psychiatrists, neurologists, and psychotherapists working in the ambulatory care sector (paid FFS). ¹³ Qualified GPs can provide basic psychosomatic services. Ambulatory psychiatrists are also coordinators of a set of SHI-financed benefits called "sociotherapeutic care" (which requires referral by a GP), intended to encourage the chronically mentally ill to use necessary care and to avoid unnecessary hospitalizations. To further promote outpatient care for psychiatric patients (particularly in rural areas with a low density of psychiatrists in ambulatory care), hospitals can be authorized to offer treatment in outpatient psychiatric departments.

Long-term care and social supports: LTCI is mandatory and is usually provided by the same insurer as health insurance and therefore comprises a similar public-private insurance mix. The contribution rate of 2.35 percent of gross salary is shared between employers and employees; people without children pay an additional 0.25 percent. The contribution rate will increase by 0.2 percent in early 2017. Everybody with a physical or mental illness or disability (who has contributed for at least two years) can apply for benefits, which are: 1) dependent on an evaluation of individual care needs by the SHI Medical Review Board (leading either to a denial or to a grouping into currently one of three levels of care); and 2) limited to certain maximum amounts, depending on the level of care. Beneficiaries can choose between in-kind benefits and cash payments (around a quarter of LTCI expenditure goes to these cash payments). Both home care and institutional care are provided almost exclusively by private not-for-profit and for-profit providers. As benefits usually cover approximately only 50 percent of institutional care costs, people are advised to buy supplementary private LTCI. Family caregivers get financial support through continuing payment of up to 50 percent of care costs.

Hospice care is partly covered by LTCI if the SHI Medical Review Board has determined a care level. Medical services or palliative care in a hospice are covered by SHI. The number of inpatient facilities in hospice care has grown significantly over the past 15 years, to 235 hospices and 304 palliative care wards nationwide in spring 2016. ¹⁴ The Act to Improve Hospice and Palliative Care passed in 2015, with the aim of guaranteeing care in underserved rural areas and linking long-term care facilities more strongly to ambulatory palliative and hospice care.

The German health care system is notable for two essential characteristics: 1) the sharing of decision-making powers between states, federal government, and self-regulated organizations of payers and providers; and 2) the separation of SHI (including the social LTCI) and PHI (including the private LTCI). SHI and PHI (as well as the two long-term care insurance systems) use the same providers-that is, hospitals and physicians treat both statutorily and privately insured patients, unlike those in many other countries.

Within the legal framework set by the Federal Ministry of Health, the Federal Joint Committee has wide-ranging regulatory power to determine the services to be covered by sickness funds and to set quality measures for providers (see below). To the extent possible, coverage decisions are based on evidence from health technology assessments and comparative-effectiveness reviews. The Federal Joint Committee is supported by the Institute for Quality and Efficiency (IQWiG), a foundation legally charged with evaluating the cost-effectiveness of drugs with added therapeutic benefits, and the Institute for Quality and Transparency (IQTiG), which is responsible for intersectoral quality assurance. It has 13 voting members: five from the Federal Association of Sickness Funds, two each from the Federal Association of SHI Physicians and the German Hospital Federation, one from the Federal Association of SHI Dentists, and three who are unaffiliated. Five patient representatives have an advisory role but no vote. Representatives of patient organizations have the right to participate in different decision-making bodies-for example, the subcommittees of the Federal Joint Committee.

The Federal Association of Sickness Funds works with the Federal Association of SHI Physicians and the German Hospital Federation to develop the SHI ambulatory care fee schedule and the DRG catalogue, which are then adopted by bilateral joint committees.

Quality of care is addressed through a range of measures broadly defined by law and in more detail by the Federal Joint Committee. As of 2016, the IQTiG is responsible for developing instruments for interfacility and intersectoral quality assurance on behalf of the Federal Joint Committee. In addition, the institute develops criteria for evaluating certificates and quality targets and ensures that the published results are comprehensible to the public.

All hospitals are required to publish findings on selected indicators, as defined by the IQTiG, to enable hospital comparisons. Volume thresholds have been introduced for a number of complex procedures (e.g., transplants), requiring that hospitals perform a minimum number of such procedures to be reimbursed for them. Process and, in part, outcome quality are addressed through the mandatory quality reporting system for the roughly 2,000 acute-care hospitals. The recently passed Hospital Care Structure Reform Act introduces a focus on quality-related hospital accreditation and payment, beginning in 2016.

Structural quality is further assured by the requirement that providers have a quality management system, by the stipulation that all physicians continue their medical education, and by health technology assessments for drugs and procedures. For instance, all new diagnostic and therapeutic procedures applied in ambulatory care must receive a positive evaluation for benefit and efficiency before they can be reimbursed by sickness funds.

Although there is no revalidation requirement for physicians, many institutions and health service providers include complaint management systems as part of their quality management programs; in 2013, such systems were made obligatory for hospitals. At the state level, professional providers' organizations are urged to establish complaint systems and arbitration boards for the extrajudicial resolution of medical malpractice claims.

The Robert Koch Institute, an agency subordinate to the Federal Ministry of Health and responsible for the control of infectious diseases and for health reporting, has conducted national patient surveys and published epidemiological, public health, and health care data. Disease registries for specific diseases, such as certain cancers, are usually organized regionally. In August 2013, as part of the National Cancer Plan, the federal government passed a bill that proposes the implementation of a nationwide standardized cancer registry in 2018 to improve the quality of cancer care.

DMPs, implemented in 2002, ensure quality of care for people with chronic illness. DMPs are modeled on evidence-based treatment recommendations, with mandatory documentation and quality assurance. Nonbinding clinical guidelines are produced by the Physicians' Agency for Quality in Medicine and other professional societies.

Strategies to reduce health disparities are delegated mainly to public health services, and the levels at which they are carried out differ among states. Health disparities are implicitly mentioned in the national health targets. A network of more than 120 health-related institutions (e.g., sickness funds and their associations) promotes the health of the socially deprived. ¹⁵ Primary preventive care is mandatory by law for sickness funds; detailed regulations are delegated to the Federal Association of Sickness Funds, which has developed guidelines regarding need, target groups, and access, as well as procedure and methods. Sickness funds support 22,000 health-related programs, e.g., in nurseries and schools. ¹⁶ With the Act to Strengthen Health Promotion and Prevention, these programs have recently been further developed and financially supported.

The Health Monitor ( Gesundheitsmonitor) was a national association of nonprofit organizations and sickness funds. To assess the accessibility of health care, it regularly conducted studies from the patient perspective-for example, on the availability of information, experiences with health care, and progress of health system reforms. The Health Monitor, which last conducted a study in 2016, ceased to exist after 15 years. A comparable survey on health access has not been provided.

Many efforts to improve care coordination have been implemented; for example, sickness funds offer integrated-care contracts and DMPs for chronic illnesses to improve care for chronically ill patients and to improve coordination among providers in the ambulatory sector. In December 2015, 9,966 registered DMPs for six indications had enrolled about 6.6 million patients (more than 8% of all the SHI-insured). ¹⁷ There is no pooling of funding streams by the health and social care sectors.

As of 2016, the Innovation Fund promotes new forms of cross-sectoral and integrated care (also for vulnerable groups) supported by annual funding of EUR300 million, or USD382 million (including EUR75 million, or USD95 million, for evaluation and health services research). Funds are awarded through an application process overseen by the Innovation Committee, based at the Federal Joint Committee. ¹⁸

As of 2015, electronic medical chip cards are used nationwide by all the SHI-insured; they encode information as to the person's name, address, date of birth, and sickness fund, along with details of insurance coverage and the person's status regarding supplementary charges. ¹⁹ In 2015, the Federal Cabinet passed a bill for secure digital communication and health care applications (E-Health Act), which provides concrete deadlines for implementing infrastructure and electronic applications and introduces incentives and sanctions if schedules are not adhered to. SHI physicians will receive additional fees for transmitting electronic medical reports (2016-2017), collecting and documenting emergency records (from 2018), and managing and reviewing basic insurance claims data online. From July 2018, SHI physicians who do not participate in online review of the basic insurance claims data will receive reduced remuneration. Furthermore, to ensure greater safety in drug therapy, patients who use at least three prescribed drugs simultaneously will receive an individualized medication plan, starting in October 2016. In the medium term, this medication plan will be included in the electronic medical record. ²⁰

Recently, there has been a shift away from reliance on overall budgets for ambulatory physicians and hospitals and on collective regional prescription caps for physicians toward an emphasis on quality and efficiency. The Hospital Care Structure Reform Act aims not only to link hospital payments to good service quality but also to reduce payments for "low-value" services.

To enhance competition, some purchasing power has been handed over to the sickness funds. For example, the funds can now selectively negotiate integrated care contracts with providers and negotiate rebates with pharmaceutical companies.

All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added medical benefit. For drugs with added benefit (evaluated by IQWiG but decided on by the Federal Joint Committee), the Federal Association of Sickness Funds negotiates a rebate on the manufacturer's price that is applied to all patients. In addition, rebates are negotiated between individual sickness funds and pharmaceutical manufacturers to lower prices below the reference price.

Since 2012, the German health care system has been undergoing a period of active reform in several areas. The most influential reform in the past year was the Second Act to Strengthen Long-Term Care, which went into effect in January 2016; this followed the First Act, which significantly expanded support for individuals in need of long-term care and for their families. The Second Act, set to start in 2017, will broaden eligibility for long-term care services, which previously have been granted only to people with considerably restricted daily functions. The new act aims to provide services more equitably, by expanding eligibility to people with physical, mental, and psychological impairments. The new benefits are being integrated into the standard legislation on benefits. ²¹

To finance these reforms, the contribution rate for LTCI will increase by 0.2 percentage points, up to 2.55 percent of income for people with children and 2.80 percent for people without children. According to the government, the increase in contribution rates will generate about EUR6.0 billion (USD7.6 billion) in additional revenue, which should cover the additional spending on long-term care by 2022. ²²

Acknowledgements

The authors would like to acknowledge Stephanie Stock as a contributing author to earlier versions of this profile.

References

¹The Federal Association of Sickness Funds, Kennzahlen der gesetzlichen Krankenversicherung; accessed Sept. 5, 2016.

²The Federal Statistical Office, Gesundheitsberichterstattung des Bundes; accessed Sept. 5, 2016.

³ Please note that, throughout this profile, all figures in USD were converted from EUR at a rate of about EUR0.786 per USD, the purchasing power parity conversion rate for GDP in 2015 reported by OECD (2016) for Germany. Organisation for Economic Co-operation and Development (OECD) (2016), "Purchasing power parities (PPP)" (indicator). doi: 10.1787/1290ee5a-en; accessed Sept. 23, 2016.

⁴R. Busse and M. Blümel, "Germany: Health System Review," Health Systems in Transition, 2014 16(2):1-296. Accessed Sept. 5, 2016.

⁵ Federal Association of Sickness Funds, Kennzahlen GKV, 2016.

⁶The Association of Private Health Insurance Companies, Zahlen und Fakten; accessed Sept. 5, 2016.

⁸ Federal Statistical Office, Gesundheitsberichterstattung, 2016.

¹¹The Federal Association of SHI Physicians, Statistische Informationen aus dem Bundesarztregister 2015; accessed Sept. 5, 2016.

¹⁴The German Hospice and Palliative Association, Stationäre Hospize für Erwachsene, stationäre Hospize für Kinder, Jugendliche und junge Erwachsene sowie Palliativstationen in Deutschland - Daten zur Entwicklung und zum aktuellen Stand; accessed Sept. 5, 2016.

¹⁵Cooperative Alliance National Health Targets (2016), Gesundheitsziele.de; accessed Sept. 5, 2016.

¹⁶ Federal Association of Sickness Funds, Kennzahlen der GKV, 2016.

¹⁷The Federal Social Insurance Office, Zulassung der strukturierten Behandlungsprogramme durch das Bundesversicherungsamt; accessed Sept. 23, 2016.

¹⁸The Federal Joint Committee, Der Innovationsfonds und der Innovationsausschuss beim Gemeinsamen Bundesausschuss; accessed Sept. 23, 2016.

¹⁹Company for Telematics Applications for the Electronic Health Card, Elektronische Gesundheitskarte; accessed Nov. 5, 2015.

²⁰Federal Ministry of Health, Gesetze und Verordnungen; accessed July 22, 2015.

²¹ Health Systems and Policy Monitor, Germany; accessed Sept. 23, 2016.

²² Federal Ministry of Health, Gesetze und Verordnungen, 2015.

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International Health Care System Profiles

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Health insurance is mandatory for all citizens and permanent residents of Germany. It is provided by two systems, namely: 1) competing, not-for-profit, nongovernmental health insurance funds ("sickness funds"-there were 118 as of January 2016 1) in the statutory health insurance (SHI) system; and 2) substitutive private health insurance (PHI).

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Esther

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This guide to healthcare in Germany includes information on German health insurance, hospitals, visiting doctors, emergency services, and more.

Under the German healthcare system, if you are a resident living and working in Germany, you may be eligible for state healthcare in Germany, provided you are registered with state health insurance in Germany. Otherwise you will typically need to take out private health insurance.

This helpful guide explains how to access the German healthcare system, and includes the following sections:

Overview of healthcare in Germany

The German healthcare system

The German healthcare system is a dual public-private system that dates back to the 1880s, making it the oldest in Europe. Today its doctors, specialists, and facilities make it one of the very best healthcare systems in the world.

Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance ( Private Krankenversicherung or PKV) to replace or top up state cover ( gesetzliche Krankenkasse or GKV).

The Federal Ministry of Health is responsible for developing health policy in Germany. The sector is regulated by the Joint Federal Committee.

Germany ranked 12th on the 2018 Euro Health Consumer Index. It has been praised for the level of choice given to customers in terms of treatment. However, it was criticized for having a low number of specialist hospitals, therefore this affected its score on quality.

Who can access healthcare in Germany?

All German residents can access the healthcare system in Germany through public health insurance. Non-residents need to have private insurance coverage to access healthcare. Temporary visitors will typically need to pay for treatment and claim a reimbursement later.

If you are from the European Union (EU), European Economic Area (EEA) or Switzerland and staying only temporarily, you may use your EHIC card. Once you become an official resident, you will have to take out compulsory German health insurance.

Healthcare system costs in Germany

Germany is one of the biggest spenders on healthcare in Europe. It spends 11.1% of annual GDP on healthcare expenditure. Only Switzerland and France spend more in terms of GDP percentage. German healthcare spending works out at just over €4,000 per inhabitant each year.

Public and private insurance contributions cover the majority of costs. On top of this, everyone has to pay a fee of around €10-15 for their first medical visit every quarter. You don't pay this if you don't seek any help during that quarter. Those with private health insurance can reclaim this.

Health insurance in Germany

If you are an employee and you earn less than €57,600 a year (€4,800 a month in 2017), you have to take part in the government health scheme - Gesetzliche Krankenversicherun or GKV - taking out health insurance as soon as you have signed your work contract.

The scheme is administered by around 110 Krankenkassen (non-profit making associations) which must all charge the same basic rate of 14.6% of your eligible gross salary; up to a maximum of €4,350 a month in 2017 (€52,200 annually). This amount is shared equally between you and your employer. You have to stay with a particular Krankenkasse for 18 months, after which time you can switch to another government scheme. Employed workers only pay contributions if they earn over €850 per month.

GKV covers you for primary care with registered doctors, hospital care (both in- and out- patient) and basic dental treatment. Non-working dependents living at the same address and registered with the Krankenkasse are covered at no extra cost.

GKV does not cover consultations with private doctors, private rooms in hospitals, alternative or complementary treatments, dental implants, or glasses/contact lenses for adults.

See our Guide to health insurance in Germany for more information.

How to register for healthcare in Germany as an expat

If you live long-term or work in Germany, you must register with the German authorities at your local town hall ( Einwohnermeldeamt). Once you are registered, have a social insurance number ( Sozialversicherungsnummer), and are making national insurance contributions, you are entitled to state-run healthcare the same as German nationals.

In order to access this, you also have to register with a health insurance fund. See rates offered by different state insurers here. A non-working spouse and children are covered by the same insurance.

Your insurer will give you a health insurance card ( Krankenversichertenkarte), which you have to take with you each time you visit any doctor, dentist, or specialist in Germany. Since 2014 an electronic eHealth card with a photo of the holder (unless under 15) is proof of entitlement to medical services and benefits. The card, which contains your name, date of birth, address, and health insurance data, is scanned when you visit a medical service.

Private healthcare in Germany

You can choose to opt out of the state insurance plan and take out private health insurance cover ( Private Krankenversicherung or PKV) if you are:

an employee earning more than €57,600 (2017);

self-employed;

working part-time and earning less than €450 a month;

a freelance professional;

an artist;

a civil servant or certain other public employee

PKV usually covers a much wider range of medical and dental treatments than GKV. Companies offer different levels of cover. Premiums depend on age at entry into the scheme and any pre-existing conditions and cover is usually per person; rather than per family as with the government insurance schemes. Part of medical insurance premiums is tax-deductible.

Employers in Germany also contribute to private health insurance fees; up to a maximum of €317.55 per month.

If you are not eligible for state health insurance, you can opt to take out private health insurance from a local or expat health insurance company. Some of the largest international health insurers include:

The PVK maintains a full list of private German health insurance companies.

Doctors and specialists in Germany

Doctors are called Ärzte; a Hausarzt is the equivalent of a GP or primary care doctor. Under the German healthcare system, you are free to choose your own doctor. Many speak at least basic English. Some doctors only treat private patients, therefore if you have state insurance, make sure to check beforehand otherwise you will have to pay for treatment.

Practice hours are usually from 8am-1pm and from 3pm-6pm from Monday to Friday; many close on a Wednesday afternoon. Few practices are open on Saturdays and only emergency services operate on Sundays.

Some doctors have an 'open door' policy where you can just turn up at the surgery; however you may have a long wait. You will need a referral from your GP to see many specialist doctors, although some specialists take direct bookings.

See our Guide to doctors and specialists for more information.

Women's healthcare in Germany

Gynecologists are accessible in Germany through public health insurance. They will provide care and support during pregnancy. Your gynecologist is also the person to see for sexual health matters, cancer screenings, and urinary tract infections.

All maternity costs are covered by statutory insurance. However, some private insurers do not unless you have chosen to be covered for this, so it's wise to check.

Pregnancy tests and basic forms of contraception are available in pharmacies. However, a gynecologist will need to prescribe birth control pills, intra-uterine devices (IUDs), and diaphragms. Emergency contraception is widely available and doesn't need a prescription. Public health insurance doesn't cover most contraception costs.

Statutory insurance covers annual screenings for every woman aged over 20 for cervical cancer, breast cancer, and ovarian cancer.

Abortions are legal in Germany during the first 12 weeks of pregnancy, however you will need to undergo counselling sessions first. An abortion can be carried out up to 22 weeks into the pregnancy if the mother's life is in danger or if the pregnancy poses serious risks to the mother's health and well-being.

For more information, see our guides to women's health in Germany and to having a baby in Germany.

Children's healthcare in Germany

Public health insurance will cover your children until the age of 18. Pediatricians will typically provide healthcare for children up until the age of 12 when they transfer to a GP. Around 90% of German children aged under 6 are seen primarily by a pediatrician. In addition, you are free to choose a pediatrician for your child.

Many specialist children's hospitals offer emergency and outpatient care. These provide treatment for a range of illnesses and diseases as well as services such as speech therapy.

Vaccinations for children in Germany are free. There is a national vaccination schedule which includes immunization against conditions including:

Chickenpox;

Hepatitis B;

Polio;

Measles, mumps and rubella (MMR)

More information can be found in our guides to children's healthcare in Germany and vaccinations in Germany.

Dentists in Germany

You can find a dentist ( zahnärzte) who operates within the statutory health insurance scheme on the KZBV website (in German). Otherwise, when you visit a dentist look for a sign saying Kassenarzt or Alle Kassen, which means that the dentist operates under the state German healthcare system.

Children and young people up to the age of 18 do not pay for dental treatment. However, check with your insurer about what the state insurance covers as there is limited cover. Furthermore, even private insurers won't fully reimburse for all treatments. In addition, dental costs in Germany are extremely high. Routine procedures are covered, however more extensive work (such as dentures and crowns) are only partially covered.

See more detailed information in our Guide to dentistry in Germany.

Hospitals in Germany

Hospitals are called Krankenhäuser. There are three main types:

public hospitals (Öffentliche Krankenhäuser) which are run by the local and regional authorities;

voluntary, non-profit making hospitals (Frei gemeinnützige Krankenhäuser) run by churches or organisations run by the German Red Cross;

private hospitals (Privatkrankenhäuser)

Your GP will need to refer you to a specialist in a hospital. You should take your EHIC or German health insurance card when you visit. Adults have to pay a fixed charge of around €10-15 per day, up to a maximum of 28 days in a year.

If you are going to be an in-patient, note that hospitals have a certain amount of space allotted to patients with public insurance and for those with private insurance.

If you have a 'private' room it means that private insurance covers it; it doesn't mean that only you can use the room. These private rooms usually accommodate two patients with a curtain separating them. Take your own soap and personal items.

For more information, see our Guide to hospitals in Germany.

Health centers and clinics in Germany

Outpatient care in Germany is generally provided by doctors and specialists from individual or joint practices. You will also find many medical centers, both public and private, where various different health professionals operate. These can include GPs, medical specialists, physiotherapists, psychotherapists, and nurses.

Pharmacies in Germany

Pharmacies ( Apotheke) are open 9am-6pm from Monday to Friday and 9am-12pm on Saturdays. They all provide addresses for services outside of opening hours.

Medication does not always come with dosage instructions on the package. Make sure you ask your doctor when and how much you should take and write down the information so you have it later. Sometimes your pharmacist will also be able to tell you about dosages, however they are less likely to speak English. If your German is not good, it is easier to get information you need from your doctor.

Check here for information about local on-call pharmacies.

You can take a prescription from your GP to any pharmacy. If the prescription is on a pink slip of paper, you will have to pay a non-refundable fixed charge (around €5-10). You have to pay the full cost for certain medications for minor ailments such as cough mixture.

If you have private insurance, you will most often get prescriptions on a blue sheet of paper; this means you have to pay the full price of the drug up front and then send the receipt to your insurance for reimbursement.

Mental healthcare in Germany

Like many European countries, Germany has seen more of a focus on mental health and mental healthcare services in recent years. There is not as much stigma around mental illness as there once was and there is more recognition of the need to look after mental well-being.

Research reveals that 5.3 million Germans suffer from depression each year. GPs can initially deal with general mental health issues, and they will prescribe necessary medication or refer patients on to specialist treatment. It is also possible to access some services such as psychiatrists, psychologists, and mental health specialists directly without referral. However, you will need to check what treatments your insurance policy covers.

You can seek treatment for more serious and enduring mental health problems in either:

psychosomatic clinics, which can deal with conditions such as severe depression, anxiety and eating disorders;

psychiatric hospitals, which have facilities for in-patient stays ranging from a few days to several months.

Other forms of healthcare in Germany

Germany recognises and practices alternative and complementary medicine. Generally speaking, around 20-30% of the population has used some form of alternative treatment. Furthermore, practitioners often use it when standard treatments are not available.

All licensed health practitioners have permission to use complementary techniques and many pharmacists train in herbal medicine. In fact, around three-quarters of qualified physicians use some type of alternative medicine and 77% of pain clinics provide acupuncture treatment.

Licensed Heilpraktikers can also deliver alternative and complementary treatments. These are practitioners of natural therapies who don't require formal medical degrees, but have to pass an exam set by the health authorities. Chiropractors in Germany need the Heilpraktiker license even if they have a medical degree.

German health insurance covers some alternative medicine, however, there have been discussions to stop reimbursing homeopathic treatment.

Public health insurance will likely cover alternative treatments if:

there are no other treatments available;

if standard treatments are likely to have detrimental side effects;

if they are cheaper and doctors consider them safe and cost-effective

In an emergency

For urgent medical treatment, go to the A&E or ER which are called Notaufnahme. Both state and private health insurance cover emergency services. If you need an ambulance, you can call the pan-European number 112 free of charge. In addition, the fire brigade ambulance service ( Rettungswagen) will take you to the nearest hospital.

Other numbers to call in a medical emergency are:

For an emergency doctor: 19 242

For a non-emergency doctor on call: 116 117

You can also phone your local surgery for details of their out of hours service. See this full list of emergency numbers in Germany.

German healthcare system: useful phrases

I need an ambulance - Ich brauche einen Krankenwagen

Heart attack - Herzinfarkt

I need a doctor - Ich brauche einen Arzt

I need a hospital - Ich brauche ein Krankenhaus

There's been an accident - Es gab einen Unfall

I am allergic to... - Ich bin alergisch gegen...

Hospital - Krankenhaus

Patient - Patient

Sick - Krank

See a full list of German medical terms and body parts.
Useful resources

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The German healthcare system - Expat Guide to Germany | Expatica

# data[].attributes.attachment_link.description
This guide to healthcare in Germany includes information on German health insurance, hospitals, visiting doctors, emergency services, and more. Under the German healthcare system, if you are a resident living and working in Germany, you may be eligible for state healthcare in Germany, provided you are registered with state health insurance in Germany.

# data[].attributes.attachment_link.readable_text
This guide to healthcare in Germany includes information on German health insurance, hospitals, visiting doctors, emergency services, and more.

Under the German healthcare system, if you are a resident living and working in Germany, you may be eligible for state healthcare in Germany, provided you are registered with state health insurance in Germany. Otherwise you will typically need to take out private health insurance.

This helpful guide explains how to access the German healthcare system, and includes the following sections:

Overview of healthcare in Germany

The German healthcare system

The German healthcare system is a dual public-private system that dates back to the 1880s, making it the oldest in Europe. Today its doctors, specialists, and facilities make it one of the very best healthcare systems in the world.

Healthcare in Germany is funded by statutory contributions, ensuring free healthcare for all. In addition, you can also take out private health insurance ( Private Krankenversicherung or PKV) to replace or top up state cover ( gesetzliche Krankenkasse or GKV).

The Federal Ministry of Health is responsible for developing health policy in Germany. The sector is regulated by the Joint Federal Committee.

Germany ranked 12th on the 2018 Euro Health Consumer Index. It has been praised for the level of choice given to customers in terms of treatment. However, it was criticized for having a low number of specialist hospitals, therefore this affected its score on quality.

Who can access healthcare in Germany?

All German residents can access the healthcare system in Germany through public health insurance. Non-residents need to have private insurance coverage to access healthcare. Temporary visitors will typically need to pay for treatment and claim a reimbursement later.

If you are from the European Union (EU), European Economic Area (EEA) or Switzerland and staying only temporarily, you may use your EHIC card. Once you become an official resident, you will have to take out compulsory German health insurance.

Healthcare system costs in Germany

Germany is one of the biggest spenders on healthcare in Europe. It spends 11.1% of annual GDP on healthcare expenditure. Only Switzerland and France spend more in terms of GDP percentage. German healthcare spending works out at just over €4,000 per inhabitant each year.

Public and private insurance contributions cover the majority of costs. On top of this, everyone has to pay a fee of around €10-15 for their first medical visit every quarter. You don't pay this if you don't seek any help during that quarter. Those with private health insurance can reclaim this.

Health insurance in Germany

If you are an employee and you earn less than €57,600 a year (€4,800 a month in 2017), you have to take part in the government health scheme - Gesetzliche Krankenversicherun or GKV - taking out health insurance as soon as you have signed your work contract.

The scheme is administered by around 110 Krankenkassen (non-profit making associations) which must all charge the same basic rate of 14.6% of your eligible gross salary; up to a maximum of €4,350 a month in 2017 (€52,200 annually). This amount is shared equally between you and your employer. You have to stay with a particular Krankenkasse for 18 months, after which time you can switch to another government scheme. Employed workers only pay contributions if they earn over €850 per month.

GKV covers you for primary care with registered doctors, hospital care (both in- and out- patient) and basic dental treatment. Non-working dependents living at the same address and registered with the Krankenkasse are covered at no extra cost.

GKV does not cover consultations with private doctors, private rooms in hospitals, alternative or complementary treatments, dental implants, or glasses/contact lenses for adults.

See our Guide to health insurance in Germany for more information.

How to register for healthcare in Germany as an expat

If you live long-term or work in Germany, you must register with the German authorities at your local town hall ( Einwohnermeldeamt). Once you are registered, have a social insurance number ( Sozialversicherungsnummer), and are making national insurance contributions, you are entitled to state-run healthcare the same as German nationals.

In order to access this, you also have to register with a health insurance fund. See rates offered by different state insurers here. A non-working spouse and children are covered by the same insurance.

Your insurer will give you a health insurance card ( Krankenversichertenkarte), which you have to take with you each time you visit any doctor, dentist, or specialist in Germany. Since 2014 an electronic eHealth card with a photo of the holder (unless under 15) is proof of entitlement to medical services and benefits. The card, which contains your name, date of birth, address, and health insurance data, is scanned when you visit a medical service.

Private healthcare in Germany

You can choose to opt out of the state insurance plan and take out private health insurance cover ( Private Krankenversicherung or PKV) if you are:

an employee earning more than €57,600 (2017);

self-employed;

working part-time and earning less than €450 a month;

a freelance professional;

an artist;

a civil servant or certain other public employee

PKV usually covers a much wider range of medical and dental treatments than GKV. Companies offer different levels of cover. Premiums depend on age at entry into the scheme and any pre-existing conditions and cover is usually per person; rather than per family as with the government insurance schemes. Part of medical insurance premiums is tax-deductible.

Employers in Germany also contribute to private health insurance fees; up to a maximum of €317.55 per month.

If you are not eligible for state health insurance, you can opt to take out private health insurance from a local or expat health insurance company. Some of the largest international health insurers include:

The PVK maintains a full list of private German health insurance companies.

Doctors and specialists in Germany

Doctors are called Ärzte; a Hausarzt is the equivalent of a GP or primary care doctor. Under the German healthcare system, you are free to choose your own doctor. Many speak at least basic English. Some doctors only treat private patients, therefore if you have state insurance, make sure to check beforehand otherwise you will have to pay for treatment.

Practice hours are usually from 8am-1pm and from 3pm-6pm from Monday to Friday; many close on a Wednesday afternoon. Few practices are open on Saturdays and only emergency services operate on Sundays.

Some doctors have an 'open door' policy where you can just turn up at the surgery; however you may have a long wait. You will need a referral from your GP to see many specialist doctors, although some specialists take direct bookings.

See our Guide to doctors and specialists for more information.

Women's healthcare in Germany

Gynecologists are accessible in Germany through public health insurance. They will provide care and support during pregnancy. Your gynecologist is also the person to see for sexual health matters, cancer screenings, and urinary tract infections.

All maternity costs are covered by statutory insurance. However, some private insurers do not unless you have chosen to be covered for this, so it's wise to check.

Pregnancy tests and basic forms of contraception are available in pharmacies. However, a gynecologist will need to prescribe birth control pills, intra-uterine devices (IUDs), and diaphragms. Emergency contraception is widely available and doesn't need a prescription. Public health insurance doesn't cover most contraception costs.

Statutory insurance covers annual screenings for every woman aged over 20 for cervical cancer, breast cancer, and ovarian cancer.

Abortions are legal in Germany during the first 12 weeks of pregnancy, however you will need to undergo counselling sessions first. An abortion can be carried out up to 22 weeks into the pregnancy if the mother's life is in danger or if the pregnancy poses serious risks to the mother's health and well-being.

For more information, see our guides to women's health in Germany and to having a baby in Germany.

Children's healthcare in Germany

Public health insurance will cover your children until the age of 18. Pediatricians will typically provide healthcare for children up until the age of 12 when they transfer to a GP. Around 90% of German children aged under 6 are seen primarily by a pediatrician. In addition, you are free to choose a pediatrician for your child.

Many specialist children's hospitals offer emergency and outpatient care. These provide treatment for a range of illnesses and diseases as well as services such as speech therapy.

Vaccinations for children in Germany are free. There is a national vaccination schedule which includes immunization against conditions including:

Chickenpox;

Hepatitis B;

Polio;

Measles, mumps and rubella (MMR)

More information can be found in our guides to children's healthcare in Germany and vaccinations in Germany.

Dentists in Germany

You can find a dentist ( zahnärzte) who operates within the statutory health insurance scheme on the KZBV website (in German). Otherwise, when you visit a dentist look for a sign saying Kassenarzt or Alle Kassen, which means that the dentist operates under the state German healthcare system.

Children and young people up to the age of 18 do not pay for dental treatment. However, check with your insurer about what the state insurance covers as there is limited cover. Furthermore, even private insurers won't fully reimburse for all treatments. In addition, dental costs in Germany are extremely high. Routine procedures are covered, however more extensive work (such as dentures and crowns) are only partially covered.

See more detailed information in our Guide to dentistry in Germany.

Hospitals in Germany

Hospitals are called Krankenhäuser. There are three main types:

public hospitals (Öffentliche Krankenhäuser) which are run by the local and regional authorities;

voluntary, non-profit making hospitals (Frei gemeinnützige Krankenhäuser) run by churches or organisations run by the German Red Cross;

private hospitals (Privatkrankenhäuser)

Your GP will need to refer you to a specialist in a hospital. You should take your EHIC or German health insurance card when you visit. Adults have to pay a fixed charge of around €10-15 per day, up to a maximum of 28 days in a year.

If you are going to be an in-patient, note that hospitals have a certain amount of space allotted to patients with public insurance and for those with private insurance.

If you have a 'private' room it means that private insurance covers it; it doesn't mean that only you can use the room. These private rooms usually accommodate two patients with a curtain separating them. Take your own soap and personal items.

For more information, see our Guide to hospitals in Germany.

Health centers and clinics in Germany

Outpatient care in Germany is generally provided by doctors and specialists from individual or joint practices. You will also find many medical centers, both public and private, where various different health professionals operate. These can include GPs, medical specialists, physiotherapists, psychotherapists, and nurses.

Pharmacies in Germany

Pharmacies ( Apotheke) are open 9am-6pm from Monday to Friday and 9am-12pm on Saturdays. They all provide addresses for services outside of opening hours.

Medication does not always come with dosage instructions on the package. Make sure you ask your doctor when and how much you should take and write down the information so you have it later. Sometimes your pharmacist will also be able to tell you about dosages, however they are less likely to speak English. If your German is not good, it is easier to get information you need from your doctor.

Check here for information about local on-call pharmacies.

You can take a prescription from your GP to any pharmacy. If the prescription is on a pink slip of paper, you will have to pay a non-refundable fixed charge (around €5-10). You have to pay the full cost for certain medications for minor ailments such as cough mixture.

If you have private insurance, you will most often get prescriptions on a blue sheet of paper; this means you have to pay the full price of the drug up front and then send the receipt to your insurance for reimbursement.

Mental healthcare in Germany

Like many European countries, Germany has seen more of a focus on mental health and mental healthcare services in recent years. There is not as much stigma around mental illness as there once was and there is more recognition of the need to look after mental well-being.

Research reveals that 5.3 million Germans suffer from depression each year. GPs can initially deal with general mental health issues, and they will prescribe necessary medication or refer patients on to specialist treatment. It is also possible to access some services such as psychiatrists, psychologists, and mental health specialists directly without referral. However, you will need to check what treatments your insurance policy covers.

You can seek treatment for more serious and enduring mental health problems in either:

psychosomatic clinics, which can deal with conditions such as severe depression, anxiety and eating disorders;

psychiatric hospitals, which have facilities for in-patient stays ranging from a few days to several months.

Other forms of healthcare in Germany

Germany recognises and practices alternative and complementary medicine. Generally speaking, around 20-30% of the population has used some form of alternative treatment. Furthermore, practitioners often use it when standard treatments are not available.

All licensed health practitioners have permission to use complementary techniques and many pharmacists train in herbal medicine. In fact, around three-quarters of qualified physicians use some type of alternative medicine and 77% of pain clinics provide acupuncture treatment.

Licensed Heilpraktikers can also deliver alternative and complementary treatments. These are practitioners of natural therapies who don't require formal medical degrees, but have to pass an exam set by the health authorities. Chiropractors in Germany need the Heilpraktiker license even if they have a medical degree.

German health insurance covers some alternative medicine, however, there have been discussions to stop reimbursing homeopathic treatment.

Public health insurance will likely cover alternative treatments if:

there are no other treatments available;

if standard treatments are likely to have detrimental side effects;

if they are cheaper and doctors consider them safe and cost-effective

In an emergency

For urgent medical treatment, go to the A&E or ER which are called Notaufnahme. Both state and private health insurance cover emergency services. If you need an ambulance, you can call the pan-European number 112 free of charge. In addition, the fire brigade ambulance service ( Rettungswagen) will take you to the nearest hospital.

Other numbers to call in a medical emergency are:

For an emergency doctor: 19 242

For a non-emergency doctor on call: 116 117

You can also phone your local surgery for details of their out of hours service. See this full list of emergency numbers in Germany.

German healthcare system: useful phrases

I need an ambulance - Ich brauche einen Krankenwagen

Heart attack - Herzinfarkt

I need a doctor - Ich brauche einen Arzt

I need a hospital - Ich brauche ein Krankenhaus

There's been an accident - Es gab einen Unfall

I am allergic to... - Ich bin alergisch gegen...

Hospital - Krankenhaus

Patient - Patient

Sick - Krank

See a full list of German medical terms and body parts.
Useful resources

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The German healthcare system - Expat Guide to Germany | Expatica

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This guide to healthcare in Germany includes information on German health insurance, hospitals, visiting doctors, emergency services, and more. Under the German healthcare system, if you are a resident living and working in Germany, you may be eligible for state healthcare in Germany, provided you are registered with state health insurance in Germany.

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https://www.youtube.com/watch?v=NdarqEbDeV0

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The German healthcare system is rated as one of the best in the world. It offers a flexible range of choices and extensive coverage. Residents who want to get insurance have many options to choose from and a wide variety of health insurance packages to meet their financial capacities and medical needs. Different health insurance plans vary in terms of coverage, costs and specific conditions.
hadlyna&qiyanah

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qistina

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https://www.cnbc.com/2019/11/22/germany-health-care-system-compared-to-united-states.html

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German health benefits are very generous. And there's usually little or no wait to get elective surgery or diagnostic tests, such as MRIs. It's one of the world's best health care systems, visible in little ways that most Germans take for granted - pc

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The German health system is divided into an insurance sector with public and private insurance funds, and a healthcare sector. The healthcare sector covers a range of services and departments, including ambulatory outpatient care (provided mainly by individual doctors at their offices), pharmaceutical care distributed by pharmacists, inpatient care in hospitals and rehabilitation clinics, and a nursing care sector

# data[].attributes.subject
The German health system is divided into an insurance sector with public and private insurance funds, and a healthcare sector. The healthcare sector covers a range of services and departments, including ambulatory outpatient care (provided mainly by individual doctors at their offices), pharmaceutical care distributed by pharmacists, inpatient care in hospitals and rehabilitation clinics, and a nursing care sector

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https://healthmanagement.org/c/hospital/issuearticle/overview-of-the-german-healthcare-system
puni

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https://www.youtube.com/watch?v=1d3QLPdHysc

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https://www.google.com/search?q=gernaby+health+care&rlz=1C1GCEA_enSG889&oq=gernaby+health+care&aqs=chrome..69i57j0l5.5633j0j8&sourceid=chrome&ie=UTF-8
Germany has what's called a universal multi-payer health care system. It encompasses both statutory health insurance for people who earn less than a certain salary, as well as private health insurance for those who earn more and choose to purchase their own.

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Germany is one of the biggest spenders on healthcare in Europe. It spends 11.1% of annual GDP on healthcare expenditure. Only Switzerland and France spend more in terms of GDP percentage. German healthcare spending works out at just over €4,000 per inhabitant each year.Public and private insurance contributions cover the majority of costs. On top of this, everyone has to pay a fee of around €10-15 for their first medical visit every quarter. You don’t pay this if you don’t seek any help during that quarter. Those with private health insurance can reclaim this. 

# data[].attributes.subject
Germany is one of the biggest spenders on healthcare in Europe. It spends 11.1% of annual GDP on healthcare expenditure. Only Switzerland and France spend more in terms of GDP percentage. German healthcare spending works out at just over €4,000 per inhabitant each year.Public and private insurance contributions cover the majority of costs. On top of this, everyone has to pay a fee of around €10-15 for their first medical visit every quarter. You don’t pay this if you don’t seek any help during that quarter. Those with private health insurance can reclaim this. 

# data[].attributes.body
https://www.expatica.com/de/healthcare/healthcare-basics/the-german-healthcare-system-a-guide-to-healthcare-in-germany-103359/
andrea

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https://vittana.org/19-pros-and-cons-of-german-healthcare-system

-sabryne

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Navigating Healthcare in Germany: Public vs. Private Insurance Explained

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https://www.youtube.com/watch?v=NdarqEbDeV0

- Shared by Mr Abdul

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https://www.youtube.com/watch?v=NrmZ3iEMqSc

- Shared by Mr Abdul