Health Care Systems in Transition

Health Care Systems
in Transition
Written by
Reinhard Busse
Annette Riesberg
Germany
2004
The European Observatory on Health Systems and Policies is a partnership

between the World Health Organization Regional Office for Europe, the
governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the
European Investment Bank, the Open Society Institute, the World Bank, the
London School of Economics and Political Science, and the London School of
Hygiene & Tropical Medicine.
Keywords:
DELIVERY OF HEALTH CARE
EVALUATION STUDIES
FINANCING, HEALTH
HEALTH CARE REFORM
HEALTH SYSTEM PLANS organization and administration
GERMANY
World Health Organization 2004, on behalf of the European Observatory on Health Systems and Policies
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Suggested citation:
Busse R, Riesberg A. Health care systems in transition: Germany. Copenhagen,
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies, 2004.
ISSN 1020-9077 Vol. 6 No. 9
Contents
Foreword ...................................................................................................v
Acknowledgements ................................................................................ vii
Introduction and historical background ................................................1
Introductory overview............................................................................1
Historical background..........................................................................12
Organizational structure and management .........................................29
Organizational structure of the health care system..............................29
Planning, regulation and management.................................................39
Decentralization of the health care system..........................................54
Health care financing and expenditure . ...............................................57
Main system of financing . ..................................................................58
Health care benefits and rationing ......................................................67
Complementary sources of financing .................................................72
Health care expenditure.......................................................................81
Health care delivery system ...................................................................91
Public health services ........................................................................91
Primary and secondary ambulatory care . ...........................................96
Secondary and tertiary hospital care..................................................104
Social care..........................................................................................116
Human resources and training...........................................................124
Pharmaceuticals ................................................................................134
Health technology assessment...........................................................153
Financial resource allocation ...............................................................161
Third-party budget setting and resource allocation...........................161
Payment of hospitals .........................................................................165
Payment of physicians ....................................................................177
Health care reforms ..............................................................................185
Objectives of health reforms .............................................................186
Content of reforms and legislation . ..................................................189
Conclusions ...........................................................................................207
References .............................................................................................213
List of tables .........................................................................................221
List of figures . .......................................................................................223
Weblinks ................................................................................................225
Glossary ................................................................................................227
Germany
Foreword
he Health Care Systems in Transition (HiT) profiles are country-based

reports that provide an analytical description of a health care system
and of reform initiatives in progress or under development. The HiTs
are a key element of the work of the European Observatory on Health Systems
and Policies.
HiTs seek to provide relevant comparative information to support policymakers and analysts in the development of health care systems in Europe. The
HiT profiles are building blocks that can be used:
to learn in detail about different approaches to the organization, financing
and delivery of health services;
to describe the process, content and implementation of health care reform
programmes;
to highlight challenges and areas that require more in-depth analysis; and
to provide a tool for the dissemination of information on health care systems
and the exchange of experiences of reform strategies between policy-makers
and analysts in different countries.
The HiT profiles are produced by country experts in collaboration with the
Observatorys research directors and staff. In order to facilitate comparisons
between countries, the profiles are based on a template, which is revised
periodically. The template provides the detailed guidelines and specific
questions, definitions and examples needed to compile a HiT. This guidance
is intended to be flexible to allow authors to take account of their national
context.
Compiling the HiT profiles poses a number of methodological problems.
In many countries, there is relatively little information available on the health
care system and the impact of reforms. Due to the lack of a uniform data
Germany
vi
European Observatory on Health Systems and Policies
source, quantitative data on health services are based on a number of different

sources, including the WHO Regional Office for Europe health for all database,
Organisation for Economic Cooperation and Development (OECD) Health
Data and data from the World Bank. Data collection methods and definitions
sometimes vary, but typically are consistent within each separate series.
The HiT profiles provide a source of descriptive information on health care
systems. They can be used to inform policy-makers about experiences in other
countries that may be relevant to their own national situation. They can also
be used to inform comparative analysis of health care systems. This series is
an ongoing initiative: material is updated at regular intervals. Comments and
suggestions for the further development and improvement of the HiT profiles are
most welcome and can be sent to [email protected]. HiTs, HiT summaries
and a glossary of terms used in the HiTs are available on the Observatorys
website at www.observatory.dk.
Germany
Acknowledgements
he Health Care Systems in Transition profile on Germany 2004 was

written by Reinhard Busse and Annette Riesberg (European Observatory
on Health Systems and Policies, Technische Universitt Berlin). It is
based on the HiT profile 2000 which was written by Reinhard Busse (then
European Observatory on Health Care Systems, Madrid) in collaboration with
Annette Riesberg (Federal Ministry of Health) and edited by Anna Dixon
(European Observatory on Health Care Systems, London School of Economics)
(1).
The European Observatory on Health Systems and Policies is grateful to
Martin Schlkopf (Federal Ministry of Health and Social Security) and Markus
Wrz (Technische Universitt Berlin) for reviewing the report. Thanks are also
extended to Helmut Brand (State Public Health Office, North Rhine-Westphalia),
Dorothea Bronner (Office of the Federal Joint Committee), Eva Susanne Dietrich
(Federal Association of Statutory Health Insurance Physicians),1 Christian
Gawlik (Federal Insurance Authority), Pekka Helstel (Federal Association of
Regional Sickness Funds), Regina Kunz (Office of the Federal Joint Committee)
and Matthias Perleth (Federal Association of Regional Sickness Funds) who
reviewed the HiT profile concerning specific aspects and provided valuable
information.
The current series of Health Care Systems in Transition profiles has been
prepared by the research directors and staff of the European Observatory on
Health Systems and Policies. The European Observatory on Health Systems
and Policies is a partnership between the WHO Regional Office for Europe,
the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the
European Investment Bank, the Open Society Institute, the World Bank, the
For reasons of international comparability and consistency with the former HiT profile (1) the names
of institutions used in the following text do not necessarily reflect the English names that institutions use
themselves (see Glossary).
1
Germany
viii
London School of Economics and Political Science, and the London School
of Hygiene & Tropical Medicine.
The Observatory team working on the HiT profiles is led by Josep Figueras,
Head of the Secretariat, and research directors Martin McKee, Elias Mossialos
and Richard Saltman.
Technical coordination, production and copy-editing was led by Susanne
Grosse-Tebbe, with the support of Shirley and Johannes Frederiksen (layout)
and Thomas Petruso (copy-editor). Administrative support for preparing the
HiT on Germany was undertaken by Pieter Herroelen.
Special thanks are extended to the WHO Regional Office for Europe health
for all database, from which data on health services were extracted; to the OECD
for the data on health services in western Europe; and to the World Bank for the
data on health expenditure in central and eastern European countries. Thanks
are also due to national statistical offices that have provided data.
The HiT reflects the state of reform and data in November 2004.
Germany
Introduction and historical background
Introductory overview
he Federal Republic of Germany is situated in central Europe and covers

an area of about 357 000 km2. The longest distance from north to south
is 876 km, from west to east 640 km. The country shares borders with
(clockwise from the north) Denmark, Poland, the Czech Republic, Austria,
Switzerland, France, Luxembourg, Belgium and the Netherlands (Fig. 1).
Germany has 82.5 million inhabitants, with 42.2 million women and 40.3
million men.
The area of the former German Democratic Republic (GDR) in the eastern
part of Germany accounts for 108 000 km2 (30%) of the total land. Its 13.5
million residents represent 16% of the countrys total population (2003 figures,
excluding the eastern part of Berlin with about 1 million inhabitants). The
population density is unevenly distributed and varies between 75 inhabitants
per km2 in Mecklenburg Western-Pomerania and 3804 inhabitants per km2
in Berlin. Of the 19 cities with more than 300 000 inhabitants only three
(including Berlin) are in the eastern part of Germany. The largest city is the
capital Berlin, with 3.4 million inhabitants. Other densely populated areas are
the Rhine-Ruhr region with about 11 million people and the Rhine-Main area
surrounding Frankfurt.
Political and economic background
Germany is a federal republic consisting of 16 states (Lnder)2 (Fig. 2), each of
which has a constitution consistent with the republican, democratic and social
The new Lnder in the area of the former German Democratic Republic (GDR), which accessed the Federal
Republic of Germany in 1990, will be called eastern part in the ensuing text according to their geographic
location in Germany. The old Lnder in the area of the former Federal Republic of Germany (FRG) will be
termed western part.
2
Germany
Fig. 1.
Map of Germany
Denmark
her
land
North
Kiel
Sea
Rostock
Bremerhaven
Lbeck
Hamburg
Emden
Bremen
Baltic
Sea
Net
Hannover
Duisburg
Essen
Kassel
Dsseldorf
Cologne
Belgium Bonn Frankfurt
am Main
Wiesbaden
Berlin
Magdeburg
Leipzig
Dresden
Mannheim
Lux.
Poland
Czech
Republic
Stuttgart
France
Switzerland
Munich
Austria
Liechtenstein
Source: The World Factbook, 2004.
principles embodied in the national constitution (known as the Basic Law or

Grundgesetz). The constitutionally-defined bodies with legislative functions are
the Federal Assembly (Bundestag) and the Federal Council (Bundesrat).
The Federal Assembly is made up of 603 members, elected every four
years. Since 1998, the coalition of Social Democrats and Greens has held the
parliamentary majority and formed the government. The main functions of
the Federal Assembly are to pass laws, elect the Chancellor and control the
government. The Federal Council, which represents the sixteen federal states,
does not consist of directly-elected representatives but of three to six members
Germany
Health Care Systems in Transition
depending on population size from each of the sixteen state governments. The
main function of the Federal Council is to approve laws passed by the Federal
Assembly. About half of all bills require the formal approval of the Federal
Council, while in other cases the Assembly may overrule a negative vote by the
Council. The requirement for passage by both chambers applies especially to
bills of vital interest to the states, such as those regarding financial affairs or their
administrative powers. Passing laws that need the approval of both chambers
is often difficult and requires compromise, since the political majority in each
chamber is typically held by opposing parties or coalitions. Compromise is often
found by the 32-member Mediation Committee (16 from the Federal Assembly
and 1 from each Land) before being passed by both chambers.
Fig. 2.
Political map of Germany at the level of the Lnder
SchleswigHolstein
MecklenburgWestern Pomerania
Hamburg
Brandenburg
Bremen
Lower
Saxony
Berlin
SaxonyAnhalt
North RhineWestphalia
Saxony
Hesse
Thuringia
RhinelandPalatinate
Saarland
Bavaria
BadenWurttemberg
Germany
The President (currently Horst Khler) is elected for five years by an

assembly consisting of the members of the Federal Assembly and an equal
number of representatives from the states according to their population size. The
Presidents major tasks are to sign new laws, formally appoint the chancellor
and the federal ministers and to fill the role of head of state.
Legislative authority lies principally with the 16 federal states (Lnder),
except in areas for which this authority is explicitly given to the federal level.
The Federations legislative authority falls into three different categories:
1. legislation pertaining to foreign affairs, defence, monetary matters, air
transport and some elements of taxation
2. legislation necessary to establish uniform laws for the whole country
3. framework legislation, though the states retain a considerable amount of
legislative latitude, e.g. in higher education, nature conservation, landscape
management, regional planning and water management.
The states can fill in any gaps left by federal legislation or in areas not
specified by the constitution. Thus they are responsible for culture and education
(see Human resources and training) almost in their entirety as a manifestation
of their cultural sovereignty. They are also responsible for legislation defining
the powers of local government and the police. The real strength of the states
lies in their participation in the legislative process at the federal level through
the Federal Council. All administration, such as tax collection, lies in their
hands, and their bureaucracy implements most federal laws and regulations.
Difficulties can arise due to the fact that the Federal Council is often dominated
by states led by parties that are a minority in the Federal Assembly and not part
of federal government.
The Federal Governments Cabinet consists of the Chancellor, who is head of
the government, and the federal ministers. The Chancellor chooses the ministers
and proposes them to the President for appointment or dismissal. He also
determines the number of ministers and their responsibilities. The Chancellor is
in a strong position primarily due to the fact that he establishes the guidelines for
government policy. The federal ministers run their departments independently
but within the framework of these guidelines. Besides the legislature and the
executive, the various separate court systems (administrative, constitutional and
civil courts) represent a strong third pillar of decision-making.
Germany is a member of the G8 group of leading industrial countries. In
2003, the gross domestic product (GDP) amounted to a total of 2130 billion
and to 25 662 per capita (Table 1). Following German unification, real GDP
growth peaked at 7.4% in 1992 and has been much lower since then, reaching
Germany
a negative real growth rate of -0.1% in 2003. Throughout this period, the real
GDP increased less than the OECD countries average (2).
Unemployment rates ranked above OECD average and have increased
recently following a recovery around the turn of the millennium (Table 1).
According to national figures, around 3.7 million people were unemployed
in 2003 at a rate of 10.5% of the workforce. In the eastern federal states,
unemployment rates were substantially higher from 16.7% in Thuringia
to 20.7% in Saxony-Anhalt than in the western federal states, where
unemployment rates ranged from 6.1% in Baden-Wrttemberg to 13.2% in
Bremen. In Berlin the unemployment rate was 18.1% (3).
The workforce as a share of the population as well as the number of
employees subject to mandatory statutory insurance have decreased slightly
since 1992. While the share of fulltime employment decreased, the share of
self-employed people and part-time employees increased. Total and public
expenditures on education have decreased during the 1990s and rank below
OECD average (Table 1).
Table 1.
Macro-economic indicators, 19922002
GDP at current prices (billion )a

GDP per capita at real 1995
prices (1000)
1992
1994
1996
1998
1999
2000
2001
2002
1 613
1 736
1 834
1 929
1 979
2 030
2 074
2 110
21.7
21.7
22.2
22.9
23.3
24.0
24.1
24.1
Government income per capita at

real 1995 prices (1000)
9.9
10.2
10.3
10.7
11.0
11.3
11.0
10.9
Government expenditure per

capita at real 1995 prices (1000)
10.4
10.7
11.1
11.2
11.4
11.0
11.6
11.7
Average annual income of bluecollar workers (1000)
20.0
21.0
23.0
23.6
24.7
25.6
26.3
27.0
45.7
44.4
44.0
44.4
44.2
44.4
44.4
43.9
Total employment
(% of population)
Unemployment
(% of work-force)
Part-time (% of work-force)
Total expenditure on education
(% BIP)
6.2
8.7
8.7
9.6
8.9
7.9
7.8
8.5
11.3
12.3
13.4
14.7
15.6
16.2
16.8
17.2
5.8
5.6
5.6
5.3
Source: OECD Health Data 2004 (2).

Note: a Billion is defined as a thousand million (109) throughout this document.
Germany
Demography and health status

In December 2003, Germany had 82.5 million inhabitants, 66.6 million in the
western part, 13.5 million in the eastern part and 3.4 million in Berlin. Since
reunification, the population in the eastern part decreased from 15.9 million
in 1991 to 13.5 in 2003, attributable to migration to the west and the very low
birth rate in the east.
Among the 7.4 million inhabitants who do not hold German citizenship,
2 million hold Turkish citizenship, 2 million come from central and eastern
European countries and the Russian Federation, 1.8 million from European
Union countries, and 1.4 from extra-European countries. Among foreign
passport holders, 3.3 million have an unlimited status, 2.3 million have been
in the country for 10 or more years and 1.6 were born in Germany. In 2002,
26.5 million German inhabitants were Catholic, 26.2 million Protestant and
98 000 Jewish by religion. The number of Muslims was estimated at about
3million in 1998 (3).
The share of the population in all of Germany below 15 years of age
decreased from 25% in 1970 to 15% in 2003, whereas the share of those over
64 years old remained at around 15% until 1993, and has since increased to
18%. The share of the age group above 80 years has remained stable over the
last ten years, at around 3.8% but is predicted to grow (3).
Valid morbidity data about the population in Germany are not easy to obtain
although the data situation has improved in recent years. An important overall
source for health data has been the Basic Health Report 1998 which has since
been updated and supplemented by reports on specific aspects. Data are available
free of charge in a web-based format (4). A useful overview of national as well
as comparative data is provided by the World Health Organizations Regional
Office for Europe (5), available via its homepage free of charge, and the health
data of the Organization of Economic Co-Operation and Development (OECD)
(2). One of the national sources for morbidity data is the Hospital Diagnoses
Statistic of the Federal Statistical Office (6), which has provided data since
1993. In 1995, the Cancer Registry Act came into effect, according to which
every federal state was to establish a cancer registry by 1999 but implementation
has been slow. Except for cancer in children, data on the incidence and
prevalence of cancer are still not available for all states and are considered
difficult to extrapolate to the national level. Data are also derived from specific
representative population surveys or the notification of infectious diseases.
Other morbidity data relate to the 88% of the population with statutory health
insurance coverage for example expenditure data, statistics on the utilization of
cash payments, hospital care and other benefits that require pre-authorization
from sickness funds, or prescription data (see Pharmaceuticals).
Germany
A national periodical survey, the micro-census, gathers subjective data on

the perceived health status of a representative sample of the population (7).
According to the 2003 survey, 89% of respondents considered themselves
healthy, 10% sick and 1% injured due to an accident. 93% of children under
the age of five were considered healthy. The largest share of healthy people was
found among 10 to 20 year olds (96%) and decreased to 85% among 6065year-olds and 72% of those over 75, who had the highest share of sick (27%)
and injured (1.1%) people. The share of Germans in good subjective health
was similar in 1992 and lower in 1999 (87%). According to various population
surveys, subjective health is higher in younger age groups and slightly higher
among men, west Germans and people with higher education (8).
Data from sickness funds indicate that the share of people on sick-leave
decreased from 4.9% of the sickness fund members in 1991 to 3.6% in 2003
(9), reflecting not only health conditions but also the tight job market (Table 1).
In 2003, 1.8 million (2% of the population) had a recognized reduced capacity
to work and received disability benefits from statutory retirement insurance.
In 2001, 6.7 million (8%) were officially registered as severely disabled (10).
The percentage of people entitled to statutory long-term care benefits was about
1.9million 2.3% of the total population in 2003, increasing by age. Only 0.6%
of those under the age of 50 were entitled, compared to 1.7% of 60 to 65-yearolds, 4.7% of 7075-year-olds and 30% of those over 80 (11). It should be noted
that many people are represented in several of these groups.
Table 2 presents some indicators of morbidity, life style and environmental
risk whose incidence and/or letality that can be influenced by curative or
preventive measures to a certain extent. Most parameters have in fact improved
between 1991 and 2001 (see Public health). Dental diseases offer an example of
likely success of preventive efforts. In 1992 and 1993, 12-year-olds in Germany
had one of the highest indices of decayed, missing and filled teeth (DMFT)
among EU countries reporting this index at that time (3.9 versus 2.9). But the
DMFT index improved to 1.7 in 1997 and 1.2 in 2000. The incidence of HIV
infections has remained among the lowest in the European Union (EU). The
incidence of clinically diagnosed AIDS (Table 2) decreased following a peak of
2.5 per 100 000 in 1994 to 0.8 in 2002, perhaps due to a concerted prevention
strategy, ready access to comprehensive advice and medical care (5).
Mortality data reflect a limited part of health conditions affecting the
population, but are more reliable than morbidity data. The former are derived
from the Cause of Death Statistics compiled by the state statistical offices and
then transferred to the Federal Statistical Office (4).
In 2003, 853 946 people died while 706 721 children were born alive (3). The
crude death rate decreased in both parts of Germany from 1975. Following the
Germany
reunification, it increased transiently in 1990 and 1991 in the eastern part, and
in 1993 and 1994 in the western part. Since then, it decreased again slowly but
continuously, despite the increasing share of elderly in society (3) (Table 2).
By 2003, life expectancy at birth reached 75.6 years for men and 81.6 years
for women (Federal Statistical Office, 2004). According to the World Health
Organization (WHO), the disability-adjusted life expectancy in 2002 was 69.6
years for men, 74.0 years for women and 71.8 years in total, ranking and just
above the EU-15 average . The percentage of life expectancy lost to disability
(7.8% for men, 9.3% for women) was the second lowest in the world after
Japan (5).
Table 2 shows that the age-standardized mortality rate decreased substantially
between 1991 and 2001, by about one fifth. The improvement is also reflected
by data on the life expectancy at birth (see Table 3) and at all other ages (5).
In fact, the substantial decrease in (age-standardized) mortality during this
period was observable in most causes of death including cardiovascular diseases
(causing about half of all deaths) and neoplasms (causing about a quarter
of deaths). Increases were observed in perinatal and neonatal mortality and
infectious diseases, the latter being mainly due to sepsis and viral hepatitis.
There was a peak of mortality from diabetes mellitus and female breast cancer
in the mid of 1990s, yet rates have decreased since then to a lower value than
in the early 1990s.
Standardized mortality rates still rank above EU-15 average (655.3).3
However, the gap has become substantially smaller since 1991. The higher
mortality can be found in most age groups except for infant mortality (4.3 versus
4.7 per 1000 life births) and child mortality (5.3 versus 5.6). The mortality
gradient was mainly due to a substantially higher mortality from cardiovascular
diseases (286.7 versus 275.1 per 100 000 in 2001), especially ischaemic diseases.
Other causes of death that ranked above the EU-15 included for example suicide
and self-inflicted injury (15.2 versus 11.5) and alcohol-related causes of death
(62.0 versus 60.7).
At the same time, mortality from neoplasms ranked below the EU-15 average
which, for example, was also true for lung cancer but not for cervical cancer
or breast cancer. Cervical cancer had both a higher incidence (16.7 vs. 12.8 in
1998, latest data) as well as a higher age-standardized mortality rate (3.3 versus
2.6 in 2001). Standardized death rates for motor vehicle traffic accidents were
also below EU-15 average (7.9 versus 10.0) though they remain a problem in
the eastern part of Germany, especially among young males. At the same time,
In the following text, the term EU-15 refers to the 15 EU member states prior to 1 May 2004, the term
EU-10 to the 10 countries that became EU members on 1 May 2004.
3
Germany
Table 2.
Trends in health risks, morbidity and mortality, 1991 and 2001
1991
Decayed, missing or filled teeth at age 12 (DMFT-12 index)
3.9b
Average amount of fruits and vegetables available
per person per year
197
Fat available per person per day (in g)
145
Pure alcohol consumed, litres per capita, in the population
aged 15 or older
12.7
Number of cigarettes consumed per person per year
1 752
SDR selected alcohol related causesa
101.6
SDR selected smoking related causesa
320.8
Persons killed or injured in road traffic accidents per 100 000
654.4
SDR all transport accidentsa
13.8
New cases of occupational diseases per 100 000
20.9
People injured due to work-related accidents per 100 000
2 568
Deaths due to work-related accidents per 100 000
1.9
Perinatal deaths per 1000 births
5.0
Maternal deaths per 100 000 live births
8.7
Infant deaths per 1000 live births
6.9
Probability of dying before the age of 5 years per 1000 live births
8.5
SDR, acute respiratory infections pneumonia and influenza,
under 5 yearsa
3.2
SDR suicide and self-inflicted injurya
15.5
SDR homicide or intentional injurya
1.1
SDR infectious and parasitic diseasea
5.2
Incidence of clinically diagnosed AIDS per 100 000
2.3
Incidence of tuberculosis per 100 000
16.9
SDR tuberculosisa
1.1
SDR bronchitis/emphysema/asthmaa
22.8
SDR trachea/bronchus/lung cancera
35.9
Incidence of cervix cancer per 100 000
17.1
SDR cancer of the cervixa
4.6
Incidence of female breast cancer per 100 000c
106.9
SDR female breast cancera
32.0
in the age group 064
20.0
in the age group 65+
128.8
SDR neoplasmsa
203.7
89.1
1 130.7
SDR ischaemic heart diseasea
158.5
SDR diabetesa
17.0
SDR diseases of the circulatory systema
388.3
74.7
2 925.7
SDR all causesa
830.8
283.9
5 255.7
Crude death rate per 100 000
1 139.0
Source: WHO Regional Office for Europe health for all database, June 2004 (5).
2001
1.2c
212
157
10.9
1 553c
62.0
242.2
609.4
8.5
33.4
1 695
1.3
5.9
3.7
4.3
5.3
1.4
11.7
0.7
8.7
0.9
8.5
0.5
18.2
34.4
16.7d
3.2
110.1d
27.5
16.4
117.5
176.6
74.3
1 004.4
122.9
16.2
286.1
48.8
2 205.4
657.6
212.6
4 258.9
1 006.0
Note: a (age-)standardized death rate per 100 000 population, b 1992, c 2000; d 1998.
Germany
10
non-lethal injuries are substantially higher. Besides a high density of cars and
the lack of a general speed limit on motorways, alcohol consumption is seen
as a contributing factor in 31% of all road accidents in 2001 (13).
German alcohol consumption is above the average of EU-15 countries as well
as the entire EU (10.9, 9.2 and 9.1 litres of pure alcohol per year respectively
in 2001). The rate of regular smokers is still higher than in the average of EU15 countries (with population shares of 35% and 29% respectively in 2001).
Germans eat about the same number of calories as their EU-15 neighbours but
fewer fruits and vegetables (212 and 240 kg per person in 2001).
The German populations health may also be analysed against the
background of a 40-year political and geographical separation which provides
a very interesting case-study for changes in health due to political, social and
economic influences on an otherwise homogenous population. The most obvious
indicator of a different pattern of population health in the western and eastern
parts of Germany is life expectancy at birth, which initially increased faster in
the eastern part (from a slightly higher level) but stagnated by the late 1960s.
In contrast, this indicator showed continued growth since the late 1960s in the
Table 3.
Life expectancy in years at birth in the western part and the eastern part of
Germany,a 19492003
Male
1949/1953
Female
Germany
West
Easta
East-west
difference
Germany
West
Easta
East-west
difference
64.6
65.1
+0.5
68.5
69.1
+0.6
1980
69.9
68.7
-1.2
76.8
74.6
-2.2
1990
72.0
72.6
69.1
-3.5
78.4
79.0
76.2
-2.8
1991
72.1
72.8
69.3
-3.5
78.7
79.2
76.6
-2.6
1991/1993
72.6
73.1
69.9
-3.2
79.1
79.5
77.2
-2.3
1992/1994
72.7
73.4
70.3
-3.1
79.2
79.7
77.7
-2.0
1993/1995
73.1
73.5
70.7
-2.8
79.6
79.8
78.2
-1.6
1994/1994
73.3
73.8
71.2
-2.6
79.7
80.0
78.6
-1.4
1995/1996
73.6
74.1
71.8
-2.3
79.9
80.2
79.0
-1.2
1996/1997
74.0
74.4
72.4
-2.0
80.3
80.5
79.4
-1.1
1997/1999
74.5
74.8
73.0
-1.8
80.6
80.7
80.0
-0.7
1998/2000
74.8
75.1
73.5
-1.6
80.8
80.9
80.4
-0.5
1999/2001
75.1
75.4
73.7
-1.7
81.1
81.2
80.6
-0.6
2000/2002
75.4
75.8
74.3
-1.5
81.2
81.5
81.0
-0.5
2001/2003
75.6
81.6
Source: HiT 2000 (1); Federal Statistical Office 2003 (14); Federal Statistical Office 2004 (10).
Note: a Data for Berlin are summarized under West.
Germany
11
western part of Germany. Between 1980 and 1990 the gap in life expectancy
widened, up to the peak in 1990 when men and women living in the eastern
part had life expectancies 3.5 years and 2.8 years shorter than their western
counterparts.
Table 3 shows an increasing equalization of life expectancy at birth between
the eastern and the western parts of Germany after reunification. By the period
of 2000 to 2002, the east-west gap had narrowed to 1.5 years among men and
0.5 among women. Between 1990 and 20002002, the gap in life expectancy
between men and women decreased from 7.1 years to 6.7 years in the eastern
part and from 6.4years to 5.7 years in the western part (Table 3).
The reasons for the differences in life expectancy in the two parts of Germany
are complex and not fully understood. Explanations for the widening gap pre1990 include differences in diet, better living conditions in the western part
during the old FRG, differences in access to high technology care, better health
care at all levels and the selective migration of pensioners from East to West
(15). For the post-1990 changes the following factors are considered influential:
selective migration, the adoption of the western German social welfare system
as a whole and a reduction in health risk factors such as alcohol, meat and fat
intake. Medical care has been identified as another important component in the
post-unification mortality decline in the eastern part (16).
For example, a study of the potential impact of medical care on changes in
mortality between 1992 and 1997 estimated that 1423% of the increase in life
expectancy between birth and age 75 of 1.4 years in men and 0.9 years in women
was accounted for by declining mortality from conditions amenable to medical
intervention. During the same period life expectancy increased comparably less
in the western part by 0.6 years in men and 0.3 years in women.
Falling death rates from hypertension, cerebrovascular diseases, cervical and
breast cancers and a 30% decline in neonatal mortality have been important
contributors (17). These results are supported by an increase of technological
infrastructure and utilization of highly specialized care, for example, dialysis
facilities, coronary catheterization (see Health technology assessment), surgery
related to ischemic heart disease and pacemaker implantation (18). While the
East-West gradient of neonatal mortality decreased in the past decade, there is
still room for improvement in neonatal care (19).
Current health concerns in Germany are mainly related to diseases associated
with demographic trends, including increases in one-person households, longterm chronic-degenerative diseases, public expectations with respect to medical
and paramedical care as well as incentives for excessive use of health care
services. In addition, the share of elderly people in the population is increasing
Germany
12
while the relative number of people of working-age is decreasing, leading to

shrinking social security revenues.
Future changes in the structure of the population will lead to a moderate
increase in the elderly populations need for prevention, therapy, and
rehabilitative and nursing care, whereas the morbidity transition will result in
less need for curative medical intervention. It is also expected that there will be
an additional need for health services responding to obstructive lung diseases,
diseases of the cardiovascular system, urogenital diseases and cancer diagnosis
and therapy. A large preventive potential for ischaemic and cerebrovascular
diseases, respiratory diseases and accidents is also foreseen.
Since 2000, a number of activities to strengthen and coordinate prevention
has been undertaken at federal level involving a broad set of stake-holders
(see Public health and Other health reform objectives): These include the
establishment of a round-table on prevention in 2001, the development of health
targets at the federal level by a multi-stakeholder committee, and subsequent
institutionalization of a prevention forum, whose activities will be supported
by a foundation. In addition, a bill for a special section of the Social Code
Book on prevention has been developed. It shall enhance the coordination of
preventive services financing, delivery and regulation (see Public health and
Health care reforms).
Historical background
The rise, continuity and prominence of statutory health
insurance
The rise of Germanys modern health care system dates back to 1883, when the
parliament passed a law that made health insurance nationwide mandatory for
certain employees (called statutory health insurance in the following text).
This statutory health insurance was to be based on the solidarity and pay-asyou go principles; and it was built upon existing voluntary or mandatory local
schemes of social insurance. Cash and in-kind benefits were to be financed by
proportional contributions from mandatory as well as voluntary members and
their employers. Self-governmental structures were to operate the sickness fund
and decide about benefit coverage beyond the legally defined scope. Germany
is therefore recognized as the first country to have introduced a national social
security system. In the following decades the principle of statutory social
insurance, called the Bismarck system, was also applied to alleviate the risks
Germany
13
of work-related accidents and disability (1884), old age and disability (1889),
unemployment (1927) and the need for long-term care (1994). The prominence
and structural continuity of social insurance is one of the key features of the
historical development of Germanys health care system to the present day.
The origins of social insurance lie in the mutual-aid societies of guilds
that emerged after the middle ages. During the nineteenth century, the rising
class of industrial workers adopted this principle by setting up voluntarist
self-help and self-regulatory structures to alleviate the risk of poverty due to
sickness and death. Contributory funds were also set up by companies and local
communities, thus relieving (and complementing) municipal funds support for
the poor and charity. In 1849 Prussia the largest of the German states made
health insurance mandatory for miners and allowed local communities to oblige
employees and their employers to pay financial contributions.
Multiple economic crises during rapid industrialization worsened already
miserable living conditions, especially of the urban working class. The
government responded to increasing workers protests by prohibiting socialist
and communist organizations including trade unions in 1878. It increasingly
perceived political repression as an insufficient means of maintaining the
existing social order. In 1876, five years after the unification of the German
states, the parliament enacted national standards for minimum contributions
and benefits, but opposed regulations for mandatory payments. The Emperors
charter of 1881 declared social welfare for the poor to be essential for national
survival in a hostile world. Motivated by paternalism and concerns about military
and economic efficiency, Chancellor Bismarck suggested a national health
service-type of system in 1881. However, state governments as well as liberal
members of parliament from business, agriculture and the church opposed taxbased financial provisions and the expansion of national government.
The legislation of 1883 reflected a compromise of these rival interests
but was opposed by leftist-liberals and social democrats. They dismissed the
carrot and stick strategy of the bill and instead called for political rights and
workers protection within the industrial process demands which were only met
gradually from the 1890s onwards. The law built upon existing local funds and
occupation-based funds (miners, guilds and companies). Health insurance was
made mandatory for workers of certain industries with hourly wages or up to a
legally fixed income ceiling. They were to pay two thirds of the contributions
while their employers were obliged to pay one third. Furthermore, the two
opponents in the class conflict were forced to cooperate in elected assemblies
and boards proportionate to their 2:1 contributions. The funds functioned on a
non-profit basis. They were initially free to choose private suppliers of health
care (physicians or any other health care professionals) and to determine the
Germany
14
nature of contractual relationships with them. The role of the national parliament
and government was limited to setting the regulatory framework and the legal
standards for the self-administrated funds, which were to be supervised by
state governments.
The law defined a minimum benefit catalogue which the self-governing
structures of funds could decide to extend, a regulation which became widely
used in many funds during the ensuing decades and was the motor of the gradual
extension of the legal minimum catalogue. Members were eligible to receive
monetary benefits in the form of sick pay equivalent to 50% of the customary
local wage for 13 weeks, maternity pay and death compensation. In addition,
a minimum set of primary health care services including medication was to be
provided while hospital care was left to the decision of the funds on a caseby-case basis.
For the statutory work-related accident insurance, employers accepted the
100% contributions to self-administered accident funds as an alternative to
third-party liability insurance schemes. Thus, they increasingly introduced
and controlled preventive safety measures and rehabilitative care which were
to precede financial compensation. The statutory insurance for old age and
working incapacity, to which employers and workers contributed equally, also
offered health care services according to the principle of rehabilitation before
compensation. Rehabilitative care, for tuberculosis patients for example, was
delivered directly by most financing agencies, including sickness funds and local
communities, in the form of inpatient treatment in the countryside. This led to
the heterogeneous development of rehabilitative care and to the popularization
of spa treatments which became an institutional niche for natural treatments
and remedies (often categorized as alternative medicine today).
During the 1880s many workers boycotted the self-administered sickness
funds and chose self-supporting funds as a legal alternative to sickness funds
(known as substitute funds). These funds were self-governing and were run
entirely by the workers. However when this choice became restricted in the
early 1890s, sickness funds became the stronghold of the social democratic
party. The national government interfered to separate the rising white-collar
movements from the blue-collar by introducing a separate string of statutory
health insurance for salaried employees in 1901. Since white-collar workers
received greater rights to choose, the existing substitute funds catered almost
exclusively for white-collar employees from that time onwards (until 1995).
The substitute funds, although contributions were now shared with employers,
maintained the historical pattern of representation that is 100% employees,
which is still the case today. The 1911 Imperial Insurance Regulation introduced
a common legal framework for social insurance. These regulations covering
Germany
15
health insurance remained in force with changes until 1988, the regulations
governing maternity benefits still remain in force today (see Health care benefits
and rationing).
The number of citizens with health insurance doubled from 1880 to 1885.
Table 4 shows that over the ensuing decades statutory health insurance was
gradually extended from 10% of the population in 1885 to 88% in the Federal
Republic of Germany (FRG) in the western part; while the (socialist) German
Democratic Republic (GDR) in the eastern part provided coverage to 100%
of the population from 1949 onwards (Table 4). The universal statutory health
insurance system of the GDR was abandoned after reunification in 1990
in favour of the social insurance type of the former FRG. The extension of
membership was achieved either by increasing the income ceiling of mandatory
membership or by adding new occupational groups to the sickness fund system,
Table 4.
Trends in statutory health insurance (SHI), 18802003

1885
1913
1925
1938
German Empire
Statutory sickness
funds
Number
Contributing members
per fund
Membership
Insured people per
population (%)
Contributing members
in population (%)
Mandatory members/
working population (%)
Contributions
% of income
Income ceiling
for mandatory
membership (multiple
of the average income)
Ratio contributions by
employees/employers
SHI expenditure
% of GDPa
Ratio monetary/service
benefits
18 776 21 342
1950
1960
1987
western part of
Germanyb
1 992
2 028
1997
2003
Germany
7 777
4 625
1 182
476
319
4 832 10 141 13 383 30 917 91 782 159 780
229
636
2 345
10
35
51
83
88
88
88
20
29
34
40
49
60
61
62
22
44
57
66
62
67
76
78
76
8.4
12.6
13.5
14.3
3.1
2.1
1.6
1.9
1.5
1.3
1.1
1.3
1.6
2:1
2:1
2:1
2:1
2:1
1:1
1:1
1:1
1:1
0.2
0.7
1.7
1.9
2.6
3.2
6.2
6.4
6.8c
1.7:1
1:1
1:4
1:8
1:12
1:12
Source: Alber 1992 (20); Federal Statistical Office (4,55), Federal Ministry of Health 2004.
Note: a including transfer payments e.g. sick pay, maternity benefit; b in the German Democratic
Republic, 2 funds covered nearly 100% of the population; c data for 2002.
Germany
16
i.e. white-collar workers from the transport and commercial sectors (1901),
domestic servants, agricultural and forestry workers (1914) or farmers (1972)
(20). Germany also managed to integrate certain social groups into the statutory
scheme that were covered by public agencies in some other European countries,
such as the unemployed, family dependants, pensioners, students, the disabled
and, in 2004, recipients of social welfare.
Contributions and expenditure increased substantially during more than
120 years of statutory health insurance (Table 4). This was the result of the
extension of benefits often following decisions by the social courts through
state intervention but mainly by the self-administered funds themselves or
by joint committees of the funds and physicians. While initially the statutory
health insurance scheme aimed primarily at preventing impoverishment by
compensating income in cases of illness, sickness funds increasingly funded
services and the prescriptions of specialized professionals. This is reflected in
the falling ratio between monetary and service/ product benefits. The trend was
accelerated even further after 1969, when FRG employers became obliged to
continue remunerating their employees during the first six weeks of sickness
(Table 4).
When looking at rising expenditures it should not be overlooked that the payas-you-go principle of contributions and expenditure were crucial in providing a
sound financial basis for health care financing even during the two World Wars,
mega-inflation in 1923, the economic crisis of 1929 and the introduction of a
totally new currency in 1948.
Collective victories of the medical profession over funds and
other professions
The shift from monetary to service benefits (Table 4) corresponded with a
growing number of health professionals (Table 5). This trend reflects a broader
transformation from nineteenth-century industrial society to what has been
called a professional society. Health care services were one of the solutions
which the rising class of professionals offered as a means of addressing social
and physical problems, with the approval of most sections of society. However
the socialization of professional health care developed alongside deep conflicts
over income and power.
The conflicts between the sickness funds and physicians working in the
ambulatory sector on a for-profit basis were one of the major factors that shaped
Germanys current health care system. Office-based physicians not only played,
and still play, a dominant role in the ambulatory sector but also affect the health
care sector as a whole. Until 1933 they gained major victories over the quasiGermany
17
public funds, over other health professions and over physicians working in the
public or non-profit private sector.
The 1883 legislation did not address the relationship of funds and doctors
or the qualifications of health care professionals, leaving these matters up to
the funds. Doctors initially hardly took any notice of this regulation, but from
the 1890s they fought for autonomy and income through strikes and lobbying.
The underlying developments were the extension of the number of patients
with insurance coverage, the restricted access of insured patients to doctors,
the dependence and low status of (salaried) doctors from the worker-dominated
funds and the doubling of the ratio of physicians per population from 1887 to
1927. From 1900 onwards the medical profession managed to nationalize its
campaign and to convince the rival panel and private doctors to make uniform
demands. The most successful interest group was the Leipzig Union, later called
Hartmann Union, which was founded in 1900 and whose membership grew
from 21 doctors to nearly 75% of all German physicians by 1910.
Since the 1911 Imperial Insurance Regulation did not address any of these
demands, physicians threatened to go on strike shortly before it took effect
in 1914. In December 1913, the government intervened for the first time in
the conflict between funds and physicians. The Berlin Convention made joint
commissions between physicians and funds obligatory in order to channel the
conflict into constructive negotiations. The ratio of doctors to fund members
was now legally fixed at a minimum of 1:1350, to be put into practice by joint
registering committees. Contracts with physicians had to be agreed with all
funds collectively.
After the Berlin Convention expired at the height of inflation in 1923,
office-based physicians went on strike repeatedly. Some funds responded by
setting up their own health care centres which although few in number were
perceived by the medical profession as a menacing throwback to nineteenthcentury conditions and socialization of medical services. Private practitioners
also felt threatened by the establishment of a broad diversity of services for
prevention, health education and social care, delivered by local communities
and welfare organizations. The government also responded to the strikes and
created the Imperial Committee of Physicians and Sickness Funds (which still
exists today as the Federal Joint Committee) as the joint body responsible for
decisions regarding benefits and the delivery of ambulatory care.
In 1923 the first cost-sharing measure in the form of a 1020% co-insurance
for pharmaceuticals and medical appliances was introduced into the statutory
health insurance (SHI) system during a period of economic recession, and an
exemption mechanism for the unemployed was already put in place (Reichelt,
1994a). In 1930 this co-insurance was replaced by a flat fee co-payment per
Germany
18
prescription and an additional co-payment for ambulatory care consultations

was introduced (Reichsministerium des Innern, 1930). These changes were
part of a number of emergency regulations passed to counteract substantial
reductions in sickness fund revenues and increases in claims for unemployment
benefits during the financial crisis at the end of the Weimar Republic (Alber,
1992). As part of emergency regulations, the supervision of doctors through a
medical service of the sickness funds and a doctor/fund-member ratio of 1:600
were also introduced. In return, ambulatory physicians were granted a legal
monopoly for ambulatory health care (1931) for which they had been lobbying
(with gradual success) over the preceding decades. These regional physicians
associations obtained the right to negotiate complex contracts with statutory
sickness funds and to distribute their payments among their medical members.
The regulations reflected a major collective victory by ambulatory physicians
over sickness funds, hospital doctors, medical officers in community health,
and other health care professionals.
State regulations had already subordinated allied health professionals (such
as midwives and nurses) under the medical profession since 1854 and they
now restricted their autonomy further by completely prohibiting them from
contracting directly with statutory health insurers. The ambulatory monopoly
for physicians in private practice meant that it was illegal for medical officers in
the community health services to provide curative services, for sickness funds
to buy and supply pharmaceuticals or medical services, and for most hospitals
to treat outpatients.
Table 5.
Health care personnel and hospital capacities, 18762002

Total
population
Number of inhabitants per

Physician
1876
1885
1900
1909
1927a
1938
1952b
1960b
1975b
1987b
1991
2002
3 136
3 004
2 047
2 085
1 447
1 371
700
699
521
356
329
274
Dentist
86 460
86 752
9 529
5 682
2 690
1 924
1 706
1 705
1 946
1 573
1 450
1 289
Pharmacist
6 877
7 483
6 414
5 982
5 789
4 182
3 514
2 415
1 802
1 922
1 528
Nurse
3 260
926
712
517
476
527
388
292
117
Hospital
bed
406
324
219
158
120
107
89
95
85
91
99
111
in millions
43.1
46.7
56.0
63.7
63.3
68.4
48.7
55.4
61.8
61.1
80.3
82.5
Source: Alber 1992 (20); Federal Statistical Office 2004 (21); Federal Statistical Office 2004 (3).
Note: a or 1928; b applies to the Federal Republic of Germany only.
Germany
19
Thus, the legalization of the physicians ambulatory monopoly contributed

substantially to their division from the hospital sector and to the marginalization
of community health services. The separation of inpatient and outpatient
care was also enhanced by the rapid expansion of acute hospital care, with
the majority of personnel working full-time from the 1920s. Acute hospital
capacities increased substantially between 1885, when there was one bed for 324
inhabitants, and 1938, when the ratio decreased to one bed for 107 inhabitants
(Table 5). The separation between inpatient and outpatient care was further
promoted by the division of financing and planning responsibilities between
the corporative associations of funds and physicians and the public agencies
at the state and community level, each with their particular traditions of health
administration and legal frameworks.
Another factor contributing to the division of inpatient and outpatient sectors
was the early specialization and professionalization of medicine. The pioneering
role of German physicians in empirical scientific research in medicine had
been strongly supported by regional and national authorities since the 1880s.
By the turn of the century most medical faculties provided chairs for all major
clinical and basic science sub-specialties, which were made obligatory subjects
for medical students by 1920. Medical and specialist training continued to
be science-oriented and based in hospitals only, as is still the case today.
The exceptional specialization process was a result of these trends and of the
competition among the medical profession for income and operational fields.
Conversely, the specialization and subsequent professionalization (including
full-time occupation and separate professional organizations) increased intraprofessional rivalries further both between medical professionals in the private
and the public sector and between generalists and specialists, a conflict which
is currently as important as ever.
Rationing and structural continuity during the National Socialism
period
During the period of National Socialism (19331945) the fundamental structures
of the social insurance system, including health care financing and delivery, were
maintained. Statutory health insurance coverage was extended to pensioners
(1941), and sickness funds became legally obliged to provide hospital care not
only to members but also to dependants (1936), which most funds had already
voluntarily provided.
Despite structural continuity, fundamental principles of statutory health
insurance were discarded. Access to services and cash benefits from statutory
health insurance, accident and old age insurance was increasingly restricted or
Germany
20
denied to the Jewish population and other stigmatized minorities due to the broad
realization of National Socialist policies of expulsion, exclusion from social
life, murder and detention in concentration camps. Forced migrant labourers
were obliged to contribute to statutory health insurance but could not count
on their formally acquired right to benefits. Service delivery was often below
standard. Members of the medical profession were instrumental in legitimizing
murder, social selection and cruelty.
In contrast to the general structural continuity of the health care system, the
management of health care and the balance of power among the main actors
was changed during the Nazi regime. Sickness funds (1934), community
health services (1935), nongovernmental organizations dealing with welfare
or health education and the health care professions organizations (19331935)
were each centralized and submitted to a leader nominated by the National
Socialist German Workers Party (following the so-called Fhrerprinzip).
Self-administration became penetrated by nominated members of the NationalSocialist Party. The participation of workers and employers was reduced to
functions in an advisory council. In addition physicians and local communities
were allowed to send representatives to the council, and the balance of power
was shifted further from the funds to the physicians.
In 1933 socialist and Jewish employees and the majority of workers
representatives in sickness funds were expelled by law. Already in 1933, one
quarter of employees in sickness funds and about one third of the doctors
working for local community welfare services were forcefully released.
Subsequent laws prohibited Jewish doctors from treating patients with statutory
health insurance (1933) and non-Jewish patients (1937) and eventually from
practising medicine at all (1938). Thus 12% of physicians in the country (and
60% of doctors practising in Berlin) were restricted from delivering health care,
which further reduced the access of Jewish patients to health care. The majority
of the medical profession the profession with the highest membership in the
National Socialist party welcomed the exclusion of Jewish doctors from the
panel.
The weakening of sickness funds was accompanied by a strengthening
of the structures of ambulatory physicians. The regional physicians and the
newly founded National Physicians Association were established as public
bodies (1934). They were also granted the right to decide over the registration
of office-based physicians themselves without negotiation with sickness funds.
In return they were forbidden to strike, and made responsible for emergency
care in the ambulatory sector as well as for the administration and control of all
ambulatory physicians. Although nature therapists were promoted ideologically
during the first years of the Nazi regime, their status of free traders was restricted
Germany
21
since 1939, when their certification and practice were submitted to the control
of public health officers.
Post-Second World War
When the National Socialist period was finally ended with Germanys surrender
on 8 May 1945, health care and virtually all other sectors of German society
began to bifurcate into two separate and differently organized systems. The
three zones occupied by western allies were to become the Federal Republic of
Germany (FRG), while the Soviet zone in eastern Germany was to become the
German Democratic Republic (GDR), and so they remained until reunification
in 1990.
In the Nuremberg war-crime trials, chaired by an international committee
of judges, some of the medical doctors who had misused their skills, power
and research in concentration camps or institutions for mentally handicapped
received capital sentences for crimes against humanity.
Health care in the first years of post-war Germany was characterized by adhoc public health interventions aimed at handling and preventing epidemics and
distributing scarce resources for health care. The western allied forces basically
supported and relied upon existing personnel and structures in health care and
administration. The British administered health affairs in a more centralized
fashion whilst the French tried to restrict centralized powers within their zone
and the whole of the western part of Germany. The Americans concentrated
mainly on ad-hoc policies, tried unsuccessfully to establish a school of public
health and blocked the re-establishment of the monopoly of regional physicians
associations until the 1950s.
The national health service in the German Democratic Republic
In contrast, the Soviets took a more interventionist role in their zone in the
eastern part of Germany which, in 1949, became the German Democratic
Republic (GDR). They called 60 health experts to advise them on designing
a new model, which came to be influenced by the social hygiene traditions of
the Weimar-era community health care services and by the health care systems
in Soviet Union, Sweden and the United Kingdom. They took an authoritarian
approach to controlling infectious diseases, and despite the protests of physicians
gradually introduced a centralized, state-operated health care system.
The resulting GDR health care system differed from its Soviet counterpart
through a structural division between ambulatory and hospital services, which
in practice, however, often operated closely together on the same premises.
Germany
22
In addition, the principle of social insurance was maintained de jure with

workers and employers sharing contribution costs but with administration
concentrated in only two large sickness funds, one for workers (89%) and one
for professionals, members of agricultural cooperatives, artists and the selfemployed (11%). De facto, however, the role of the social insurance system
was extremely limited.
As in most socialist countries, the majority of health care personnel were
employed by the state, with a few delivering ambulatory care in solo practices but
most through community-based or company-based health care centres, usually
staffed by a range of medical specialists and other health care professionals.
Unlike the neighbouring Soviet bloc countries, not all health care institutions
were formally nationalized. Instead, independent institutions could continue to
exist but faced increasing difficulties when exercising their role as health care
providers. As a result, the number of non-profit hospitals decreased from 88 to
75 between 1960 and 1989, and the number of private hospitals fell from 55
to2 in the same period. However, in 1989 about 7% of all hospital beds were
still not state-owned and a few physicians were still in private practice (18).
Local communities provided preventive services, encompassing health
education, child and maternity health and specialist care for chronic diseases
such as diabetes or psychiatric disorders. These health care services were
complemented by comprehensive social support provided by the state, such as
housing, day-care and crches, which also contributed to the policy imperatives
of increasing the population and the active workforce. Thus, they soon achieved
a type of health care system which the political left of the Federal Republic of
Germany (FRG) in the western part of the country and in many other western
countries aspired to until at least the 1960s.
However, due to under-financing, personnel shortages and lack of access to
modern equipment, the GDR health care system gradually began to fall behind
the standards of western industrialized countries beginning in the 1970s and
visibly worsening in the second half of the 1980s. In the hospital sector, the
GDR had about a quarter fewer hospital cases per 1000 population than in the
west yet hospital occupancy fell below 75% in the 1980s.
This lack of modern medical care has been associated with population
health. Available evidence suggests, for example, that shortages in surgical
capacity may have been related to higher infant death rates due to congenital
anomalies of the heart and cardiovascular diseases in the GDR than in the FRG
in the 1980s. Other data indicate under-treatment or less effective treatment of
hypertension, as the prevalence of recognized but untreated hypertension was
shown to be lower, while rates of treated but uncontrolled hypertension were
found to be higher than in the FRG. Further evidence suggests possible underGermany
23
treatment of elderly stroke patients in the former GDR, which was reflected in
a high case fatality especially among those over 65. A recent study reported a
case-fatality rate of about 20% after proximal femoral fractures in the former
GDR in 1989considerably higher than that in the FRG. Although other factors
such as case mix have to be considered, these findings point to the possible
effect of differences in medical care on the widening mortality gap between the
two parts of divided Germany. This gap to the disadvantage of the GDR had
developed since the mid-1970s while previously life expectancy had improved
almost equally, with even a slight advantage for men in the GDR during the
1960s and early 1970s (Table 3). In 1989, a National Health Conference had
decided to introduce profound health care reforms with increased investment, but
the GDR ceased to exist after November, when the Berlin Wall was opened.
The continuation of the social insurance system in the Federal
Republic of Germany
The local sickness funds, labour unions and the Social Democratic Party
campaigned for a single statutory insurance fund for health, old age and
unemployment in order to increase bargaining leverage over the monopoly
that ambulatory physicians already enjoyed in different regions. However, the
conservative Christian Democratic Party won the first elections in 1949 and
by 1955 had basically restored the Weimar Republic health care system on a
national level (in coalition with the employers). Sickness fund contributions were
now shared equally between employees and employers as well as representation
(except in the substitute funds). The insurance for work-related accidents and
disability continued to be entirely financed by employers, yet trade unions were
granted a 50% representation. (Due to the power of the Allies, the health care
system in West Berlin was governed by slightly different arrangements and a
unified health insurance was maintained until the early 1960s.)
Self-administration became predominantly a field for corporatist
representatives with relatively little transparency and democratic rights
for insured members. Private ambulatory physicians were again granted a
monopoly with the corresponding rights, power and duties. In addition, the
legal ratio of physicians to fund members was increased to 1:500 and then
abolished completely in 1960 in favour of professional self-regulation after
the Constitutional Court had declared the freedom to choose ones work a
constitutional right.
The period from 1955 to 1965 could be characterized as a period of struggle
over cost-reducing structural reforms that a coalition of physicians, sickness
funds, media and health product companies were able to subvert. Health care
Germany
24
reform proposals failed in 1960 and in 1964, both of which contained provisions
for user charges far exceeding those introduced during the cost-containment
period. From 1965 to 1975, costs for health care increased substantially, due to
rising prices and wage costs (including a shift from religious orders to secular
personnel), demographic trends, the supplementary use of more expensive
equipment and the modernization and expansion of health care services and
infrastructure. Ambulatory physicians developed an increasingly sophisticated
system of fee-for-service remuneration. New services for secondary prevention
and partly for occupational medicine were put under the auspices of office-based
physicians, which saved costs for public health services but also decreased their
role in the health care system.
The 1970s saw an extension of reform-oriented social, psychiatric and
nursing services, mainly delivered by private non-profit organizations at the
community level. In addition, new membership groups were brought under
the roof of statutory health insurance (farmers, the disabled and students). In
1972 the responsibilities of states and funds in financing hospital reform were
clarified and converted to the dual financing method, which made funds
pay for services and personnel while states were to finance investment but no
running costs. Therefore, it is important to note that the growth of the health
care sector and health care expenditure was the result of an explicit political
strategy. It aimed at overcoming the infrastructural deficits and shortcomings
caused by the destruction suffered during the Second World War as well as the
insufficient mode of financing hospital investment that existed at the time.
After the oil crisis (from 1975 onwards), the continuous cost increases
attracted criticism of health care providers financial interests. The era of costcontainment in German statutory health insurance began in 1977, with the
introduction of the Health Insurance Cost-Containment Act, ending the period
of rapid growth in health care expenditure, especially in the hospital sector.
Since 1977, the main cost-containment target in health care has been that the
sickness funds and providers pursue a goal of stability in contributions. This
requirement pegs increases in contribution levels to the rate of increases in
contributory income. Ensuring compliance with this legislation was one of
the main tasks of Concerted Action in Health Care, a round-table for the rival
corporatist organizations which was established in the 1980s by the Christian
Democratic government (in power from 1982 until 1998) to decide on how
to contain costs jointly. The committee was expanded over the years to about
130 representatives, but due to continued conflicts did not meet its political
expectations. It last met in 1997, and was finally abolished in 2003 after the
red-green government had consulted stakeholders in a series of smaller ad-hoc
round-tables (see Organizational structure of the health care system).
Germany
25
The basic principle behind German style cost-containment was an

income-oriented expenditure policy to guarantee stable contribution rates.
This was an important objective in a time of economic restructuring and growing
international competition, since the contributions are jointly paid by employers
and employees. Therefore, increases in contribution rates are seen as a question
of international competitiveness.
The drive for cost-containment, which intensified after re-unification,
was realized through a long series of legislation (see Content of reforms and
legislation) applying a variety of measures for expenditure control and costshifting and incentives to increase technical and allocative efficiency.
The transfer of the FRG health care system to the eastern part of
Germany
In 1990, after the fall of the Berlin Wall, the transitional GDR government and
the FRG government signed the Treaty of German Reunification, integrating
the 17 million former GDR citizens quickly and comprehensively into the
system of the old FRG. The transformation of the new Lnder in the eastern
part according to FRG standards already existing in the western part not only
affected the widely criticized political and economic system but also the social
security and health care, which the public had regarded more positively. Yet
ideas for a third way, for example, one uniform health insurance system in the
eastern part of Germany or in the whole country, were dismissed on practical,
political, legal and lobbyist grounds.
Only minor compromises were made concerning the financing and delivery
of health care. For example, the Treaty of Reunification granted the community
health care centres (polyclinics) only five-years grace after which they were to
negotiate jointly with regional physicians associations. But the time limit and
the restrictions on remuneration that could be achieved by these centres they
received per capita payments instead of the fee-for-service that office-based
physicians collected did not offer great prospects for the future. By May
1992, 91% of physicians, who previously had worked in different ambulatory
public settings, were running their own single practices. There are only a few
polyclinics (in Berlin and the federal state of Brandenburg) that have managed
to continue operating either as a network of distinct solo-practices or as
cooperatives. It is only since 2004 that this interdisciplinary form of delivery
has been admitted for the whole of Germany, as medical care centres, headed
and staffed by physicians.
In addition, the German health insurance types of the old FRG expanded
quickly into the new Lnder in the eastern part, but this has resulted in a lower
Germany
26
percentage of privately insured citizens (2% versus 10% in 1993) and a higher
proportion of general regional fund members (61% versus 64% in 1991). The
federal government supported the upgrading of infrastructure in the eastern part
through an immediate aid programme of several billion Euros, directed mainly
towards hospitals and nursing homes.
Health care reforms in a unified Germany after 1990
These extraordinary tasks increased the pressure on the system and contributed
to the increasing speed of health care reform legislation in the 1990s, and
especially after the turn of the millennium (see Health care reforms). The
leading reform principles since reunification have been expenditure control
and enhancing technical efficiency by increasing (regulated) competition, while
avoiding adverse effects on equity and securing quality. Rationalization was
given priority over rationing, and few benefits were taken out. At the same time,
a substantial number of innovative drugs and technologies were reimbursed,
and the service profile was shifted towards long-term care, palliative care and
prevention.
Health policy under the Christian Democratic-Liberal government (1982
1998) after reunification can be divided into two major periods: First, the health
care reforms from 1988 until the mid-1990s were characterized by stronger
expenditure control in all sectors of care. On the other hand pro-competitive
regulations among payers and in the hospital sector were introduced, buffered by
measures to avoid adverse effects on equity and quality. In addition, new benefits
were introduced to meet health needs of the population more appropriately and
at efficient points of care. In particular, access to long-term care benefits was
extended substantially by introducing statutory long-term care insurance as a
new fifth pillar of social insurance (see Social care). Second, the three reform
acts in 1996 and 1997 emphasized income raising out-of-pocket payments.
Preventive and rehabilitative benefits were reduced and youth was excluded
from denture benefits while budgets were relaxed.
The health care legislation by the Social Democratic-Green government
(since 1998) can be divided into three shorter phases (see Health care reforms):
First, from 1998 to 2000 the majority of legal arrangements of the 1996 and 1997
acts were removed and replaced by strict cost-containment measures targeting
all sectors of provision. In addition, the catalogue was extended by minor
benefits (socio-therapy, patient information), complemented by a modernization
of health professional education. Second, between 2000 and 2003, a variety
of small acts were introduced following a change of minister and a roundtable consultation of a broad range of actors. The pharmaceutical spending
Germany
27
caps were lifted and replaced by negotiation powers for the actors of the SHI
self-governance and finally prescription feedback for physicians. In addition,
a decisive realization of the legislation on diagnosis-related groups (DRGs) as
a payment system in hospitals and a reform of the risk structure compensation
scheme that reallocates revenues among sickness funds (see Main source of
financing and coverage) were undertaken. Third, with the introduction of the
Statutory Health Insurance Modernization Act in 2004, many of these reforms
were pushed a step further or made obligatory. In addition, a policy turn toward
private financing and benefit exclusion partly reverted on solutions of the 19961997 reforms. Furthermore, innovative delivery models of care were given a
firm basis, thereby diversifying the delivery landscape of health care.
While health care reforms with their focus on efficiency and appropriateness
have shaped the performance of health care providers and payers substantially,
one should keep in mind that non-health reforms had substantial influence.
First, the principle of institutional transfer of the German reunification had
substantial impact on structural reforms in the eastern part and required
substantial investment to decrease inequalities. Second, a broad series of welfare
reforms impacted on the revenue side of health care, usually by diminishing
the contribution of welfare recipients (pensioners, the unemployed, students
or social welfare recipients). Partly, revenues were also increased by making
people with minor part-time jobs pay contributions. Third, European Union
legislation and jurisdiction has exerted considerable influence health care
goods and services; though largely out of the public eye, it is expected to have
profound impact on health care in the future. In addition, a fundamental reform
of the financial basis and the institutional arrangement of the health care system
and long-term care insurance are under heated public debate, including the
extension to universal coverage.
Germany
Organizational structure and

management
Organizational structure of the health care system
fundamental facet of the German political system and the health care
system in particular is the sharing of decision-making powers between
the Lnder, the federal government and legitimized civil society
organizations. In health care, governments traditionally delegate competencies
to membership-based, self-regulated organizations of payers and providers.
Their knowledge and motivation, that are actually involved in financing and
delivering health care covered by statutory insurance schemes. In the for health
care most prominent scheme, the statutory health insurance, sickness funds,
their associations and associations of SHI-affiliated physicians have assumed the
status of quasi-public corporations. These corporatist bodies constitute the selfregulated structures that operate the financing and delivery of benefits covered
by statutory health insurance within the legal framework. They are based on
mandatory membership and internal democratic legitimization. They may define
and raise membership fees and finance or deliver services to their members.
In joint committees of payers (associations of sickness funds) and providers
(physicians or dentists associations or single hospitals) legitimized actors
have the duty and right to define benefits, prices and standards (federal level)
and to negotiate horizontal contracts, to control and sanction their members
(regional level). The vertical implementation of decisions taken by senior levels
is combined with a strong horizontal decision-making and contracting among
the legitimated actors involved in the various sectors of care.
All major actors as well as their main interrelationships are shown in Fig.3.
Beyond the established decision-making corporatist organizations, other
organizations have recently been given formal rights to contribute to decisionmaking bodies by consultation (e.g. nurses and allied health professions),
Germany
30
participation and proposals (patient organizations) or becoming a deciding and

financing partner at the table (private health insurance for case payments in
hospitals). A separate group of actors are the courts which will be dealt with
separately after the federal, Lnder and corporatist levels.
The German constitution (known as the Basic Law) requires that living
conditions shall be of an equal standard in all Lnder. However, health promotion
or protection is not specifically mentioned as a goal. (This was different in the
German Democratic Republic, where Article 35 of the constitution named
health protection as a state objective.) As mentioned, the constitution defines
areas of exclusive federal legislation and concurrent legislation. Health is not
an area exclusive to federal legislation but specific topics relevant to health are
included in the concurrent legislation, for example, social benefits, measures
against diseases that threaten public safety, protection against ionizing radiation,
certification of physicians and other health professions, pharmaceuticals
and drugs, and the economy of hospitals. However, federal law where it
exists in these areas takes precedence over Lnder law. In addition, parts of
environmental policies fall into this category. Implicitly, all other aspects of
(public) health are therefore the responsibility of the Lnder.
Federal level
At the national level, the Federal Assembly, the Federal Council and the Federal
Ministry of Health and Social Security are the key actors. In 2002, the divisions
for social security of the former Ministry of Labour and Social Policy were
integrated into the former Ministry of Health. As before 1991, one ministry is
responsible for all branches of social security except unemployment, which is
now integrated in the Ministry of Economy and Labour. Since then the Ministry
of Health and Social Security (in the following text called Ministry of Health)
has been reorganized into eight areas with two or three sub-divisions each:
administration
European and international health and social policy
planning, future of the social state, innovation and information
pharmaceuticals and health protection
health care, statutory health insurance, securing long-term care
prevention, combating disease and biomedicine
social insurance, retirement insurance, Social Code Book, social
compensation
issues of disabled people, social welfare.
Germany
Fig. 3.
31
The organizational relationships of the key actors in the health care system,
2005
Proposals
for health
reform acts
Federal
Ministry of
Health
Federal parliament
Federal Assembly
(Bundestag)
Federal Council
(Bundesrat)
Representation
State
ministries
responsible
for health
Supervision
Supervision of country wide funds (via Federal

Insurance Office)
Valuation
Committee
Supervision
Supervision
Obligation to contract
Federal
Association of
SHI Physicians
Hospital
Financial negotiation
Super
vision
Financial negotiation
17 (regional)
physicians
associations
Freedom to choose
Physician
Obligation to secure
hospital care
O
bl
Fr
ig
at
ee
io
do
n
m
to
to
tre
ch
at
oo
se
Insuree /
Patient
O
bl
am iga
bu tion
la to
to s
ry e
ca cur
re e
at
se
tre hoo
to
c
n
to
io
m
at
ig
do
bl
e
e
O
Fr
Enlistment in hospital plans
Legislative frame
16 regional
hospital
organizations
German
Hospital
Organization
Sickness fund
Sickness funds in
one region
Federal
associations of
sickness funds
Supervision
Institute for
Hospital
Reimbursement
Supervision
Federal Joint Committee
Commissioning
Supervision,
commissioning
Accreditation ,
supervision
Institute for Quality and Efficiency
Statutory health insurance

Accredited patient
organizations
Germany
32
The ministrys former division of consumer protection (mainly food-related)

and veterinary medicine had been shifted already to a new Ministry of Consumer
Protection and Agriculture in 2001 when the Ministers of Health and Agriculture
resigned in the BSE crisis.
Linked to the Ministry of Health and Social Security are the Narcotic Drug
Commissioner of the Federal Government (since 1998), the Commissioner of
the Federal Government for the Concerns of Disabled People (since 2002),
the Commissioner of the Federal Government for the Elections in Statutory
Insurance (since 2002) and the Commissioner of the Federal Government for
the Concerns of Patients (since 2004). The Ministry of Health is consulted by
ad-hoc committees and the Advisory Council for Evaluating the Development
in Health Care which previously reported to the Concerted Action in Health
Care.
The Ministry of Health is assisted by subordinate authorities (not included
in Fig. 3) with respect to the execution of licensing and supervisory functions,
scientific consultancy work and information services to the population or
scientific community:
The Federal Institute for Pharmaceuticals and Medical Devices (BfArM)
licenses pharmaceuticals and supervises the safety of pharmaceuticals and
medical devices (see Health technology assessment).
The Federal Institute for Sera and Vaccines (Paul-Ehrlich-Institute) licenses
sera and vaccines.
The Federal Institute for Communicable and Non-Communicable Diseases
(Robert Koch-Institute) has the tasks of surveillance, detection, prevention
and control of diseases. It is responsible for issuing and publishing health
reports and epidemiological bulletins. Since 2001, its role in infectious
disease control has been strengthened with respect to monitoring, the
coordination of interventions, international cooperation, risk communication
as well as performing microbiological and epidemiological research (see
Public Health).
The Federal Centre for Health Education (BZgA) is responsible for
developing and disseminating health education materials. It organizes,
coordinates or supports prevention campaigns and performs social marketing
research for conceptual and evaluative purposes (see Public Health).
The German Institute for Medical Documentation and Information (DIMDI)
has the task of providing information to the public and professionals in all
fields of the life sciences. After initially concentrating on health care and
Germany
33
medicine, DIMDI now offers a broad collection of databases covering the

entire spectrum of life sciences and social sciences. It has organized the
prioritization, out-sourcing and publication of health technology assessment
reports since 2000 (see Health technology assessment).
The first three institutions are the successors of the Federal Health Institute,
which was more independent of the ministry but was dissolved after being
accused of mishandling the requirement to carry out HIV testing of blood
products in 1993.
Other federal institutions relevant to the health care system are the Federal
Insurance Authority (for social insurance actors) and the Federal Authority for
Financial Services Supervision, responsible for supervising private for-profit
insurance (not included in Fig. 3).
Lnder level
The federal structure is represented mainly by the 16 state governments and, to
a very small extent, by the state legislatures. In 2003, 13 out of the 16 Lnder
governments had a ministry with health in its name. However, none has an
exclusive health ministry. In most of these Lnder it is most commonly combined
with Labour and Social Policy (which is also the case in the remaining three
Lnder), less commonly with family or youth affairs, and only in one Land is
it combined with environmental affairs, a combination more common in the
1970s and 1980s.
Within a Lands Labour Ministry, health is typically one of four or five
divisions. In Lower Saxony for example, the health division is further subdivided into units concerned with
public health services and environmental hygiene
health promotion, prevention and AIDS care
state-owned hospitals
hospital planning
supervision of health professions and their professional institutions
psychiatry and illegal drugs
pharmaceuticals and supervision of pharmacists and their professional
institutions.
Most other areas affecting health such as traffic, city planning or education
are controlled by other ministries.
Germany
34
Corporatist level
Providers
For the statutory health insurance scheme, corporatism is represented by the
SHI-affiliated physicians and dentists associations on the provider side and the
sickness funds and their associations on the purchasers side. These bodies have
assumed the status of a quasi-public corporation and are based on mandatory
membership.
Physicians treating SHI-insured patients are organized in regional physicians
associations, based on obligatory membership and democratically elected
representation. There is a physicians association in each of the 16 Lnder. In
addition, the highly populated Land North Rhine-Westphalia has two physicians
associations. From 2005, the management of the now 17 physicians associations
will be rendered more efficient by introducing a long-opposed professional fulltime executive board to replace a board of part-time voluntary physicians. In
addition, the number of elected members represented in the regional physicians
assembly will be reduced and the majority voting system will be replaced by
a proportional election system to better represent smaller groups among the
physicians and psychologists. Also, the associations no longer distinguish
between their ordinary members, that is, physicians in private practice, and
other members, mainly hospital physicians who are specially accredited to treat
SHI patients on an ambulatory basis (see Primary and secondary ambulatory
care). Since the Psychotherapy Act of 1999, psychologists with a subspecialization in psychotherapy were admitted to the physicians associations.
This was done to balance the provision and reimbursement of psychotherapy
between physicians and psychologists.
SHI-accredited dentists are organized in the same way as physicians, that
is, through dentists associations in the Lnder and a Federal Association of
SHI Dentists.
The German Hospital Organization has increasingly been integrated into
decision-making bodies of the statutory health insurance structures. Formally
it does not have the status of a quasi-public corporation but represents the
interests of hospitals as an organization based on private law. It is, however,
increasingly charged with legal responsibilities as well. The membership of
the German Hospital Organization consists of 16 Lnder organizations and
12 associations of different types of hospitals, for example, university, public
municipal, or private for-profit. Other organizations have gained consultative
rights but no decision-making powers in recent years.
Germany
35
Payers
The payers side is made up of autonomous sickness funds organized on a
regional and/or federal basis. In January 2004 there were 292 statutory sickness
funds with about 72 million insured people (about 50.7 million members plus
their dependants) (Table 6) and 49 private health insurance companies covering
around 7.1 million fully insured people. On 1 January 2004:
37% of all SHI members were insured with one of the 17 general regional
funds (Allgemeine Ortskrankenkassen, AOK);
33% were insured at one of the 10 substitute funds, formerly open to either
white collars or to blue collars;
21% were covered by one of the 229 company-based sickness funds (BKK)
and
6% were covered by 20 guild funds (IKK).
Special rules apply to the sickness funds for farmers (14), miners (1) and
sailors (1) with closed and comparably small membership (4% in total).
All funds have non-profit status and are based on the principle of selfgovernance. By law, sickness funds have the obligation to raise contributions
from their members, which includes the right to determine what contribution
rate is necessary to cover expenditure. In most funds, the management is made
up of an executive board of two full-time managers responsible for the day-today management of the fund, and an assembly of delegates deciding on bylaws
and other regulations of the fund, passing the budget, setting the contribution
rate and electing the executive board. Usually, the assembly is composed
of representatives of the insured and employers, whereas the assemblies of
the substitute funds are entirely comprised of representatives of the insured
population. Both the representatives of the employees and insured and of the
employers are democratically elected every six years. Many representatives are
linked to trade unions or employers associations.
The total number of sickness funds has decreased steadily since the general
regional funds and the substitute funds were legally opened to all those seeking
insurance through the Health Care Structure Act of 1993 (Table 6). The first
wave of mergers in 1994/1995 affected the general regional funds. As some of
them were very small, they merged into single general regional funds per Land.
In 1995, the guild funds followed partly before they opened themselves to
outside members. The latest wave of mergers has been that of the company-based
sickness funds, also often as a prelude to competition. From the beginning of
1999, the open company-based sickness funds had more members than those
that remained closed, with an exclusive in-company membership.
Germany
36
Table 6.
Number of sickness funds, 19932004 (on 1 January)
1993 1995 1997 1998 1999 2000 2001 2002 2003 2004
General
regional funds
269
92
18
18
17
17
17
17
17
17
Company-based
funds
744
690
457
386
361
337
318
282
255
229
Substitute funds
15
15
14
13
13
12
12
12
12
10
Guild funds
169
140
43
43
42
32
28
25
24
20
Farmers funds
22
21
20
20
20
20
19
17
15
14
Sailors fund
1
1
1
1
1
1
1
1
1
1
Miners fund
1
1
1
1
1
1
1
1
1
1
Total
1 221
960
554
482
455
420
396
355
325
292
Source: Federal Ministry of Health and Social Security 2004 (9,30).
Other statutory insurance funds

Corporatist institutions similar to the sickness funds exist in other health-related
statutory insurance schemes as well:
accident funds covering curative and rehabilitative care services for workrelated accidents and diseases,
retirement funds, responsible for most rehabilitative measures, and
since 1995, long-term care funds which are formed by the existing sickness
funds (see Social care).
Professional chambers
Outside the scope of the statutory health insurance, legally established
professional chambers exist for physicians, dentists, pharmacists,
veterinarians, and since 2003 for psychologists providing psychotherapy. By
law, all these health care professionals must be members of their respective
chambers at the Land level. The chambers are regulated by laws of the Lnder,
and are responsible for secondary training and accreditation and continuing
education, setting professional, ethical and community relations standards. To
coordinate these affairs at federal level, the Lnder associations have formed
federal chambers such as the Federal Physicians Chamber (also called the
German Medical Association). Federal chambers are, however, based on private
law and therefore can only pass recommendations. Professionals organized in
chambers enjoy certain exclusive rights, such as the right to maintain their own
pension schemes. Nurses, midwives and physiotherapists are not organized
in chambers but in a variety of professional organizations with voluntary
membership. Nurse organizations have associated in an umbrella organization
called German Nursing Council which by law is consulted on statutory health
insurance decisions affecting nursing.
Germany
37
Other actors
Voluntary organizations outside the above-mentioned legal actors are too
numerous to be listed. They may be differentiated by their main focus of
interest (scientific, professional, political or economic) and by the group they
represent.
There are 145 medical scientific organizations, united in the Association
of the Scientific Medical Societies. Physicians organizations outside the
corporatist field are of two types, professional and politico-economic. The
former includes organizations for general practitioners and for other (sub)
specialties, working on professional standards and defending their interests
among the wider group of all physicians. Another type of professional
organization are local physicians unions, which have as their main functions
continuing education and providing a forum for physicians from all sectors
working in a particular region. The organizations, which are clearly designed
for lobbying, comprise the Organization of German Doctors the Hartmann
Union as the successor of the Leipzig Union which was formed in 1900 to
defend the economic interests of physicians (see Historical background) and
has its main membership base in the ambulatory sector, and the Marburg Union,
which was formed in 1948 to defend the rights of hospital physicians. Another
organization is the Organization of Democratic Physicians which often finds
itself in opposition to the traditional physicians organizations since it views
itself as a lobby for better health and health care rather than better working
conditions for physicians.
Psychologists are organized in the Professional Organization of Psychologists.
Those providing psychotherapy within SHI are organized mainly in two
organizations, the German Psychotherapist Organization and the Organization
of SHI-affiliated Psychological Psychotherapists.
The main voluntary organizations of nurses with a professional focus are
the independent German Nursing Association and the Federation of German
Nurses Associations as the representation of Catholic, Protestant and Red Cross
nurses associations. Besides these, the German Nursing Council represents 9
other organizations of nurses, midwives, child nurses and care-takers of the
elderly. Other professional groups are represented in a variety of professional
bodies, the main being the German Organization for Physiotherapy, the Federal
Organization of Speech Therapy, the Organization of Ergotherapists.
The most important organization for pharmacists outside the corporatist
sector is the German Pharmacists Organization, the lobbying group for private
pharmacists. Together with the pharmacists chambers it forms the Federation
of Pharmacists Organizations.
Germany
38
The organization of the German pharmaceutical industry changed in the

1990s, when the large, research and international companies formed their own
organization, the Association of Research-based Pharmaceutical Companies (42
manufacturers representing about two thirds of the market), so that the remaining
Federal Association of the Pharmaceutical Industry (ca. 300 members) has
become the organization of small and medium size companies only. The split
was partly attributable to disagreements over whether to support negative or
positive prescription lists. Two other associations represent pharmaceutical
manufacturers with special interests: The Federal Association of Pharmaceutical
Manufacturers (320 members) for producers of over-the-counter medications
and the smaller German Generics Association (27 members) for generics
producers. The latter has recently been complemented by an organization called
Pro Generics representing internationally active generic manufacturers.
The interests of producers of medical technologies and medical devices are
represented by the Federal Association Medical Technologies.
Another important group on the providers side is the Federal Alliance
of Voluntary Welfare Organizations of the six leading non-profit welfare
organizations which own and manage hospitals, nursing homes, home care
agencies and ambulance transportation. In the latter area, the non-profit
organizations actually provide the majority of services. The six associations are
the Workers Welfare Organization (with roots in the Social-Democratic workers
movement), the German Red Cross, the Catholic German Caritas Organization,
the Association of Protestant Welfare Organizations, the Welfare Organization
of the Jews in Germany and the Association of Independent Voluntary Welfare
Organizations.
Turning to the payers side, the 49 major private health insurance companies
(2004) are represented through the Association of Private Health Insurance,
a rather powerful lobby group when it comes to defending the private health
insurance sector. Of the 49 private insurers, 30 are traded on the stock
market.
There is also a large and diverse spectrum of self-help groups, disabled
organizations and organizations of socially insured people. There are about
40000 to 60000 health-related self-help groups with about 3 million members.
Of these only about 360 are also organized at federal level (22). Many disabled
organizations and disease specific self help groups are organized in a Federal
Alliance for the Support of Disabled which is also organized at state level in
14 Lnder. An increasing number, about 1.8 million in 2004, are organized in
two organizations promoting the rights of citizens and insureds in governmental
welfare schemes and in statutory insurance. Of these, the German Council of
Disabled People represents an alliance of independent self-help groups or their
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39
umbrella organizations for disabled people, chronically ill people or social

insured people.
Since 2004, four federal organizations have been accredited by the Federal
Ministry of Health to send delegates to the Federal Joint Committee (see
Planning, regulation and management). Besides the Council of Disabled
People, the three other organizations represent institutions for informing and
counselling patients and consumers, namely the Federation Consumer Centres,
the Federal Alliance of Patient Centres and Initiatives and the German Alliance
Self-Help Groups, an alliance of contact centres to promote the development
of self-help groups (22).
Furthermore, the mainly publicly funded Foundation for the Testing of
Consumer Goods (and Services) and other consumer protection agencies
have started to investigate contribution rates, the service quality and benefit
package of sickness funds, and to evaluate the performance of hospitals and
other providers and to advise the public accordingly. All of the above-named
organizations are politically independent, not associated with particular political
parties.
Planning, regulation and management

Federal level
Issues of equity, comprehensiveness and the rules for providing and financing
social services are regulated at the federal level. All SHI schemes are regulated
through the Social Code Book (SGB) the cornerstone of social insurance
legislation but fall within the authority of different ministries. The Social
Code Book has regulated the statutory insurance schemes in the new eastern
Lnder since 1 January 1991, in the same way as in the western Lnder, except
for certain special, mainly transitional regulations.
The entitlements, rights and duties of insureds covered by statutory insurance
schemes are layed down in Social Code Book I and specified in subsequent social
code books. Health-related social services are regulated through several statutory
insurance schemes, most importantly SHI. Others include accident insurance,
retirement insurance (including responsibility for part of the rehabilitative
measures) and, since 1995, long-term care insurance. Statutory health insurance
(under the authority of the Federal Ministry of Health since 1991) is dealt with
in Social Code Book V (SGB V), amended and supplemented by various reform
laws. In fact, it was modified about 100 times between its inception in December
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40
1988 and December 2003. Book I defines the general rights and responsibilities
of the insured and Books IV and X define responsibilities and administrative
procedures common to all social insurance agencies.
Chapter 1 of SGB V defines the basic principles of the SHI. The remaining
chapters regulate the following issues:
mandatory and voluntary membership in sickness funds (chapter 2);
contents of the sickness funds benefit packages (chapter 3);
scope of negotiations between the sickness funds and providers of health
care, most notably the physicians associations (chapter 4);
Advisory Council for Evaluating the Development in Health Care (chapter 5);
organizational structure of sickness funds and their associations (chapters
6 and 7);
financing mechanisms including the risk compensation scheme between
funds (chapter 8);
tasks and organization of the medical review boards (chapter 9);
collection, storage, usage and protection of data (chapter 10);
administrative fines and penalties (chapter 11), and finally
special regulations for the eastern part of Germany (added through the ReUnification Treaty as chapter 12).
Chapter 4 is the core chapter regulating the corporatist or self-regulated
structure of the SHI system. It defines what has to be and what may be selfregulated through joint committees of funds and providers (for example, the
details of the benefit package or the relative points for services) or through
direct negotiations (for example, the total remuneration for ambulatory or
dental care); the level at which these negotiations have to take place; how the
composition of the joint committees is decided; what happens if they cannot
agree, etc. (details will be discussed in the appropriate sections).
While the rules are defined by the legislature through SGB V at the
federal level, the Federal Ministry of Health is responsible for supervising
compliance by the federal associations of physicians and sickness funds and
the joint committees (see the respective sub-section below). The supervision
of nationally operating sickness funds is the responsibility of the Federal
Insurance Authority, which is also charged with calculating the risk-structure
compensation mechanism among all sickness funds.
Long-term care is also regulated under the authority of the Federal Ministry
of Health through Social Code Book XI (SGB XI), which is in most parts
similar to SGB V in its main content. Other health-related duties at the central
level include legislation in the areas of pollution and ionizing radiation, which
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41
is the responsibility of the Federal Ministry for the Environment and Nuclear
Energy, and supervision of private health insurance companies by the Federal
Authority for Financial Services Supervision (under the authority of the Federal
Finance Ministry).
Patient rights are codified in a broad diversity of legislation and jurisdictions.
A patient charta summarizes central elements. A charta for recipients of
long-term care is currently being developed in a similar process by various
stakeholders and under the auspices of the federal ministries of justice and
health.
Lnder level
The Lnder governments are responsible for maintaining hospital infrastructure,
which they do through hospital plans and their funding (see Secondary and
tertiary hospital care and Hospital payment). The investments are paid for
independently of actual ownership of the hospitals and according to the priorities
of the Land government. While the responsibility for major investments
(buildings and large-scale medical technology) is undisputed, sickness funds
are now responsible for financing building maintenance and repairs, by adding
1.1% to the negotiated hospital budget. With the exception of Bavaria, all Lnder
have refused to pay for these since 1993.
A second major responsibility of the Lnder is public health services (subject
to certain federal laws concerning diseases dangerous to public safety). Some
Lnder operate them themselves while the majority of the Lnder devolve
responsibility for community health services to local governments. The public
health tasks comprise supervision of employees in health care institutions,
prevention and monitoring of transmissible diseases, supervision of commercial
activities involving food, pharmaceuticals and drugs, environmental hygiene,
counselling, provision of community-based psychiatric services, health
education and promotion and clinical examination of school children. Since
the 1970s, most of the preventive measures, such as screening programmes and
health check-ups for children and adults, were included in the sickness funds
benefits package and thus are carried out by office-based physicians.
Additionally, the Lnder are responsible for undergraduate medical, dental
and pharmaceutical education and the supervision of the regional physicians
chamber as well as the regional physicians association(s) and the sickness
funds operating in the Land.
The Lnder co-ordinate their (public) health activities through the Working
Group of Senior Health Officials and the Conference of Health Ministers, both
of which are unable to pass binding decisions, however. In addition, the Lnder
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42
have established various joint institutions to enable them to perform certain tasks.
For example, the Lnder of Bremen, Hamburg, Hesse, Lower Saxony, North
Rhine-Westphalia and Schleswig-Holstein maintain the Academy of Public
Health Services in Dsseldorf to train their public health physicians. A similar
academy is run by Bavaria with the support of Baden-Wrttemberg, RhinelandPalatinate, the Saarland, Saxony, and Thuringia (so that only MecklenburgWestern Pomerania and Saxony-Anhalt run their training for public health
physicians independently). A joint institution of all Lnder is the Institute for
Medical and Pharmaceutical Examination Questions, which is responsible for
preparing and evaluating written examinations in the undergraduate education
of physicians, dentists and pharmacists. From 2004, the Institute will mainly
exert consultative functions in the education of physicians since the regulation
for approbation of physicians of 2003 rules that medical schools shall be more
autonomous in examining students and designing curricula.
Corporatist level
While the Federal Government, the Federal Assembly and the Federal Council
have assumed increasing responsibility in reforming health care through
legislation since the 1980s, the health care system of the population-rich
country is still characterized by a relatively strong degree of decentralized and
autonomous decision-making. Of particular importance are corporatist actors
of payers and providers which are operating the statutory health insurance and
other statutory insurance schemes. Governments and parliaments at federal
or Lnder level typically do not take part in the decision-making bodies of
the statutory health insurance, the statutory long-term care insurance nor the
statutory accident insurance (while federal government has decisional powers
and financial duties for example in the statutory unemployment insurance). The
operations of the non-profit corporatist SHI actors are financed by their respective
mandatory members and organized on the basis of internal representative
democratic structures. Furthermore, a large part of decision-making is realized
by horizontal negotiations in joint committees among provider organizations
and payer organizations at federal level and regional level.
While the decision-making powers of SHI bodies have been reduced in
most European countries in order to reach cost-containment targets, they have
been increased in Germany. The federal governmental aim to exercise more
control of the types and delivery of services included in the benefit has led to
enhanced state supervision of decisions taken by the self-governance but has
not led to a centralization of decision-making powers towards governmental
authorities. It paradoxically led to the creation of new committees within the
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43
self-governance of the statutory health insurance system which is charged with

implementing those legal stipulations.
Within self-governing structures, federal legislation promoted competition
at the level of sickness funds while centralizing decision-making powers
towards the federal level to secure uniform standards (23). The shift towards
joint committees meant a relative decrease of physicians autonomy in favour
of increased powers for sickness funds.
Payers
The corporatist institutions on the payer side the sickness funds have a
central position within the SHI system, as defined by the social code book. The
sickness funds have the obligation to raise contributions from their members
and to determine what contribution rate is necessary to cover expenditure. Their
responsibilities include negotiating prices, quantities and quality assurance
measures with providers on behalf of all sickness funds members. Services
covered by such contracts are usually accessible to all fund members without
any prior permission from the fund. Permission is necessary, however, for
preventive spa treatments, rehabilitative services and short-term nursing care at
home. In cases where there is doubt, the sickness funds must obtain an expert
opinion on the medical necessity of treatment from their Medical Review Board,
a joint institution of the sickness funds.
A reform to make these benefits together with non-emergency ambulance
transportation and physiotherapy optional, that is, to leave it to the individual
sickness fund to decide upon inclusion of these services in its benefit package,
failed late in 1996 as the sickness funds threatened to remove them altogether.
Their main argument was that without these benefits they could offer lower
contribution rates which would attract a healthier clientele, thus widening the
gap in contribution rates and possibly forcing generous funds out of the market
since expenditure for voluntary benefits would be outside the risk compensation
mechanism among the funds.
Providers
The corporatist institutions on the provider side have to provide all personal
acute health care services. The most prominent examples are the physicians
and dentists associations, which have corporatist monopolies and missions
to secure ambulatory care. The monopoly means that hospitals, communities,
sickness funds and others do not have the right to offer ambulatory medical
care except for purposes mandated by legislation or by joint commissions of
payers and providers. These exceptions have been gradually extended in recent
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44
years (see Primary and secondary ambulatory care). The mission includes the
obligation to meet the health needs of the population, to guarantee provision of
state-wide services in all medical specialties and to obtain a total, prospectively
negotiated budget from the sickness funds which the physicians associations
distribute among their members (see Payment of physicians). Regional
physicians associations and regional dentists associations are obliged to
secure the provision of ambulatory care during practice hours and out-of-hour
services. The monopoly also implies that regional physicians associations
negotiate collective contracts with the numerous sickness funds that operate in
their region for ambulatory care, for example (Fig. 3). They distribute financial
resources among their members according to nationally uniform but regionally
adapted rules (Fig. 15). The monopoly also means that neither hospitals (with
a few exceptions, such as university outpatient clinics), nor sickness funds, nor
municipalities, nor non-medical health professionals have the right to provide
ambulatory services outside the scope of the collective contracts.
The legal obligation to deliver ambulatory care includes the provision of
out-of-hour services within reasonable distances, but since 1997 no longer
includes emergency care. The physicians associations must provide health
services as defined by both the legislature and contracts with the sickness
funds. The physicians associations must guarantee the sickness funds that this
provision meets the legal and contracted requirements. Due to the necessity of
intervening and controlling delivery in this way, the physicians associations
were established as self-governing bodies, facilitating their work, which is
constantly influenced by doctors freedom of diagnosis and therapy and supports
the principle of a democratically legitimized cooperative.
Ambulatory medical care is therefore the classic sector in which the
corporatist institutions have the greatest power. Social code book V concentrates
mainly on regulating the framework, that is, generic categories of benefits and
the scope of negotiations between the sickness funds and the physicians and
dental physicians associations. These negotiations determine both the financing
mechanisms and the details of the ambulatory benefit package. As a general
rule, both the scope of services which can be reimbursed through the sickness
funds and the financing mechanisms are tightly regulated, sometimes legally
but usually through negotiations between providers and sickness funds.
Due to the absence of corporatist institutions in the hospital sector, hospitals
contract individually with the sickness funds. Usually, all sickness funds with
more than a 5% market share in a particular hospital negotiate the contract with
that hospital. However, the conditions regarding both the range and number
of services offered and the remuneration rates are valid for all sickness funds.
After the Federal Ministry of Health had unsuccessfully proposed to make the
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45
hospital organizations corporatist bodies, a weaker regulation was included in

the second SHI Restructuring Act to widen the hospital organizations legal
powers, for example to negotiate the catalogue of prospective case and procedure
fees with the sickness funds.
Joint institutions
An important aspect of self-regulation is termed joint self-regulation by at
least two actors, and comes in two different forms: negotiations leading to
contracts and decisions by joint committees. While some delegated tasks always
require decisions by joint committees (for example, defining the benefits), others
are only decided by joint committees if no agreement can be found in open
negotiations (for example on the budget for ambulatory care). In still others,
a joint committee is the first level of appeal against decisions of another joint
committee (for example, in the case of claims review). On the federal level,
joint self-regulatory institutions in the German system include the Federal Joint
Committee, the Valuation Committee and the Extended Valuation Committee.
On the level of each of the 16 Lnder, there are arbitration committees (if
bilateral negotiations for example on reimbursement increases lead to no
result), accreditation committees, accreditation arbitration committees, claims
review committees and claims review arbitration committees. Atypical joint
self-regulatory institutions include government representatives; this was the
case with the committees to plan the infrastructure of high-level technologies,
until their abolition in 1997.
Since 2001, the federal associations of sickness funds and the German
Hospital Organization have been jointly running the independent Institute
for the Development of the Hospital Payment System, which supports the
continuous technical development of the diagnosis-related group system (see
Payment of hospitals).
The most important body for the benefit negotiations between sickness
funds and physicians concerning the scope of benefits used to be the Federal
Committee of Physicians and Sickness Funds, which was responsible for the
ambulatory sector. Established in 1923, it was the oldest joint institution in
the German statutory health insurance system. During the last few decades, it
issued around 20 directives to regulate the certification of sickness, the provision
of screening services or family planning, the prescription of pharmaceuticals,
medical aids and care by non-physicians such as physiotherapists, the
quality-assurance of diagnostic imaging techniques, needs-based planning
of the distribution of physicians in private practice, or the inclusion of new
technologies and procedures into the ambulatory benefits package. The second
SHI Restructuring Act gave the Federal Committee new competencies in July
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46
1997, when it became responsible for technological assessment of the existing

benefits, for defining a positive list for care by non-physicians and for directives
on providing rehabilitative entitlements. The Federal Committee had several
sub-committees, one of which made proposals for decisions concerning the
effectiveness of new diagnostic and therapeutic methods according to a set of
criteria that were outlined in directives first passed in 1990. After the extension
of the committees mandate, this sub-committee was renamed the Medical
Treatment Sub-committee and passed new evaluation directives (see Health
technology assessment).
In 2000, a joint committee was introduced for the hospital sector consisting
of representatives of sickness funds and the German Hospital Organization.
The committee was charged with quality assurance functions and with
decision-making on benefit exclusions but was not required to provide positive
decisions on benefit coverage as was its ambulatory counterpart. In addition, a
Coordinating Committee was introduced to for the committees for ambulatory
physician care and hospital care. It also was charged with identifying areas
of over-utilization or under-utilization as well as with passing intersectoral
treatment health care guidelines and disease management programmes.
Since the Statutory Health Insurance Modernization Act came into force
in 2004, the various joint committees for the ambulatory sector, the hospital
sector and the coordination committee have been unified into one common
committee, the Federal Joint Committee. The main body of the Committee
consists of nine representatives of the federal associations of sickness funds
(three for general regional funds, two for substitute funds and one each for
company-based, guild, farmers and miners funds) and nine representatives
from provider groups (four from the Federal Association of SHI Physicians,
one from the Federal Association of SHI Dentists, and four from the German
Hospital Organization), two neutral members with one proposed by each side,
and a neutral chairperson accepted by both sides who has the decisive vote
if no agreement can be reached. In addition, nine non-voting representatives of
formally accredited patient organizations have been given the right to participate
in consultations and to propose issues to be assessed and decided upon.
Based on the legislative framework of the Social Code Book, the Federal
Joint Committee issues directives relating to all sectors of care. Some directives
are passed by the Plenary, the central decision-making body of the Federal
Joint Committee, e.g. the bodys standing rules and the rules of procedures
for assessing technologies for inclusion or exclusion from the SHI benefit
catalogue.
Furthermore, the Federal Joint Committee is composed of 4 additional
bodies, each of which passes directives for a distinct field of regulation. They
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47
consist of actors involved in the respective field. While federal associations of

sickness funds (decision-making powers) and patient representatives (no vote)
are represented in all of the four committees, the composition of providers
varies, i.e. the Federal Association of SHI Physicians is represented in the
Committee on Ambulatory Care, the Committee on Physician Issues, but not
the Committee on Dental Care where the Federal Association of SHI Dentists
is represented. The German Hospital Organization delegates representatives
to the Committee on Hospital Care and the Committee on Physician Issues.
These joint committees consist of various joint sub-committees that prepare
recommendations, conclusions and directives, partly supported by working
groups.
Their directives are legally binding for actors in statutory health insurance
although subject to complaints at social courts. They are mainly concerned with
the coverage of benefits and assuring that SHI services are adequate, appropriate
and efficient (Table 7). They seek to clarify rules for patients access and to
steer accountable behaviour of all office-based physicians individually. Other
directives concern planning of capacities or price setting. The four committees
have the following functions:
1) The decision-making body with the broadest range of responsibilities is the
Committee on Ambulatory Care, the successor of the Federal Committee of
Physicians and Sickness Funds. It consists of sub-committees for medical
procedures, psychotherapy, sickness certification, prevention, family
planning, care provided by allied health professionals and medical aids,
pharmaceuticals, prescription of hospital care and patient transport, home
nursing care, rehabilitation, socio-therapy, quality reporting and assurance
as well as needs-based planning.
Apart from directives concerning the named fields of health care the
Committee has e. g. issued a definition for chronically ill persons who are
eligible to co-payment limitations or a directive about conditions for SHIaffiliated physicians to employ a physician colleague.
Directives relating to care provided by allied health professionals are
developed in consultation with the federal organizations of the providers
concerned, for example physiotherapists, speech and language therapists,
ergo-therapists (the so-called partner model). In a similar mode, nursing
associations are consulted when directives on home nursing care are amended
by the committee.
The committees directives on evaluating technologies sets the criteria for
deciding upon benefit coverage in the ambulatory sector of statutory health
insurance, where a new method has to obtain a positive evaluation in order
to be covered and reimbursed by SHI (see Health technology assessment).
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48
The directive on pharmaceuticals entails a broad range of decisions

upon coverage, prescription recommendations for physicians and price
determination for outpatient drugs covered by SHI (Table 7). Decisions upon
coverage include the listing of brands for substances which the ministry put
on a negative list or exemptions from co-payments. Instead of excluding
drugs from SHI coverage altogether the predecessors of the Committee
preferred to inform about efficacy, safety and prices of substances by
indication and to issue prescription recommendations based on relations
of benefits and price. The committee is also responsible for selecting and
grouping drugs to be subjected to the reference price scheme, which since
2004 relates not only to off-patent drugs but also again to patented drug
(see Pharmaceuticals).
The needs-based planning directives for ambulatory care of SHI-affiliated
physicians provide the framework for planning the number of SHI-affiliated
physicians across all specialties needed to provide appropriate health care at
the Lnder level through joint committees of physicians and sickness funds
(see Human resources).
2) The Committee on Dental Care, the successor of the previous Federal
Committee of Dentists and Sickness Funds, issues directives on dental
treatment and orthodontic treatment, case-finding, individual prophylaxis,
dentures, procedures to assess new and existing technologies, as well as
needs-based planning.
3) The Committee on Hospital Care is the successor of the previous Committee
for Hospital Care. It consists currently of the Sub-Committee for Methods
to Evaluate Technologies which prepares directives for decisions upon the
exclusion of technologies (in contrast to the ambulatory pendant which
has to decide upon the inclusion of technologies), the Sub-Committee for
External Quality Assurance in Hospitals and the Sub-Committee for Other
Forms of Quality Assurance in Hospitals.
4) The Committee on Physician Issues is the successor of the previous
Coordinating Committee and consists currently of the Sub-Committee for
Ambulatory Treatment in Hospitals which issues for example a list of highly
specialized conditions that may be treated in outpatient departments, the SubCommittee for Disease Management Programmes and the Sub-Committee
on Quality Assurance which has to report on and evaluate quality assurance
programmes and to issue recommendations for uniform standards quality
assurance across professions and sectors.
All directives issued by the Federal Joint Committee are transferred to the
Federal Ministry of Health. Unless the ministry objects to a directive for formal
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49
reasons within a period of two months the directive becomes binding for the
concerned SHI actors at federal level, Lnder level, and local level as well as
for individual providers and insured patients.
Once a decision to include a technology into the benefit catalogue of
ambulatory SHI-affiliated physician services has not been objected by the
Ministry of Health, another joint committee at federal level determines
reimbursement issues and requirements for physicians who want to want to
claim reimbursement for the delivery of this technology from statutory health
insurance (see Health technology assessment). This Valuation Committee
consists of representatives from sickness fund associations and the Federal
Association of SHI Physicians. In particular it determines the relative value of
a technology compared to other technologies in the Uniform Value Scale (see
Payment of physicians).
The decision-making in the Federal Joint Committee shall be assisted by the
Institute for Quality and Efficiency, a foundation which is paid for by the stakeholders of self-governance (rather than the federal government, as originally
planned). The establishment of the Institute was approved by the supervising
Federal Ministry of Health in July 2004. It has the legal tasks of:
evaluating the efficacy and safety of drugs as a basis for deciding whether
a drug falls under the reference price scheme or not;
writing scientific reports and statements on questions of the quality and
efficiency of SHI benefits;
giving recommendations on disease management programmes;
evaluating evidence-based guidelines for epidemiologically important
diseases;
researching, evaluating and presenting up-to-date medical knowledge of
diagnostic and therapeutic interventions of selected diseases;
providing comprehensible information to citizens on the quality and
efficiency of care.
Supervision and conflict resolution
Supervision of corporatist decisions whether those of single institutions
or joint committees is a multi-layered endeavour involving self-regulatory
institutions themselves, the government and the social courts. The government
is the Federal Ministry of Health in cases concerning federal associations of
sickness funds and providers, joint institutions and their decisions and contracts.
Nation-wide sickness funds are supervised by the Federal Insurance Authority.
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Table 7.
Decision-making competencies in German health carea by sector, 2004

Coverage
decisions
Licensing/
Accreditation
Financing
decisions
Quality
assurance
Ambulatory care
(primary and
secondary care)
basic definition
by federal law;
details mainly
delegated to
actors on federal
level
basic definition
by federal law;
details
delegated to
actors on
federal (rules)
and Lnder
(actual
implementation)
levels
mainly
delegation to
actors on Lnder
level;
limited since
1999 as
increases in
regional budgets
are limited by
federal law
mandated by
federal law
(internal QM);
details delegated
to actors on
federal (rules)
and Lnder
(actual
implementation)
levels
In-patient care
until 1999
implicitly
included in
financing
decisions; since
2000 mainly
delegated to
actors on federal
level
de facto
by Lnder
governments;
Legally sickness
funds may
de-contract
hospitals,
but the final
decision is taken
by the Land
government.
capital financing:
mainly bottomup devolution by
Lnder;
running costs:
delegation to
actors on local
level, preparation
of the DRG
system mainly
federal level
with substitutive
execution
by federal
government
mandated by
federal law
(internal and
external QM);
actual
implementation
delegated to
actors on Lnder
level
Trans-sectoral
care
basic definition
by federal
law; details
delegated to
actors on
federal (rules)
and Lnder
(actual
implementation)
levels
basic definition
by federal law;
details
delegated to
actors on federal
(rules) and
Lnder (actual
implementation)
levels
basic definition
by federal law;
details delegated
to actors on
federal (rules)
and Lnder
(actual
implementation)
levels and
selective contract
partners
basic definition
by federal law;
details delegated
to actors
on federal
(rules) and
Lnder (actual
implementation)
levels and
selective
contract partners
Dental care
basic definition
by federal law;
details mainly
delegated to
actors on federal
level
basic definition
by federal law;
details
delegated to
actors on federal
(rules) and
Lnder (actual
implementation)
levels
mainly
delegation to
actors on Lnder
level; limited
since 1999 as
increases in
regional budgets
are limited by
federal law
basic definition
by federal law;
details delegated
to actors on
federal (rules)
and Lnder
(actual
implementation)
levels
Germany
Coverage
decisions
51
Licensing/
Accreditation
Financing
decisions
Quality
assurance
Pharmaceuticals mixture of
governmental
regulation
(negative
list; in future
positive list) and
delegation to
actors on federal
level
Basic definition
by federal and
EU law;
licensing by
governmental
agency at
federal level or
EU agency
Legal definition
of wholesaler
and pharmacy
surcharges for
prescription
drugs;
ex-factory
prices mainly
manufacturers
decision;
delegation of
reference price
setting and aut
idem to actors
at federal level;
negotiation
and control of
target volumes
per practice at
regional level
Basic definition
by federal law;
pharmacovigilance by the
governmental
and European
licensing agency
at federal level;
details and
implementation
of prescription
quality
improvement
delegated to
actors at federal
and regional
level
Public health
services
none
bottom-up
devolution by
Lnder;
further devolved
to municipal level
in most Lnder
supervised
by higher
administrative
level;
internal quality
management
as part of
administrative
modernization
initiatives at
municipal or
state level
legislation
only on certain
aspects at
federal level,
for example
infectious
diseases,
radiation;
state legislation
and regulation
varying by state
Source: own compilation.

Note: a actors refers to the (corporatist) associations of the self-governance representing the
payers (sickness funds) and providers (SHI-affiliated physicians, hospitals) at Lnder level and
federal level of the statutory health insurance system.
For actors, decisions and contracts on the Lnder level, the government is
the statutory health insurance unit within the Lnder ministry responsible for
health.
Supervision and enforcement can be divided into several levels:
formal governmental approval of (or lack of objection to) decisions taken
by self-regulatory bodies;
governmental veto of self-regulatory decisions if these are not taken
according to the law;
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the federal governments right to intervene where no decisions have been

taken (Ersatzvornahme) as for example applied during the introduction
of diagnosis-related groups as a payment system in hospitals (see Payment
of hospitals);
legal action against institutions that do not fulfil their charge.
While the theoretical threat of closing sickness funds applies mainly
to financial instability or incompetence, the ultimate threats to physicians
and dentists associations are more related to their behaviour as corporatist
institutions. As a first step, a state commissioner may be installed if no board is
elected or if the elected board refuses to act according to its legal responsibilities
( 79a SGB V). In the case of 50% or more members of an association refusing
to treat sickness fund-insured patients, the association loses its legal monopoly
to provide care which is then passed to the sickness funds ( 72a SGB V).
Both of these threats were only came into force in 1993 as a result of
the announcements by self-governing associations to disobey certain legal
requirements. The instalment of a state commissioner has been used twice.
In 1995, the government of Lower Saxony removed the board of the dentists
association due to its refusal to sign required remuneration contracts with the
sickness funds. It installed a senior government official as state commissioner,
who then signed contracts on behalf of the dentists association. Only afterwards
were the board members allowed to return to office. Another case occurred in
Bavaria in February 2004, when the state government installed a commissioner
at the dentists association for six weeks after the dentists assembly had decided
to make patients pay co-payments for preventive visits (although these are
excluded from co-payments by law). In November 2003 the assembly had
decided not to implement major parts of the SHI Modernization Act and to
prepare for giving back the mandate to guarantee to provide dental care for
SHI-insured patients.
Furthermore, in July 2004, the government of Lower Saxony was the first
to pass the obligation to provide care to the sickness funds, after one quarter
(44) of the orthodontists of the regional dentists association of Lower Saxony
had given back their SHI accreditation in protest against income loss following
the federal contract between the Federal Association of SHI Dentists and the
federal associations of sickness funds, which attributed lower monetary values
to orthodontic specialist procedures and higher values to general dentistry
procedures. Since the regional dentists association was not able (or willing) to
provide alternative sources of care, the Social Ministry found that the criteria
for sufficient access were no longer guaranteed in three planning areas and
delegated the legal duty to guarantee the provision of orthodontic care to the
Germany
53
sickness funds. These have to act jointly, and contract selectively with university
outpatient departments, local dentists with a qualification in orthodontics and
orthodontic specialists in other states.
Beyond this rare mode of state intervention, disputes are usually resolved
during the joint negotiations. If the actors cannot resolve disputes over tasks that
have been delegated to them by law, a sophisticated system of joint arbitration
committees and regulations is applied to make sure that a regulatory vacuum is
avoided and that contracts among the responsible actors are in place in time.
Self-administration has been regarded as a sound basis for effective
negotiations, public trust and safeguard against unwanted government
interference. However self-governance is also criticized as lacking transparency
and accountability. In a sector-specific report, Transparency International (1999)
criticized state governments weak exertion of their supervisory powers on
health care actors and failure to control fraud and corruption adequately. Various
fraudulent claims have received substantial publicity since then, resulting in
criminal charges. Since 2004, sickness funds as well as regional associations of
physicians and dentists have been obliged to install internal corruption units.
Social courts
Many corporatist decisions as well as parliamentary laws or governmental
regulations may be challenged before the social courts, which exist at the
local, state, and federal levels, constituting a separate court system. Until 2003,
filing a legal case was free of charge. Since then, differential user fees apply
for socially insured people, individual providers, social insurance institutions
or private sector actors. Within health care, cases resolved by social courts
include, for example: patients suing their sickness fund for not granting a
benefit; individual physicians disputing the calculations of the Claims Review
Arbitration Committee at state level; or medical device companies objecting to
the non-inclusion of their product in the ambulatory medical services benefits
package. In fact, the number of complaints that drug manufacturers have filed
against the price-setting and grouping of drugs under reference price schemes or
against prescription recommendations through the directive on pharmaceuticals
seems exceptionally high in international comparison. Most of the claims
challenged the legitimacy of the Federal Committee of Physicians and Sickness
Funds, the predecessor of the Committee on SHI-affiliated Physician care, to
intervene into the drug market as a nongovernmental actor within statutory
health insurance structures. The committees legitimacy to define reference
prices was approved by the European Court of Justice in early 2004 based on
the legal delegation of public tasks for public purposes.
Germany
54
Another example is the Federal Social Courts refusal of some companybased funds complaint against their obligation to contribute to the risk structure
compensation among all sickness funds, as upheld by the Federal Constitutional
Court in July, 2004 (see Main source of financing and coverage).
Decentralization of the health care system

Decentralization can take on different forms, reflecting an increasing level of
autonomy from governmental powers: deconcentration, devolution, delegation
or privatization. The usual term decentralization does not capture the entire
realm of German-style federalism, however. At first sight the considerable
power of the Lnder might look like a case of devolution but this is not a true
description, since powers were never passed down from the federal level to the
Lnder, which predate the Federal Republic (which they actually founded).
Instead, the opposite of devolution took place in Germany: the Lnder passed
certain rights and responsibilities, as defined in the constitution, to the federal
level and retained others.
Deconcentration is only of minor importance in the German health care
system, due to most levels of administration (with the exception of some
Lnder administrations) lacking any sub-level administrative offices since all
political units from the local level upwards have their own autonomous, elected
representatives and governments.
As may be seen from the section on planning, regulation and management,
the most striking component of the decentralized health care system is the
delegation of state power to corporatist actors (Table 7). While most of the
legal rights and obligations of the corporatist associations of sickness funds
and providers are the result of a long process (see Historical development), the
transfer of the existing West German system to the eastern part constituted a
real delegation of responsibilities by the government to corporatist actors.
Privatization is another important feature of the German health care system.
Unlike other areas (for example higher education), public and private health care
seem to be untainted by ideology. Notably, public is only used on the delivery
side (for public hospitals), while public funding through the sickness funds is
labelled statutory. The sickness funds have been said to transcend public
and private categories since they are private in formal ownership, but public in
their responsibilities and liabilities (24). They co-exist with private insurance
companies providing substitutive, supplementary, and complementary voluntary
Germany
55
health insurance (see Complementary sources of financing). The switch to

private health insurance is not seen as a political statement but rather as a way
to pay less or for traditionally excluded self-insured as a necessity.
Out-sourcing of maintenance services to private companies occurs frequently
but has never caused any public debate. In fact, some health care sectors are
based entirely on private providers, for example, the office-based ambulatory
care and dentistry or the private pharmacies. In other sectors, both private nonprofit and for-profit providers co-exist with public providers, for example in the
social care sector (see Social care) in the hospital sector (with a trend towards
more privatization, Table 8). In fact, the vast majority of hospitals, including the
private, for-profit, are part of the hospital plan, may treat SHI-insured patients,
and are regulated by the same set of rules. Only a few private, for-profit hospitals
are not integrated in the hospital plan, do not treat SHI-insured patients and
are thus exempt from most regulations ensuring equal distribution, access and
financial sustainability (see Hospital care).
Germany has a mix of public (usually meaning ownership by local
governments), non-profit and for-profit hospitals. While the structure of German
hospitals did not change dramatically in the 1990s, a clear trend is noticeable.
The overall bed reductions took place entirely as a result of bed reductions in
public hospitals while private, non-profit hospitals kept their numbers stable
and private, for-profit hospitals increased theirs by 81% from a low level of
3.7% in 1990 to 8.3% of total general hospital beds (Table 8).
The increase of private for-profit ownership was mainly realized through
take-overs of previously publicly owned hospitals. Take-overs of previously
public hospitals by private investors are more frequent in the eastern part (where
the share of privately owned beds in the acute sector was more than double
compared to the western part). More than half of all private beds belong to
hospital chains, which are responsible for the dynamic growth of the private,
for-profit sector.
There are several reasons for the ongoing trend toward privatization. First,
there is a shrinking public share of investment financing because of a rather
precarious economy, and since many hospitals are need capital, an obvious
solution the attraction of private capital. Second, agreements between trade
unions and e mployers are more inflexible and expensive than collective
agreements in the private sector. Furthermore, laws allow stronger participation
of employees in public hospitals than in private hospitals, which may increase
resistance against rationalization of cost-containment in personnel expenditures.
Third, the complementary public sector pay-as-you-go retirement insurance is
becoming more and more expensive because of the demographic shift (25).
Germany
56
Table 8.
1990
2002
Change
Development of the public-private mix in ownership of general hospitals,

19902002
Public
Beds
% share
387 207
62.8
272 203
53.9
-29.7%
Not-for-profit
Beds
% share
206 936
33.5
190 426
37.7
-8.0%
Private
Beds
% share
22 779
3.7
41 965
8.3
+84.2%
Source: own calculations based on Federal Statistical Office 2004 (52).
Germany
Total
Beds
616 922
504 684
-18.2%
Health care financing and expenditure
ealth care financing in Germany is characterized by a pluralistic funding

system. Statutory health insurance is the major source of financing
health care, covering nearly 88% of the population in 2003. Ten per
cent (10%) took out private health insurance which includes about 4% civil
servants with free governmental care and complementary private insurance.
Furthermore, 2% of the population was covered by other, sector-specific
governmental schemes (military, persons on substitutional service, police,
social welfare and assistance for immigrants seeking asylum). Another 0.2% of
the residents, that are about 170 000, had no prepaid coverage for health care
(7). Among the uninsured there are mainly self-employed, rich and poor, and
persons who previously failed to pair contributions to the statutory insurance
or premiums to the private health insurance.
Even though SHI dominates the German discussion on health care
expenditure and reform(s), its actual contribution to overall health expenditure
was only 57% in 2002 (Table 9). The other three pillars of statutory insurance
contributed an additional 10.5% of total health expenditure: statutory retirement
insurance financed 1.7% (mainly for medical rehabilitation), statutory (workrelated) accident insurance 1.7%, and statutory long-term care insurance
financed 7.0%. Governmental sources contributed another 7.8%. Altogether,
public sources accounted for three quarters of total expenditure on health and
private sources for one quarter. Private households financed 12.2% of total
expenditures on health in 2002 (figures include negligible expenditures of
nongovernmental organizations). Private insurers financed 8.4% which includes
expenditures for comprehensive health insurance
The most distinct changes over the last 10 years are the introduction of longterm care insurance and the increase in out-of-pocket payments.
Germany
58
Main system of financing

Contributions towards statutory health insurance with its 292 (January 2004)
sickness funds constitute the major system of financing health care in Germany
(see also Organizational structure). The sickness funds are responsible for
collecting contributions, purchasing benefits on an in-kind basis and paying
providers (see also Financial resource allocation).
Table 9.
Main sources of finance, in percentage of totala, 19922002

1992
1994
1996
1998
1999
2000
2001
2002
Public sources
77.7
77.0
77.2
75.3
74.8
75.5
74.9
75.2
Taxes
13.0
12.9
10.8
8.1
8.0
7.9
7.8
7.8
Statutory health insurance
60.7
59.7
57.4
56.7
56.8
56.9
57.0
56.9
Statutory retirement insurance
2.3
2.4
2.4
1.7
1.7
1.8
1.8
1.7
Statutory accident insurance
1.8
1.9
1.7
1.7
1.8
1.7
1.7
1.7
Statutory long-term care insurance
n. a.
n. a.
4.9
7.0
7.1
7.2
7.0
7.0
Private sources
22.3
23.0
22.8
24.7
25.2
24.5
25.1
24.7
Out-of-pocket payments/NGOs
10.7
11.1
11.3
12.6
12.3
12.2
12.3
12.2
Private insurance
7.3
7.6
7.3
7.8
8.3
8.2
8.2
8.4
Employer
4.3
4.3
4.2
4.2
4.1
4.1
4.1
4.1
Source: Federal Statistical Office 2004 (12).

Note: n.a.: not applicable; NGO: nongovernmental organization.
Sickness fund membership is mandatory for employees whose gross income

does not exceed a certain level. This limit was increased from 3375 per month
to 3825 gross salary per month starting in January 2003 to reduce the number
of high earning voluntary members leaving statutory health insurance (adapted
year, to 3862 in 2004). In 2003, ca. 88% of the population were covered by
statutory health insurance (nearly 78% mandatorily and 10% voluntarily) (7).
Contributions for SHI are dependent on income, and not risk, and include
non-earning spouses and children without any surcharges. Contributions are
based on income from gainful employment (up to a level of 3487.5 in 2004),
pensions, or unemployment benefits, and not from savings or possessions at
present. Such broadening of the income base was introduced transiently for
voluntarily insured pensioners in 2000, but was soon refuted by jurisdiction.
The total sum of the income of all the insured up to that level (the so-called
contributory income) is among the most important figures in health policy since
its growth rate from year to year determines the level of cost-containment. It is
influenced on the one hand by changes in wages and employment rates and on
the other hand by regulatory interventions defining the contribution base for
social transfer payments. Thus, growth in average contributory income is not
Germany
59
necessarily the same as wage increases. Higher than average wage increases
for workers earning less, increase the contributory income disproportionately,
while rising unemployment especially hidden unemployment through people
leaving the workforce and becoming dependants decreases the contributory
income disproportionately. Reforms of the statutory retirement insurance and
statutory unemployment benefits also had large effects on the contributory
income of the sickness funds.
From 1949 until 2004, contributions have been shared equally between the
insured and their employers (Table 4). Taking the current average contribution
rate of 14.2% as an example (summer 2004), the insured person pays 7.1% out
of his or her pre-tax income below the upper threshold (e3487.5 in 2004 and
e3525 in 2005) and the employer pays the same amount in addition to wages.
For people with earnings below a threshold of 400, only employers have to
pay for contributions (at a rate of 11% for all funds). Until 1998, income up to
that level was not liable for sickness fund contributions. From July 2005, the
parity shall be shifted towards higher contributions from the employees side.
They will have to pay a special contribution of 0.4%, which shall be increased
to 0.9% (i.e. employers then save 0.45%) (see Health care reforms). These two
measures will lead to a financing mix of approximately 54% for employees
and 46% for employers.
For artists and students the federal government takes over half of the
contributions. In the case of retired and unemployed people, the retirement funds
and the Federal Agency for Employment respectively take over the financing
role of the employer; in practice, these transfer 100% of the contribution rate to
the sickness funds. Since 2004, pensioners have to pay contributions also from
company pensions and other non-statutory pensions from which they deduct
the full contribution rate.
Sickness funds collect the contributions directly from the employers or the
mentioned public agencies; sanctions apply in case of evasion. The sickness
funds operate on a pay-as you-go principle and may officially not incur deficits
or accumulate debts. They are free to set their own contribution rates. Their
decision is, however, subject to approval by the responsible state authority.
German health policy is primarily concerned about the contribution rates
rather than the percentage of total health expenditures or statutory health
insurance expenditures of the GDP since these have risen considerably faster
than the rate of GDP. In fact, statutory health insurance expenditure has
grown at GDP level which was achieved by a variety of cost-containment
measures including sectoral budgets, rational prescribing, price reductions and
downsizing. Yet over the last 25 years, the revenues from contributions have
increased slower than both GDP and health expenditure. This led to repeated
Germany
60
deficits and increasing debts although sickness funds increased their contribution
rates (Table 10, Fig. 4). From 2001 to 2003, the statutory sickness funds made
deficits of circa 3 billion per year. Because the sickness funds are not allowed
to incur long-term debts they were forced to raise contribution rates. The average
contribution rate has increased quite steeply from 13.5% of gross earnings in
2001 to 14.3% throughout 2003 and in April 2004 (Table 10). Similar to the
last substantial increase of contribution rates (from 12.4% to 13.2% between
1991 and 1993), the rise in contribution rates and deficits was followed by a
major health care reform which was conceptualized jointly by government and
opposition parties (26) (see Health care reforms).
The problem with revenues from contributions is that it is not based on the
total economy but only on that part on which health insurance contributions are
based (i.e. income of insured persons up to the threshold). Major reasons for
the shrinking income base of sickness funds are the decreasing wage quota in
the total economy, the decreasing share of the social insurance relevant part of
wage, the increasing share of pensioners (as pensions are only around 48% of
gross wages), the ongoing high rate of unemployment (since 2000, contributions
for unemployed are only half as high as those for employed persons), and a.
Although mini-jobs are included into mandatory statutory health insurance since
1999, the current system oriented at life-long fulltime employment status,
does not respond to nor profit well from the current working biographies and
arrangements involving semi-entrepreneurship, part-time basis and multiple
jobs.
Competition and risk structure compensation
Traditionally, the majority of insured people had no choice over their sickness
fund and were assigned to the appropriate fund based on geographical and/
or job characteristics. This mandatory distribution of fund members led to
greatly varying contribution rates due to different income and risk profiles.
Only voluntary white collar members and since 1989 voluntary blue collar
members had the right to choose among several funds and to cancel their
membership with two months notice. Other white collar workers (and certain
blue collar workers) were able to choose when becoming a member or changing
jobs. Since this group grew substantially over the decades, around 50% of the
population had at least a partial choice in the early 1990s.
The Health Care Structure Act of 1993 gave almost every member the right
to choose a sickness fund freely (from 1996) and to change between funds on
a yearly basis with three months notice. All general regional funds and all
substitute funds were legally opened to everyone and have to contract with
Germany
Table 10.
61
Trends in financing statutory health insurance (SHI), 19922003
SHI revenues
(billion )
SHI expenditures
(billion )
SALDO (billion )
SHI expenditure
cash benefits
(billion )
in-kind benefits
(billion )
as % of GDP
Average SHI
contribution rate
(%)
Contribution to
long-term care
insurance (%)
Total social
insurance
contribution (%)
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
103
114
119
120
124
126
128
131
134
136
140
141
108
108
117
124
126
125
128
131
134
139
144
145
-4.8
5.3
1.4
-3.7
-3.6
0.9
0.3
0.3
0.02
-3.0
-3.1
-2.9
9.6
9.3
8.7
11.1
9.4
9.7
9.3
9.3
9.4
9.9
10.3
8.5
99.0
99.2
109
113
117
116
118
122
124
129
133
136
6.1
6.0
6.2
6.3
6.4
6.2
6.1
6.2
6.1
6.2
6.3
6.4
12.7
13.2
13.2
13.2
13.5
13.6
13.6
13.6
13.6
13.5
14.0
14.3
n. a.
n. a.
n. a.
1.0
1.7
1.7
1.7
1.7
1.7
1.7
1.7
1.7
36.8
36.5
37.2
39.0
39.2
40.8
41.9
42.1
41.1
40.8
41.3
42.1
Source: Federal Ministry of Health 2004 (27); Federal Statistical Office 2004 (12).
Note: n. a.: not applicable.
all applicants. The company-based funds and the guild funds may choose to
remain closed, but if they open, they too have the obligation to contract with
all applicants. Only the farmers, and sailors funds as well as the minors fund
retain the system of assigned membership.
As this date-fixed opportunity was felt to encourage many insured people to
switch (see below), the opportunity to do so in 2001 (for 2002) was cancelled.
Since 2002, change is possible at any time but the interval to remain insured
with a particular fund will be 18 months. However, voluntary members those
earning above the threshold can still move from one fund to another at any
time with two months notice. A decision to leave the SHI system in favour of
private insurance cannot be revoked, however.
To provide all sickness funds with an equal position or a level playing field
for competition, a risk structure compensation scheme (RSC) was introduced
in two steps, in 1994 and 1995, the latter including retirees, replacing the
former sharing of expenses for retired people between funds). The RSC seeks
to equalize differences in expenditures among sickness fund insureds (due
to age, sex and disability). Characteristically, the German RSC also seeks to
equalize contribution rates due to differences in income levels from proportional
contributions.
Germany
62
Basically, the RSC requires all SHI members to contribute an equal share of
their income, about 13.5% in 2004, via their sickness fund to a scheme which
than redistributes resources according to the risk structure of the SHI insureds
per fund. In practice it is the sickness funds that are required to provide or receive
compensation for the differences in their contributory incomes as well as in
averaged expenditures. About 90% of a sickness funds expenditures are RSC
relevant since they are being spent for benefits that are covered by the uniform,
comprehensive SHI package and that determine a sickness funds contributionneed (need for finances). The remaining expenditures for administration and
fund-specific benefits enacted in its statutes are not taken into account.
For both sexes, the average expenditure for the RSC-relevant benefits is
calculated for one-year age brackets using actual expenditure data (the actual
calculation is always retrospective and only estimated for the current year).
About 90% of all expenditures are subject to the redistribution through the risk
compensation scheme
The sum of these average expenditures for all insureds of a sickness fund
determine that funds contribution need. The sum of all funds contribution
needs divided by the sum of all contributory incomes determines the
compensation schemes rate, which is used to calculate the compensated sum
paid to funds, or the sum required from those funds making payments into the
scheme. The risk compensation mechanism also equalizes for different income
levels among fund members as well as differences in the number of dependants
(since they are included on the expenditure side while they enter the contribution
calculations as zero).
The impact of both the free choice and the risk structure compensation
scheme on the structure of the sickness funds, the actual movement of members
between funds, the development of the contribution rates and transfer-sums
between funds can be summarized as follows:
Even before the period of actual free choice for the insured began, sickness
funds began to merge (Table 6).
The percentage of insured ready to switch funds is increasing steadily. While
only 9.3% of all SHI-insureds indicated they were thinking of changing their
fund in 1998, this percentage increased to 23.4% in 2003 (28).
Members increasingly leave one fund and join another. While no data on
actual moves are available, net gains and losses in membership may be taken
as an indicator: From the introduction of free choice of funds in January
1996 until January 2004, the general regional funds have lost 16% of their
membership, to 18.6 million. The substitute funds, traditionally with whitecollar membership, have lost 11%, to 15.8 million, although in the first years
Germany
63
they gained in membership. Other funds, like miners and farmers, have lost
5.5%, to 1.7 million, mainly due to death of the relatively old membership.
The most substantial gain of members was achieved by the company-based
funds which doubled their membership to 10.4 million. Further gains were
made by the substitute funds, traditionally with blue-collar membership
(5% increase, to 1.0 million insured), and guild funds (3% to 3.1 million)
(9,29).
These net gains and losses are correlated to the contribution rates of the
funds, that is, funds with higher than average contribution rates lose members
while those with lower than average rates gain members.
The importance of the contribution rate is further highlighted by several
survey studies. For people who have moved from one fund to another, lower
contributions were cited as the prime motive, while for people considering
a move, both the contribution rate and better benefits are equally important.
People not considering a move regard better benefits to be more important.
People joining a sickness fund for the first time mostly cited other reasons
for choosing a particular fund.
Movement of members between funds has not equalized the different risk
structures, but the first opportunity to change funds segregated membership
further, i.e. the healthier, younger, better-earning people moved more often
and towards cheaper funds, which in turn has increased the transfer sums
(Table 11). This development implies that a risk compensation mechanism
will be needed permanently, not just temporarily.
The RSC scheme and not competition has reduced contribution
rate variation among funds. While in 1994, 27% of all members paid a
contribution rate differing by more than one percentage point from the
average, this number had dropped to 7% in 1999. Around 2000, however,
the increasing movement of relatively healthy people to cheaper funds
has temporarily stopped this positive development. When considering
associations of sickness funds, contribution rates vary less than between
single funds. Furthermore, differences in contribution rates between the
associations have been reduced, also in recent years (Fig. 4).
Concerns about the increasing amount required for redistribution and risk
selection practices among sickness funds led to the enactment of two additional
laws: The Act to Equalise the Law in Statutory Health Insurance made the risk
structure compensation mechanism uniform for all of Germany from 2001. This
led to an increase of the West-East transfer of financial resources (Table 11).
On the other hand, the income basis of SHI in the eastern part of Germany was
broadened by adjusting the limits for contributions, mandatory membership,
and exemption from co-payment to levels in the West.
Germany
64
Table 11.
Transfer sums in the risk structure compensation (RSC) scheme absolute

and relative to total SHI expenditure for the western and eastern parts,
19952003
Western part
RSC / SHI
expenditurea
(billion )
1995
1996
1997
1998
1999
2000
2001
2002
2003
6.90/
7.27/
7.71/
8.22/
8.30/
8.30/
9.09/
9.28/
9.87/
97.29
100.41
98.23
99.74
102.68
105.05
108.89
111.79
113.14
Eastern part
RSC
as %
of SHI
RSC / SHI
expenditurea
(billion )
7.1
7.2
7.8
8.2
8.1
7.9
8.3
8.3
8.7
2.36/
2.51/
2.63/
2.80/
3.29/
3.73/
4.43/
4.66/
4.93/
Germany
RSC
as %
of SHI
19.70
20.47
20.05
19.97
20.52
20.89
21.75
22.54
23.08
12.0
12.3
13.1
14.0
16.0
17.8
20.4
20.7
21.4
RSC / SHI
expenditurea
(billion )
9.23/
9.78/
10.34/
11.01/
11.60/
12.03/
13.52/
13.94/
14.79/
RSC
as %
of SHI
116.99
120.88
118.29
119.71
123.21
125.94
130.63
134.33
136.22
7.9
8.1
8.7
9.2
9.4
9.6
10.3
10.4
10.9
Source: own calculations based on Ministry of Health (27).

Note: RSC = risk structure compensation; a total expenditure of sickness funds without spending
on administration and fund-specific benefits as detailed in the funds articles (ca. 90% of total).
Fig. 4.
Annual contribution rates by sickness fund association, 19822004a
contribution rate in % of contribution-relevant incomes
15.0
14.5
14.0
13.5
13.0
RSC to include
risk pool (2002),
DMP (2003)
12.5
12.0
2001: uniform RSC

across East and West
11.5
11.0
10.0
1982
1999: uniform East/West

contributory income levels
1995: RSC to include also pensioners
10.5
1994: RSC across sickness funds

1984
1986
1988
1990
1992
1994
1996: free choice of sickness funds

1996
1998
2000
2002
2004b
year
AOK
BKK
IKK
EAK ARB
EAK ANG
Overall
Source: own compilation based on data from Federal Ministry of Health 2004 (30), Federal
Ministry of Health 2002 (29), Federal Ministry of Health 1991 (31).
Note: RSC: risk structure compensation; DMP: disease management programmes; AOK:
regional sickness funds; BKK: company-based funds; IKK: guild funds; EK ARB: substitute funds
traditionally for blue collars; EK ANG: substitute funds, traditionally for white collars; a data for
19821990 refer to the western part only, overall average rates include sailors fund, excluding
miners and farmers funds; b state of 1 January, for all other years: annual average rates are
used.
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65
The Act to Reform the Risk Structure Compensation Scheme was passed in
2001 to compensate better for differences in the morbidity structure, to avoid
cream-skimming among sickness funds and to give them an incentive to offer
special treatment offers to chronically ill insureds. In addition to the existing
compensation for differences in income as well as expenditure by age, sex and
invalidity among insureds, the law introduced a high risk pool and separate
RSC categories for people participating in Disease Management Programmes.
From 2007, the RSC scheme shall be morbidity-oriented.
The courts have repeatedly approved the present risk structure compensation
scheme among sickness funds. The last decision of the Federal Social Court
was also upheld when the Federal Constitutional Court declined in July 2004
to accept the appeal of two company-based sickness funds.
Disease management programmes
The Act to Reform the Risk Structure Compensation Scheme introduced Disease
Management Programmes (DMPs) as a new form of SHI-organized managed
care instrument to reduce risk selection among funds through incentives to
improve the care of the chronically ill. Thus insureds enrolled in a DMP are
treated as a separate category in the risk structure compensation scheme.
The Act defined a complicated process for the introduction of DMPs: The
then newly formed Coordinating Committee (now the Federal Joint Committee)
was charged with recommending to the Ministry of Health which major chronic
diseases to select and the minimum common requirements for DMPs for these
diseases. This was a new division of labour, with the self-governing bodies
proposing, and the Ministry passing, an ordinance. The Act also stipulated the
factors to be taken into account when selecting a disease for DMPs, namely the
number of patients, potential for quality improvement, existence of evidencebased guidelines, need for trans-sectoral care, potential for improvement through
patients initiative, and high expenditure.
Based on the defined minimum requirements, sickness funds contract with
providers and install their own provisions of informing and convincing their
members to enrol voluntarily. Other requirements include patient education and
an evaluation of the programmes. Sickness funds then apply for accreditation
of their DMP at the Federal Insurance Authority, which mainly checks whether
the DMP fulfils the legal requirements. Upon accreditation, the sickness funds
run and coordinate the disease management programmes.
A few weeks after the Act became law, the Coordinating Committee proposed
the first four conditions for DMPs: diabetes mellitus type II, breast cancer,
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66
coronary heart disease, and asthma/chronic obstructive lung disease. The process
to define the minimum standards was most disputed and time-consuming. A
major blockade occurred in the summer of 2002, when a federal assembly of all
regional physicians associations passed a motion that no regional association
should sign a DMP contract until federal elections later that year. After the reelection of the federal government, progress was smoother but still with hurdles
and delay. One reason was the need to disentangle the contracts between several
sickness funds and groups of providers. While DMPs have to be offered by
individual sickness funds, they had usually collectively negotiated the conditions
with the associations of statutory health insurance physicians. The sickness
funds still have to build their own specific patient enrolment regulations, patient
information systems and evaluation according to that contract.
In February 2003, the Federal Insurance Authority accredited the first
DMPs for breast cancer in North Rhine. The DMPs are based on a uniform
contract between all sickness funds of the region and the regional physicians
association as well as a number of hospitals. Measures for quality assurance
include standardized documentation, feedback reports to physicians, patient
information and reminder systems (32).
On 12 October 2004, 5525 applications for DMPs had been received. Of
these, the Federal Insurance Authority had decided on 3068. For 1030 sickness
funds had signalled to the Authority to be ready to start. 471 applications were
being handled by the authority and 956 had not been dealt with (BVA 2004).
Of the 5525 applications for accrediting DMPs, 3133 concerned diabetes,
1624 breast cancer, and 768 coronary heart disease. The ordinance for chronic
obstructive lung disease/asthma had been issued, but applications were not yet
available. Most of DMPs are based on contracts of sickness funds with regional
physicians associations. In only few cases sickness funds have contracted
selectively with a network of physicians. Furthermore, a relatively small share
of the hospitals have become contract partners until now (33).
The current degree of activities indicates that the incentives for sickness
funds to offer DMPs and increase the number of enrolled insureds are working.
Critics maintain that DMPs would still not save money, but require an additional
monetary input. In a longer term, a disadvantage is also that sickness funds are
not very flexible in adapting their DMPs to experience or new treatment options,
since most changes require a change of the underlying uniform requirements.
These have to be issued by the Ministry of Health in form of an ordinance
based on recommendations from the Federal Joint Committee. Although
documentation requirements have been reduced in a 2004 ordinance, the
requirements for accreditation and documentation of DMPs are still perceived as
a hurdle by physicians. DMPs may serve as a concerted improvement of patient
care by implementing guidelines linked to patient information and data-based
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67
feedback. They were implemented rather hasty and without gaining experiences
from pilot projects since the sickness funds have financial interests in getting
DMPs started and enrolling insured.
The evaluation will be planned and supervised by the Federal Insurance
Authority. The various programme versions per DMP shall be compared to
each other. Due to data protection concerns and the dynamic evolution of the
programmes a controlled study design seemed not feasible. Information about
best practice and barriers in implementing DMPs shall inform the public and
political debate that is mainly concerned with the feasibility and the success
of DMPs in minimizing risk selection, redistributing financial resources and
improving the quality of care of chronically ill patients.
Health care benefits and rationing

Independent of the status, the amount of contribution paid or the duration of
insurance, members and their dependents are entitled to the same benefits.
Benefits and recipients of statutory long-term care insurance are described in
the section Social care. Concerning the main source of finance, the statutory
health insurance, the following types of benefits are currently included in the
benefit package, usually in generic terms through chapter 3 of the Social Code
Book V:
prevention of disease, health promotion at the workplace;
screening for disease;
treatment of disease (ambulatory medical care, dental care, drugs, care
provided by allied health professionals, medical devices, inpatient/
hospital care, nursing care at home, and certain areas of rehabilitative care,
sociotherapy);
emergency and rescue care, patient transport in certain health conditions;
certain other benefits like patient information.
In addition to these benefits in kind, sickness funds give sick pay to their
employed members 70% of the last gross salary (max. 90% of net salary), from
week 7 up to week 78 of certified illness, while employers continue to pay 100%
of the salary during the first 6 weeks of sickness. The ratio of cash benefits to
in-kind benefits has decreased substantially since SHI began 120years ago
(Table 4). In 2004, the share of cash benefits has again decreased since funeral
allowances have been excluded.
Further benefits that have been legally excluded from SHI health insurance
coverage since 2004 include glasses, lifestyle medications and all over-theGermany
68
counter medications with few exceptions. From 1989 to 1996 and again from
2000, health promotion measures were offered by sickness funds directly to
their members. While the second SHI Restructuring Act had abandoned this
benefit, it has been partly reintroduced through the SHI Reform Act of 2000.
While the Social Code Book regulates preventive services and screening
in considerable detail (for example concerning diseases to be screened for
and screening intervals) but leaves further regulations to the Federal Joint
Committee (or its predecessors), the Committee has considerable latitude in
defining the benefits package for curative diagnostic and therapeutic procedures.
The decision-making process concerning coverage is described in more detail
in the chapter Health technology assessment. All procedures covered in the
ambulatory sector are listed in the Uniform Value Scale together with their
relative weights for reimbursement (see Payment of physicians). The range of
covered procedures is wide, from basic physical examinations in the office to
home visits, antenatal care, terminal care, surgical procedures, laboratory tests
and imaging procedures including magnetic resonance imaging.
Until 1997, exclusions were not explicitly possible but the legal mandate to
evaluate already covered technologies made this possible. So far the committee
has taken decisions upon only a small number of technologies with limited
medical benefits, for example osteodensitometry for asymptomatic patients.
Nevertheless, the committees decisions have raised protests from providers and
the public. Until 1997 exclusion of benefits was thus limited to other sectors.
Consequently, certain dental services like gold or ceramic inlays, some medical
devices, funeral allowances for those insured after 1989, and pharmaceuticals
for so-called trivial diseases like the common cold, or travel-related diseases
and pharmaceuticals that are either cheap or unproven were incrementally
excluded from the SHI benefits package.
While benefits for ambulatory physician services are legally defined in generic
terms only, one can observe more details in the description of dental especially
prosthetic benefits in Social Code Book V. One reason was the dysfunction of
the Federal Committee of Dentists and Sickness Funds, until 2003 in charge of
decision-making on ambulatory dental care concerning benefits, accreditation
and quality. The SHI Contribution Rate Exoneration Acts regulation to remove
crown/denture treatment from the benefits package for people born after 1978
(even though they still had to pay the full sickness fund contribution rate) was
politically contentious. The Act to Strengthen Solidarity in SHI re-introduced
these benefits from 1999. A new legal initiative to exclude dentures from the
SHI catalogue in favour of mandatory co-insurance was modified in 2004 in
favour of a special contribution to be paid only by employees from July 2005.
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69
Dentures thus continue to be part of the benefit catalogue, and were excluded
in practice for about a year (see Health care reforms).
Another sector comprises the therapeutic services of allied health
professionals other than physicians, such as physiotherapists, speech and
language therapists, and occupational therapists. Insured patients are entitled
to such services unless they are explicitly excluded by the Federal Ministry of
Health, which is currently not the case ( 32 and 34 SGB V). According to 138
SGB V, services provided by allied health professionals may be delivered to the
insured only if their therapeutic use following quality assurance guidelines is
recognized by the Federal Joint Committee. In the Committees directives for
care provided by allied health professionals, the conditions for the prescription
of these services have been reformed in consultation and cooperation with
professional bodies which however have no right to take part in the Federal Joint
Committees final decision-making (see Planning, regulation and management).
The list of services provided by allied health professionals reimbursable by
statutory health insurance is now linked to indications and therapeutic targets.
Non-physician care may be ordered only if a disorder can be recognized, healed
or mitigated or if aggravation, health damage, endangerment of children or the
risk of long-term care can be avoided or decreased.
As mentioned previously (see Organizational structure of the health care
system), psychologists specializing in psychotherapy are the exception to the
rule as they have become members of the physicians associations and therefore
no longer have the status of non-physicians.
Home nursing care is regulated separately. Mandated by the second
SHI Restructuring Act, the Federal Committee passed directives to clarify
responsibilities and improve cooperation among the sickness funds responsible
for acute home nursing care and the long-term care funds. However,
organizational responsibilities and financing obligations are still subject to
debate, for example the Federal Social Court decided that medical aids for
recipients of statutory long-term care insurance have to be paid by their statutory
sickness fund.
The range of services provided in the hospital sector has traditionally been
determined by two factors: the hospital plan of the state government, and the
negotiations between the sickness funds and each hospital. The introduction of
DRGs as the dominant form of payment in hospital care since 2004 will also
affect the range of services. Access to and financing of innovative interventions
is subject to especially intense debate (see Payment of hospitals).
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70
Priority-setting and rationing: the publics and the experts views

Decision-making on benefit coverage at the political level or in joint committees
of SHI represents a form of explicit priority setting. Since 1999, the Federal
Committee of Physicians and Sickness Funds and its successor, the Federal
Joint Committee/ Committee of SHI-affiliated Physician Care have applied a
formal tool to select technologies for decision-making. The development of
health targets and other initiatives to stimulate a discussion about priority-setting
include for example the health target initiative project (see Health targets).
The public has been supporting the political priority of rationalization over
benefit reduction and favours a comprehensive benefit package. If a choice had
to be made between substantial benefit cuts and an increase in contribution
rates, 70% of the socially insured population would opt for the latter (28).
The majority of them would also pay more to get access to better quality care
and therapeutic innovations. A 2004 survey indicates a shift in public opinion,
however: a relative majority favours benefit cuts over increasing contributions.
On the other hand, 80% said they would accept a gatekeeping system by family
doctors and 17% would accept a restricted pool of physicians if contributions
were decreased substantially (34). In a further survey in 1998, a three quarter
majority favoured restrictions on pharmaceuticals. Seventy-four per cent (74%)
were of the opinion that drugs lacking explicit proof of effectiveness should not
be paid for by the sickness funds. Seventy-three per cent (73%) were in favour of
restricting physicians choices to cheaper drugs in cases where pharmaceuticals
differ in price but not effectiveness. Another survey in the summer of 1998
showed that the majority of the population (59%) backed the decision of the
Federal Committee of Physicians and Sickness Funds to exclude lifestyle
drugs such as Viagra, a measure that was legally enacted in 2004 (see Health
technology assessment).
The vast majority of the population also approves of the main principles of
statutory health insurance solidarity in financing and needs-based access to
benefits according to several recent surveys (28,35). In a 2002 survey, around
80% of the SHI-insured population approved of financial redistribution between
people with high and low income, good and bad health, younger and older age.
In this respect net payers hardly differed from net recipients (36).
At the same time, in several surveys over the last decade (35) about 40%
of respondents favoured the inclusion of health risks in the calculation of
sickness fund benefits, mainly through bonuses for healthy lifestyle and, less
frequently, through extra contributions for people with risky behaviours or
elimination of lifestyle related diseases from coverage. The notion of rejecting
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71
rationing in favour of equal treatment opportunities independent of age, income

or status may be stronger in the eastern part, possibly due to a longer history
of advocating equity.
Beyond transplantation services, there are no formal requirements to
document waiting lists, though institutions use lists for planning purposes. The
scant available literature on institutional waiting lists and implicit rationing in
practice shows, that for cardiac interventions and ambulatory eye surgery in the
early 1990s were reduced substantially when capacities were expanded. In minor
surveys, waiting times are reported by a small share of respondents, mainly
for services at sub-specialty treatment centres. The German Hospital Institute
evaluating the impact of the shift from retrospective to prospective payment in
hospital care in 1995 (see Payment of hospitals) found that 21% of hospitals
reported to use waiting lists in 1997; their number is estimated to have increased
substantially. Many reported that waiting times had been prolonged and that
waiting lists were not only due to limited capacities but to the hospital target
budgets which render the treatment of SHI patients financially less attractive,
since degressive prices applied once the target budget had been exceeded. The
prospective budget in SHI was indicated to favour faster access for non-SHI
insured persons. A quantification of these reports and follow-up studies are
not available at present (37). The introduction of the case payments based on
diagnoses-related groups shall again be evaluated considering its impact on
quality, risk selection and access.
Based on a survey of all major stake-holders in health care, including payers,
providers, self help groups and government agencies, the Advisory Council for
the Concerted Action in Health Care documented evidence for under-provision
of health care services as well as over-provision and avoidable harm due to
the omission or commission of health care interventions (16). The reasons
reported for under-use were complex for most issues and seldom related to a
lack of capacities, except in some rural areas of the eastern part and some subspecialties. Reported under-provision of diagnostic services was often attributed
to lack of skills, under-provision of prevention to structural deficits and underprovision of pharmaceuticals in ambulatory care to budgetary constraints or
insecurity of SHI-affiliated physicians about legitimate conditions to exceed
prescription limits. The Federal Association of SHI Physicians recently
documented substantial underprovision of drugs by SHI-affiliated physician
care for patients with selected chronic and rare diseases if compared to the
(merely expert-based) clinical guidelines and estimated that additional finances
were required (38).
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Complementary sources of financing

Even though statutory health insurance dominates the discussion on health
care expenditure and reforms, its actual contribution to overall expenditure
is only 57%. Complementary sources thus contribute 43% to the total health
expenditure, of which statutory insurance schemes for retirement and accidents
contribute 1.7% each (see Historical background) and the statutory insurance
for long-term care 7% (Table 9) (see Social care).
The long-standing role of statutory retirement funds in financing a large part
of medical rehabilitation services is characteristic of the German health care
system. The financing of medical rehabilitation, often in inpatient institutions
owned by the retirement funds, shall serve as a means to prevent disability and
incapacity to work which would. 39% (1.8 billion) of the retirement funds
expenditures on rehabilitation services were spent on medical rehabilitation,
while the other resources were spent on occupational rehabilitation.
Three other complementary sources of finance can be identified: taxes, outof-pocket payments and private health insurance. According to National Health
Accounts (Table 9), taxes were overtaken as the major complementary source
by out-of-pocket financing in the early 1990s.
Taxes
Taxes as a modest source of finance are used for various purposes in the health
care system. The 1972 Hospital Financing Act introduced the dual financing
principle in the acute hospital sector, which means that investment costs are
financed out of taxes from state and federal level and that running costs are
paid by the sickness funds or private patients (who may be reimbursed by
private health insurers). In order to be eligible for investment, hospitals have
to be listed in the hospital plans set by the Lnder, independent of ownership.
Through this mechanism, public, owners of private non-profit and private forprofit hospitals receive tax money for investments in their hospitals as long
as these investments are according to the hospital plans and as long as money
allocated for this purpose is available (see Payment of hospitals).
Taxes are also used for funding research funding in university hospitals and
the education of medical doctors, dentists, pharmacists, nurses and other health
professionals in public schools. Other purposes include free governmental
health care schemes for police, military, other officials, young civil service,
prisoners, immigrants seeking asylum and municipalities on services for the
severely disabled. Since 2004, all recipients of social welfare, that are not insured
elsewhere, and a part of immigrants seeking asylum have to choose a sickness
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73
fund and will have the same rights and duties as other insureds. Municipalities
do not pay contributions on behalf of the recipients of social welfare, but
reimburse sickness funds for health care services that were actually delivered
to the individual. It is expected that the shift from the reimbursement principle
to in-kind benefits and from private sector prices to statutory health insurance
prices will decrease municipal spending further.
Taxes as a source of health care financing have decreased throughout the last
decade (Table 9). The most substantial decrease was observed in spending on
long-term care, reflecting the relief of municipal budgets after the introduction
of statutory long-term care insurance (see Social care) but other spending on
investments e.g. has been decreased as well.
With the exception of subsidies for artists and the farmers funds expenditure
for retired farmers, sickness funds or long-term care funds did not receive any tax
subsidies until 2004. Since then sickness funds receive a fixed amount from the
federal budget for several benefits relevant to family policies: maternity benefits,
sick-pay for parents caring for sick children, in-vitro fertilization, sterilization
for contraceptive purposes, and prescription-only contraception up to the age of
20. To compensate for increasing spending, the tobacco tax is being increased
by almost 1 per pack in three steps by 2005. The transfers from the federal
government are legally fixed, independent of actual utilization of benefits and
actual revenue from tobacco tax (see Health care reforms).
Out-of-pocket payments
Out-of-pocket expenditure as a share of total expenditure increased from
10.7% of total expenditure in 1992 to 12.2% in 2002 (Table 9). Out-of-pocket
payments relate to co-payments for benefits partly covered by prepaid schemes
and to direct payments for benefits not reimbursed by ones prepaid scheme.
Table 12 gives an overview of co-payments for the various types of services
and products covered by SHI between 1994 and 2004.
Co-payments and corresponding exemption mechanisms have a long tradition
in the German health care system, most traditionally in pharmaceuticals, for
which cost-sharing was introduced in 1923 and has existed ever since (39).
Nominal co-payments were in place from 1977 until 1989, when reference
prices were introduced. Between 1989 and 1992 no co-payment had to be
paid for reference-priced drugs above the price differential. Since 1993 flatrate co-payments have to be paid above the differential between the actual and
reference prices (Table 12). It is noteworthy that because of competition within
the reference-price groups and the legal obligation for physicians to inform
patients that they are liable for the price difference for reference-priced drugs,
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74
very few drugs now exceed the reference price. In 1993, the co-payment amount
was linked to the price of the drug sold an idea re-introduced from 2004. From
1994 until 2003, it was linked to package size as an incentive to patients to ask
for larger package sizes (Table 12). The graded scheme was meant to provide
an incentive for physicians to prescribe larger package sizes with lower average
costs-per-dose resulting in overall cost savings per patient treated.
The overall amount of SHI pharmaceutical co-payments continuously
increased from 0.6 billion in 1991 to 2.7 billion in 1998. The then newly
elected Social Democratic/Green coalition government lowered nominal copayment rates immediately after the elections. As a consequence, aggregate
co-payments for pharmaceuticals decreased to 2 billion the following year
and remained stable at 1.8 billion from 2000 to 2002 (40). Higher levels
of co-payments for pharmaceuticals after July 1997 resulted in 20% of all
prescriptions and 4% of pharmaceutical sales volume in the SHI market being
below the co-payment ceiling which in effect constitutes a 100% co-payment.
Co-payments for pharmaceuticals grow with age and are higher for women
than men (39).
In other areas, cost-sharing was reduced in the 1970s by enlarging the benefit
package, but cost-sharing was increased again later. New areas for cost-sharing
since the 1980s are charges for inpatient days in hospitals, rehabilitative care
facilities and ambulance transportation. Most of these were cost-containment
measures to shift spending from the sickness funds to patients; they were not
intended to reduce overall spending. For example, patients were told that the
co-payment for hospital treatment had to be paid to cover food.
In the Health Care Reform Act of 1989, cost-sharing was advocated for two
purposes: to raise revenue (by reducing expenditure for dental care, physiotherapy
and transportation and making patients liable for pharmaceutical costs above
reference prices) and to reward responsible behaviour and good preventive
practice (dental treatment) with lower co-payments. These cost-sharing
regulations were part of a complete restructuring of co-payments, resulting
in generally higher cost-sharing. Crown and denture treatment were removed
from the benefit package for everyone born after 1978. Prosthetic treatment
was no longer directly reimbursed through the sickness funds but patients were
required to obtain private treatment and receive a fixed reimbursement from the
sickness fund. Through this regulation, prosthetic treatment became the first area
in German SHI to use contracts between patients and providers. While the
law had established limits for private billing until 1999, the ministry estimated
that at least one third of dentists overcharged. Accordingly, the regulation was
abolished late in 1998 in favour of the former co-insurance regulation.
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75
From 2004, co-payments and other out-of-pocket payments are expected

to rise again substantially for SHI-insured patients since the bulk of expected
savings through the SHI Modernization Act (4% of current expenditures)
will be achieved by shifting costs to users via increased co-payments or the
exclusion of benefits (for example eye glasses, transport to ambulatory care and
over-the-counter medications). Co-payment amounts have been increased and
standardized to 10 per inpatient day and to between 5 and 10 for services
and products in ambulatory care. Co-payments of 10 per quarter now also apply
to the first contact at a physicians (not necessarily a GP) or dentists office and
when other physicians are seen without referral during the same quarter.
Exemptions from co-payments have a long tradition in Germany, being
granted either to specific population sub-groups, to the poor or to people with
substantial health care needs. Population sub-groups which have usually been
exempt from user charges were children and adolescents up to the age of 18 years
(except for dentures, orthodontic treatment and transportation) and pregnant
women. According to studies of differing methodologies, the number of people
fully exempt from co-payments tripled between 1993 and 2000 from 10% to
about 30% of the population. In 2001, 47% of prescriptions were exempted
from co-payments (39).
From 2004, the general exemption due to poverty or other reasons has
been abolished, and the regulations for partial exemption have been tightened.
According to the new definition an SHI-insured person is eligible for exemption
from user charges for benefits covered by statutory health insurance once
more than 2% of the gross household income per annum has been spent on copayments, or 1% of the gross household income for a sufferer from a serious
chronic illness, defined as one that has been treated at least once per quarter
for at least a year and is associated with at least one of the following additional
characteristics:
a need for long-term care grade II or III
a 60% severe disability or a 60% incapacity to work OR
a certificate from the treating physician that the omission of continuous
health care (at least one physician contact per quarter for the same disease)
would cause a life- threatening aggravation, a reduction of life expectancy
or a long-term reduction in the quality of life.
This definition of chronic illness was approved by the Minister of Health
in March 2004, after the first draft of the Federal Joint Committee had been
refused as too restrictive (it required evidence of at least two hospital stays in
the previous 2 years or 8 physician visits per year or 70% disability or 70%
working incapacity).
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Table 12.
Co-payment/ co-insurance levels,a 19942005

19941996
Ambulatory medical
treatment ()
Pharmaceuticals()d
small pack ()
medium pack ()
large pack ()
Conservative dental
treatment ()
Crowns and denturesh
1st half 2nd half

1997
1997
1998
1999
2000
2003b
2004
2005
10c
510e
1.5
2.6
3.6
0
2
3.1
4.1
0
4.6
5.6
6.6
0
4.6
5.6
6.6
0
4.1
4.6
5.1
0
4.1 (4)
4.6 (4.5)
5.1 (5)
0
50%i
40%f
35%g
50%
40%f
35%g
100%
above
fixed
sumi
50%
40%f
35%g
10c
for people born

before 1979h
50%
40%f
35%g
55%
45%f
40%g
for people born

after 1978
Orthodontic treatment
Transportation to and
from medical facility
inpatient treatment
or emergencies
( per trip)
ambulatory
treatment
Non-physician care
(for example home
nursing,
physiotherapy)
Hospital stay and
inpatient rehabilitation
after a hospital stay
( per day)l
Preventive spa or
inpatient rehabilitation
unrelated to hospital
stay ( per day)
100%
100%
100%
above
fixed
sum
100%
020%j
020%j
020%j
020%j
020%j
020%j
020%j
10.2
10.2
12.8
12.8
12.8
12.8
(13)
510e
100%
100%
100%
100%
100%
100%
100%
10%
10%
15%
15%
15%
15%
6.1
6.1
8.7
8.7
8.7
8.7 (9)
10%
plus10/
prescriptionk
10
6.1
12.8
12.8
12.8
12.8
8.7 (9)
10
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Source: modified from Busse, 2000 (1); Gericke et al., 2004 (39).
Note: a Several rates in this table were lower in the eastern part of Germany until 1999;
b
in brackets: changes for 2002/2003;
c
per physician or dentist consulted per quarter except referrals;
d
with price of drug as maximum; plus the difference between the price and the reference price;
e
10% with min. 5 and max. 10;
f
if insured had regular annual check-ups for the last five years;
g
if the insured had regular annual check-ups for the last ten years;
h
100% for major dental work (more than four replacement teeth per jaw or more than three per
side of mouth, except multiple single bridges, which may exceed three);
i
fixed sum is higher for insured with regular check-ups for 5 and 10 years respectively;
j
if eating, speaking or breathing is severely limited and treatment is begun under age 18, otherwise
100%; full cost is reimbursed retrospectively by the sickness fund if a predefined treatment plan
is entirely completed;
k
for short-term home nursing limited to 28 days per year;
l
until 2003 limited to a total of 14 days per calendar year, from 2004 limited to 28 days.
The number of people possibly targeted by these exemption rules is difficult

to estimate. There is probably substantial overlap between the following relevant
groups: About 1.5 million received long-term care benefits grade II or grade
III and about 3 million (of a total of 6.7 million) had a level of 60% severe
disability in 2001 (3). About half of the 1.8 million people received disability
benefits from statutory retirement insurance due to incapacity to work in 2003
(4). In practice, by September 2004, an estimated 3.1 million insured had been
exempt from co-payment.
The exemption rules do not apply to benefits that are not covered by the
SHI package, or to price differentials for reference-priced pharmaceuticals.
Besides the SHI exemption mechanism, relief from income tax is granted for
out-of-pocket health care spending over 600 per year and a certain percentage
of the annual household income.
Private health insurance
Private health insurance (PHI) has two facets in Germany: to fully cover a portion
of the population and to offer supplementary and complementary insurance for
SHI-insured people. Between 1975 and 2002, the number of people having full
cover rose from 4.2 million to 7.7 million, representing 6.9% and 9.3% of the
population respectively (41,42). Both types are offered by 50 private health
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78
insurers, united in the Association of Private Health Insurance. In addition, there

are around 45 other very small and usually regional private health insurers. In
terms of premium turnover, the full-cover segment is more than four times as
large as the supplementary insurance segment. People with full-cover private
health insurance consist of three main groups:
active and retired permanent public employees such as teachers, university
professors, employees in ministries etc., who are excluded de facto from SHI
as they are reimbursed by the government for at least 50% of their private
health care bills and purchase private insurance to cover the remainder;
self-employed people who are excluded from SHI unless they have been a
member previously (except those who fall under mandatory SHI cover like
farmers), and
employed people who have opted out of SHI once their income exceeded
the threshold. Employees whose earnings are initially below the limit, but
then exceed it as a result of an increase in wages may remain in the SHI
voluntarily if they have been covered by it for the last 12 months or for 24
months within the last 60 months. Employees whose occupational income
exceeds the cut-off limit from the start of their first gainful employment or
up to two months after returning from another country may have voluntary
SHI coverage if they apply within three months. This option does not apply
to civil servants and soldiers.
Employees who have left the statutory health insurance scheme but who are
brought back within its scope by an increase in the cut-off limit or a reduction
of their salary may be exempt from mandatory membership if they have been
outside SHI for at least 5 years. Since 2000, this choice only applies to those
younger than 55; those older than 55 have to remain in voluntary health insurance
no matter how low their income is.
Private health insurers are forced by law to set aside savings for old age
from the insurance premiums when the insured are young (whereas statutory
health insurance is financed on a pay-as-you-go basis, financing of private health
insurance is based on capital cover). Since premiums still rise with age, and entry
of privately insured people into SHI is not permitted in ordinary circumstances,
private insurers are obliged to offer an insurance policy with the same benefits
as SHI at a premium that is not higher than the average maximum contribution
to sickness funds. People who have had continuous private coverage for at least
10 years and who are at least 65 years old can opt for the so called standard
tariff (2000), which guarantees that insurance premiums are not higher than
the maximum average SHI contribution. The regulation for this tariff entails
that benefits and chargeable prices are restricted (or extended) to the catalogue
of statutory health insurance. In addition, private health insurers announced in
Germany
79
2004 the voluntary introduction of a new basis tariff which also provides the
benefits of the SHI package without a prior health examination.
Fully privately insured patients usually enjoy benefits equal to or better
than those covered by SHI. This depends, however, on the insurance package
chosen; for example it is possible not to cover dental care. In the private health
insurance market, premiums vary with age, sex and medical history at the time
of underwriting. Unlike in SHI, separate premiums have to be paid for spouses
and children, making private health insurance especially attractive for single
Table 13.
Changes in per capita SHI and PHI expenditure, 19922002 in the western
part of Germany
Ambulatory physician care

Dental care
Pharmaceuticals (ambulatory
care)
Medical aids, prostheses
and ambulatory non-medical
services
Hospital care
Total
SHI (in %)
+24
+6
PHI (in %)
+70
+33
Ratio PHI to SHI

2.9
5.5
+32
+84
2.6
+49
+33
+36
+67
+55a
+50
1.4
1.7
1.4
Source: Association of Private Health Insurance, 2003 (42).

Note: aHospital care relates to general services and not to optional services in private health
insurance for accommodation (-10%) and for head physician care (+22%) which however are
included in total expenditures of private health insurers (last line).
people or double-income couples. Physicians, dentists and pharmacists are

allowed to opt out of SHI and buy substitutive PHI while students or in their
early years in the profession, even if their income does not exceed the usual
threshold (42).
From 1999 to 2000, the number of PHI policies jumped by 240 000, followed
by a similar increase in 2001. This development probably has to do with rising
SHI contribution rates that give a strong incentive for single young people
without health problems to move to private insurance. This prompted the reelected government to increase the threshold for opting out by approximately
13%, from 3375 to 3825 per month from 2003. Policies with high deductibles
and/or excluding certain benefits like dental care are mainly bought by the selfemployed, as for all employees the employers contribute 50% of PHI premiums,
up to a ceiling of 241.50 per month (in 2003). Between 1989 and 2001 total
contributions to PHI increased from 8.7 billion to 21.7 billion (43).
Unlike SHI insureds, privately insured people generally have to pay providers
directly and are reimbursed by their insurer. While a price list for privately
Germany
80
delivered medical services exists as an ordinance issued by the Federal Ministry

of Health, physicians usually charge more by a factor of 1.7 or 2.3 (which are
the maximum levels for reimbursement by the government and by most private
health insurers for technical and personal services, respectively) or even more.
The real fee-for-service reimbursement for privately insured people has led to
cost increases on average considerably higher than in SHI (Table 13).
The second market for private health insurers is supplementary insurance, for
example to cover extra amenities like hospital rooms with two beds or treatment
by the head-of-service. Since sickness funds are prohibited from offering these
extra policies, people must obtain private coverage. Based on microcensus data,
the number of people with supplementary PHI is estimated at around 7.5 million
(9% of the population; excluding private health insurance during travel). It had
increased from 5.3 million in 1991 to 7.6 million in 1998 (42).
A third market is complementary health insurance to cover co-payments
for benefits that are not fully covered by the main insurer of an insured: While
traditionally not enrooted in the system, a considerable growth of the number
of insured took place from 1996 due to the introduction of a new insurance
segment to cover crowns and dentures, which were excluded from the SHI
benefits package for people born after 1978. They were reintroduced from
1999. Around 4.5 million policies each are issued for optional hospital benefits
and optional outpatient insurance. Both are taken by 6% of SHI enrolees. The
latter segment experienced its heyday in 19971998 due to benefit package
restrictions in dental care. The number of insured children with complementary
coverage dropped from 2.2 million to 1.4 million between 1998 and 1999 after
the reintroduction of these benefits. Approximately 900 000 people (1.3% of
SHI insureds) had complementary insurance against loss of income, a benefit
useful for voluntary SHI-insured self-employed people with an income much
above the threshold (as sick pay is based on that amount). The latter came to
account for 13% of revenues of private health insurers
Until 2003, there were few insurance policies which covered co-payments.
Many complementary policies offer, among other services, allowances for copayments for benefits like medical aids, remedies or hospital stays while such
allowances for pharmaceutical co-payments are offered less and less.
Germany
81
Health care expenditure

Total and public expenditure
Germany continues to spend a substantial amount of its wealth on health care,
in 2002, 2840 per inhabitant according to national figures (44). Altogether total
health expenditures accounted for 234 billion and 11.1% of the gross domestic
product (GDP). OECD and WHO put figures slightly lower at 2789, 230
billion and 10.9% respectively (2). By international comparison, the health care
system is expensive, both in percentage of GDP (Fig. 5, Fig. 6) and absolute
figures (Fig.7). Among OECD countries Germany ranked sixth in per capita
expenditure and third in the share of GDP spent on health in 2002.
Table 14.
Trends in health care expenditurea, 19702002

1970 1980 1990 1992 1995 1996 1997 1998 1999 2000 2001 2002
Total expenditure on
health care
- in current prices
(billion )
21.7
- in constant 1995
GDP prices
(billion )
55.2 102.1 125.7 173.2 190.4 197.4 196.7 199.1 203.6 208.4 213.6 216.9
- in current prices
per capita ()
223
824 1 600 1 982 2 331 2 434 2 441 2 495 2 563 2 613 2 708 2 789
- in current
prices per capita
(US$PPP)
266
955 1 729 1 962 2 263 2 410 2 416 2 470 2 563 2 640 2 735 2 817
- as share of GDP
(%)
6.2
8.7
8.5
9.9
10.6
10.9
10.7
10.6
10.6
10.6
10.8
10.9
- as share of total
expenditure on
health care (%)
72.8
78.7
76.2
80.9
80.5
80.6
79.1
78.6
78.6
78.8
78.6
78.5
- as share of GDP
(%)
4.5
6.8
6.5
7.7
8.5
8.8
8.5
8.3
8.4
8.3
8.5
8.6
66.4 108.3 159.8 190.4 199.4 200.2 204.7 210.4 214.9 223.0 230.0
Public expenditure
on health care
Source: OECD Health Data, 2004 (2).

Note: US$PPP: US dollar in purchasing power parities; a 19701990: data relate to the western
part only.
From 1992 to 2001, health expenditure increased from 9.9% of the GDP to
10.8%. However, the real annual growth of total health expenditures by 2.2%
during this period was smaller than in the 3.2% average of OECD countries.
The overall increase is perceived differently depending on the use of various
deflators, none of which is tailored specifically to the health care system as a
Germany
82
Fig. 5.
Trends in total expenditure on health care in Germany, selected countries

and EU-15 average, 19902002 (percentage of GDP)
12
11
10
9
8
7
6
5
4
1990
1991
1992
1993
France
Norway
EU-15 average
1994
1995
1996
Germany
Switzerland
1997
1998
1999
2000
2001
2002
Netherlands
United Kingdom
whole. While the nominal increase of total expenditures was 38.5% between
1992 and 2001, the real increase was 20% if the GDP deflator was applied,
15% when the consumer price index was used and 12% when the health care
price deflator was applied. The latter two reflect private expenditures on health
related goods but not the prices in the public sector of health care.
The public share of total health expenditures, including governmental and
various social insurance sources, has decreased slightly throughout the last
decade (Tables 9,14) despite the introduction of new benefits as part of the
statutory long-term care insurance. This trend reflects a relative increase of
private sources and a decrease in tax spending. German national data (Table9)
are continuously around 3.5 percentage points lower than those of OECD or
WHO (Table 14, Fig. 8). Depending on the source, Germany occupies a middle
(Table 9) or relatively high (Table 14, Fig. 8) position in the public share of
funding .
In the context of the overall economy, indicated as a share of GDP, the largest
increase of public spending on health care occurred in the 1970s and in the
early 1990s. Since 1995, public expenditures on health have remained stable at
around 8.5% of GDP (Table 14), the highest value of any OECD country.
Germany
Fig. 6a.
83
Total expenditure on health as a % of GDP in the WHO European Region,

2002 or latest available year (in parentheses)
Western Europe
Switzerland
11.2
Germany
10.9
Iceland
9.9
France
9.7
Greece
9.5
Portugal
9.3
Sweden
9.2
Netherlands
9.1
Belgium
9.1
EU-15 average
9.0
Denmark
8.8
Israel
8.8
Norway
8.7
Italy
8.5
United Kingdom
7.7
Austria
7.7
Spain
7.6
7.3
Ireland
7.3
Finland
6.2
Luxembourg
Central and south-eastern Europe
9.7
Malta
9.0
Croatia (1994)
8.2
Slovenia (2001)
7.8
Hungary
7.6
Serbia and Montenegro (2000)
7.4
Czech Republic
6.6
Turkey (2000)
6.5
EU-10 average
6.1
Poland
6.1
Cyprus (2001)
5.8
Lithuania
5.7
Slovakia
5.5
Estonia
4.9
Latvia
4.7
Bulgaria (1994)
4.5
The former Yugoslav Republic of Macedonia (2000)
4.2
Romania
3.5
Bosnia and Herzegovina (1991)
1.9
Albania (2000)
CIS
5.1
Georgia (2000)
4.7
Belarus
4.2
Armenia (1993)
3.6
Republic of Moldova
3.5
Turkmenistan (1996)
3.4
Ukraine
2.9
CIS-12 average
2.9
Russian Federation (2000)
2.4
Uzbekistan
1.9
Kyrgyzstan
1.9
Kazakhstan
Azerbaijan 0.8
% of GDP
10
15
Source: WHO Regional Office for Europe health for all database, June 2004.
Note: CIS: Commonwealth of independent states; EU: European Union; EU-10 average: for new member states after 1 May 2004;
EU-15 average: for member states prior to 1 May 2004. Countries without data not included.
Germany
84
Fig. 6b.
Total expenditure on health as a % of GDP in the European Union,

Germany
10.9
France
9.7
Malta
9.7
Greece
9.5
Portugal
9.3
Sweden
9.2
Netherlands
9.1
Belgium
9.1
EU-25 average
9.0
Denmark
8.8
Italy
8.5
Slovenia (2001)
8.2
Hungary
7.8
United Kingdom
7.7
Austria
7.7
Spain
7.6
Czech Republic
7.4
Ireland
7.3
Finland
7.3
Luxembourg
6.2
Poland
6.1
Cyprus (2001)
6.1
Lithuania
5.8
Slovakia
5.7
Estonia
Latvia
0
5.5
4.9
% of GDP
12
Note: EU: European Union; EU-25 average: all member states. Countries without data not
included.
Germany
Fig. 7a.
85
Health care expenditure in US $PPP per capita in the WHO European Region,
Western Europe
Switzerland
3445
Norway
3083
Luxembourg
3065
Germany
2817
Iceland
2807
France
2736
Netherlands
2643
Denmark
2580
Sweden
2517
Belgium
2515
Ireland
2367
EU-15 average
2323
Austria
2220
Italy
2166
United Kingdom
2160
Finland
1943
Greece
1814
Portugal
1702
Spain
1646
Israel (2001)
1623
Slovenia (2001)
1405
Cyprus (2001)
1293
Malta (2001)
1174
Czech Republic
1118
Hungary
1079
EU-10 average (2001)
756
Slovakia
698
Poland
654
Estonia (2001)
559
Lithuania (2001) 491
Latvia (2001) 446
Turkey (2000) 387
Croatia (1994) 358
245
Romania (2001)
229
Bulgaria (1994)
214
Albania (2000)
67
CIS
Belarus (2001) 351
243
CIS-12 average (2001)
183
Ukraine (2001)
148
Georgia (2000)
136
Kazakhstan (2001)
107
86
Armenia (1993)
Uzbekistan (2001)
64
Kyrgyzstan (2001)
63
Republic of Moldova (2001)
62
Turkmenistan (1994)
49
25
Azerbaijan (2001)
12
Tajikistan (1998)
1000
2000
US $PPP
3000
4000
EU-15 average: for member states prior to 1 May 2004; EU-25 average: for all member states. Countries without data not
included.
Germany
86
Fig. 7b.
Health care expenditure in US $PPP per capita in the European Union, 2002
or latest available year (in parentheses)
Luxembourg
3065
Germany
2817
France
2736
Netherlands
2643
Denmark
2580
Sweden
2517
Belgium
2515
Ireland
2367
Austria
2220
Italy
2166
United Kingdom
2160
2128
EU-25 average
1943
Finland
1814
Greece
1702
Portugal
1646
Spain
1405
Slovenia (2001)
1293
Cyprus (2001)
Malta (2001)
1174
Czech Republic
1118
1079
Hungary
698
Slovakia
Poland
654
Estonia (2001)
559
Lithuania (2001)
491
Latvia (2001) 387

0
1000
2000
US $PPP
Note: EU: European Union; EU-25 average: all member states.
Germany
3000
4000
87
Fig. 8a.
Health care expenditure from public sources as a percentage of total health

care expenditure in countries in the WHO European Region, 2002 or latest
available year (in parentheses)
Western Europe
85.4
Luxembourg
85.3
Norway
85.3
Sweden
84.0
Iceland
83.4
United Kingdom
83.1
Denmark
78.5
Germany
76.0
France
75.7
Finland
75.6
Italy
75.2
Ireland
71.4
Spain
71.2
Belgium
Portugal
70.5
Austria
69.9
Israel
68.0
Netherlands (2001)
63.3
Switzerland
57.9
Greece
52.9
100.0
Romania (2001)
100.0
Croatia (1996)
100.0
Bulgaria (1994)
100.0
Bosnia and Herzegovina (1991)
93.9
91.4
Czech Republic
89.1
Slovakia
86.7
Slovenia (2001)
Albania
82.6
Estonia
76.3
Latvia
73.3
Poland
72.4
Lithuania
71.7
Hungary
70.2
Malta
69.1
Turkey (2000)
62.9
Cyprus (2001)
33.4
CIS
Kyrgyzstan (1992)
96.8
Kazakhstan (1998)
95.7
Belarus (1997)
94.1
Ukraine (1995)
92.0
Republic of Moldova
89.9
Georgia (2000) 8.2
0
25
50
75
100
Percentage
Note: CIS: Commonwealth of independent states; countries without data not included.
Germany
88
Fig. 8b.

care expenditure in countries in the European Union, 2002 or latest available
year (in parentheses)
Czech Republic
91.4
Slovakia
89.1
Slovenia (2001)
86.7
Luxembourg
85.4
Sweden
85.3
United Kingdom
83.4
Denmark
83.1
Germany
78.5
Estonia
76.3
France
76.0
Finland
75.7
Italy
75.6
Ireland
75.2
Latvia
73.3
Poland
72.4
Lithuania
71.7
Spain
71.4
Belgium
71.2
Portugal
70.5
Hungary
70.2
Austria
69.9
Malta
69.1
Netherlands (2001)
63.3
Greece
52.9
Cyprus (2001)
33.4
0
25
50
75
Percentage
Note: EU: European Union; EU-25 average: for all member states.
Germany
100
Table 15.
89
Total and SHI expenditures on health by institution as a share of GDP (%)

by type of service, 19922002
1992
1994
1996
1998
1999
2000
2001
2002
SHI expenditure
6.14
6.20
6.36
6.13
6.15
6.13
6.21
6.32
Inpatient institutions
2.31
2.49
2.52
2.52
2.48
2.47
2.44
2.47
Acute hospitals
2.21
2.37
2.37
2.38
2.34
2.32
2.30
2.33
Ambulatory institutions
3.26
3.11
3.28
3.12
3.16
3.16
3.25
3.31
physician offices
1.07
1.11
1.13
1.12
1.12
1.12
1.11
1.11
pharmacies
1.03
0.86
0.93
0.89
0.94
0.95
1.03
1.07
Rescue and emergency

providers
0.06
0.08
0.08
0.08
0.09
0.09
0.09
0.09
Administrationa
0.35
0.35
0.36
0.35
0.36
0.36
0.37
0.38
Outside the country
0.02
0.02
0.02
0.02
0.02
0.02
0.02
0.02
Total expenditure
10.1
10.4
11.1
10.8
10.8
10.8
11.0
11.1
Inpatient institutions
3.89
4.19
4.29
4.23
4.22
4.20
4.20
4.25
Acute hospitals
2.88
3.07
3.05
3.08
3.04
3.01
3.00
3.02
Ambulatory institutions
4.70
4.64
5.01
4.94
4.96
4.95
5.08
5.14
physician offices
1.36
1.42
1.46
1.48
1.49
1.48
1.49
1.49
pharmacies
1.40
1.27
1.36
1.38
1.40
1.40
1.49
1.53
Rescue and emergency

providers
0.08
0.10
0.10
0.10
0.10
0.10
0.11
0.11
Administrationa
0.54
0.56
0.60
0.61
0.62
0.61
0.62
0.65
Outside the country
0.02
0.02
0.02
0.02
0.02
0.02
0.02
0.02
Source: authors calculations based on Federal Statistical Office, 2004 (12).

Note: a includes expenditures of payers, expenditures of providers are part of reimbursement for
health services/products; expenditures of patient organizations or governmental agencies are
not included (except disease management administration which is paid by sickness funds).
Structure of health care expenditure

The allocation of resources within the overall health care budget showed some
distinct features and trends between 1992 and 2002 (Table 15). While total
nominal health expenditure increased by 39%, spending on medical goods
increased by 41% and spending on services by 30%. Among the latter the
largest increase of 121% was seen in nursing care following the introduction
of statutory long-term care insurance in 1993 (see Social care).
Statutory health insurance expenditures developed close to the GDP but
came to exceed GDP growth rate in 1996 and again in 2002. Table 15 shows,
that, following an increase in the early 1990s, SHI expenditures on ambulatory
physician services and acute hospital services even decreased since 1997 and
1998 respectively. In international comparison, spending on acute hospital care
is low due to the strong ambulatory care sector offering almost all medical
specialties (45).
Germany
90
In contrast to these highly controlled sectors of personal health services,

SHI expenditures on pharmaceuticals increased above average, joint by smaller
expenditure items like rescue services or administrative costs. Administrative
costs differ substantially between the statutory and private sectors. In
2002, administration and marketing accounted for 6.1% of sickness funds
expenditures, as compared to 16.7% for private insurers (42).
Per capita expenditure in the eastern part has increased much more than
in the western part, but is still lower than in the western part, particularly in
personal health services, except in emergency care and home nursing care. In
contrast pharmaceutical costs have even overtaken expenditure in the western
part, partly due to the higher risk structure of the population and partly to the
less rational prescribing of physicians in the eastern part (18).
Germany
Health care delivery system
key feature of the health care delivery system in Germany is the clear
institutional separation between (1) the public health services, (2)
primary and secondary ambulatory care, and (3) hospital care, which
has traditionally been confined to inpatient care. The following chapter is
arranged accordingly. In separate sections, emergency care, hospital outpatient
care, day-case surgery, and integrated care are accounted for.
Public health services

While the specific tasks of the public health services and the levels at which
they are carried out differ among Lnder, they generally include activities linked
both to sovereign rights and care for selected groups, such as:
surveillance of communicable diseases;
health reporting;
supervision of hospitals, institutions for ambulatory surgery and ambulatory
practices of physicians and non-medical therapeutic professions;
supervision of commercial activities involving food, pharmaceuticals and
drugs;
overseeing certain areas of environmental hygiene;
physical examinations of school children and certain other groups;
diagnostic and in exceptional circumstances therapeuticservices
for persons with specific communicable diseases including sexually
transmittable diseases and tuberculosis;
provision of community-oriented psychiatric services;
Germany
92
health education and promotion;

cooperation with and advice to other public agencies.
These functions are exerted by roughly 350 public health offices across
Germany, which vary widely in size, structure and tasks. In 2000, 78 were
run by state governments (in Bavaria and Hamburg), while 274 were run by
municipalities in the other 14 Lnder.
In the first decades of the Federal Republics history, the Lnder defended
their responsibility for public health services against several attempts by
the federal government to extend its influence in this sector. Originally,
immunizations, mass screening for tuberculosis and other diseases as well as
health education and counselling were in the hands of the public health services.
Since the 1970s, however, the rules of the Social Code Book have been extended
to include many of the individual preventive services that were transferred to
office-based physicians. Before 1970, only antenatal care was included in the
sickness funds benefit package. Since 1971, screening for cancer has become
a benefit for women over 20 years old and men over 45. At the same time,
regular check-ups for children under the age of four were introduced (and
extended to children under the age of six in 1989 and to adolescents in 1997).
Also in 1989, group dental preventive care for children under 12 and individual
dental preventive care for 12- to 20-year-olds became sickness fund benefits;
individual preventive care was extended to 6 to 20-year-olds in 1993. Regular
health check-ups such as screening for cardiovascular and renal diseases and
diabetes for sickness fund members over 35 were also introduced in 1989.
Health promotion was made mandatory for sickness funds in 1989, was
eliminated in 1996 and reintroduced in a modified form in 2000. Since 2003,
the existing cancer-screening benefits covered by SHI (cervix/genitals, breast,
skin, rectum/colon, prostate) have been extended to cover colonoscopy (two
tests, after age 55 and 65) as an alternative to stool-testing and a systematic
mammography screening programme for women aged 5069.
The legal mandate for case finding and check-ups means that office-based
physicians are obliged to deliver these services as part of the regional budget for
physician services. For other services the physicians were able to negotiate fees
with the sickness funds. Thus, preventive services are now delivered under the
same regulations as curative services, meaning their exact definition is subject
to negotiations between the sickness funds and the physicians associations.
The current directives of the Federal Joint Committee on preventive services
include clinical and lab services for screening and information about test
results and prognosis, while health education is still given low priority in the
reimbursement and documentation requirements.
Germany
93
The shift in responsibilities for immunizations from public health offices

to physicians practices has resulted in immunization rates that are rather low
by international standards (Fig. 9). Although vaccination rates of children have
improved in recent years (Table 2), immunization is still an area of underprovision (46,47). The average vaccination rate at school entry was 97% for
tetanus, 74% for pertussis and 37% for hepatitis B between 1999 and 2001.
Vaccinations are performed comparably late, and fewer than 25% of children
receive the recommended second vaccination for mumps, measles and rubella.
In addition, the influenza vaccination recommended for the elderly was received
by only one third of people above the age of 69 years (47). Since the enactment
of the Infection Protection Act in 2000, school entry examinations include
documentation of vaccination status but vaccinations may not be performed
by the examining public health office physicians.
After many of health promotion and prevention services were taken from
the public health service, it became much smaller and even less publicly visible.
The number of physicians working in the public health service decreased from
4900 in 1970 (western part of Germany only) to 3300 in 1996 and about 3000
in 2002. Besides physicians, social workers (2000) and assistants of physicians
or dentists (2000) were the largest professional groups working in public health
offices in 2002, followed by administrative personnel, health supervisors, and
dentists (4). From 1992 to 2002, total expenditure on public health offices
remained virtually stable in nominal terms and thus decreased in real terms. In
2002, total expenditure on public health offices accounted for 2.0 billion or
0.09% of GDP compared to 1.9 billion and a GDP share of 0.12% in 1992.
Since 2000, the public health services functions in controlling communicable
diseases have been reorganized according to the long-sought Infection Protection
Act. The surveillance procedures were streamlined and essentially centralized
at the Federal Institute for Communicable and Non-Communicable Diseases,
the Robert Koch Institute, an agency to better evaluate and inform the public
about infectious diseases and cooperate with European disease-control agencies.
Besides supervising hygienic standards of hospitals, public health offices also
check hygienic standards in practices of ambulatory physicians, dentists and
other health professionals. Hospitals and ambulatory surgery facilities are now
required to report nosocomial infections and multi-resistant microbes, with
recommendations for improving the situation. The Robert Koch Institute collects
their data as part of an anonymous benchmarking, publishes the aggregate results
and provides feedback to individual institutions (see Organizational structure
of the health care system).
According the Infection Protection Act, not only hospitals but all types of
shared facilities including homes, schools, and prisons must provide hygienic
Germany
94
Fig. 9a.
Levels of immunization for measles in the WHO European Region,

Western Europe
Andorra (2002)
Poland
Spain
Finland
Portugal
Netherlands (2002)
Denmark
Israel (2002)
Iceland
Germany
Luxembourg
San Marino
Sweden (2002)
Greece (2002)
France
Monaco (2002)
Norway
Italy
Switzerland
United Kingdom
Austria (2002)
Ireland
Belgium (2002)
Hungary
Czech Republic
Slovakia
Latvia
Lithuania
Romania
The former Yugoslav Republic of Macedonia
Bulgaria
Estonia
Croatia
Slovenia (2002)
Malta
Albania
Serbia and Montenegro
Cyprus
Bosnia and Herzegovina
Turkey
CIS
Kyrgyzstan
Kazakhstan
Ukraine
Uzbekistan
Belarus
Tajikistan
Azerbaijan
Turkmenistan
Republic of Moldova
Armenia
Georgia
60
98
98
97
97
96
96
96
95
93
91
91
91
91
88
86
85
84
83
82
80
79
78
75
100
99
99
99
98
97
96
96
95
95
93
93
90
87
86
84
75
100
100
99
99
99
98
98
98
97
96
94
80
80
Percentage
Note: CIS: Commonwealth of independent states; countries without data not included.
Germany
100
Fig. 9b.
95
Levels of immunization for measles in the European Union,

Hungary
100
Czech Republic
99
Slovakia
99
Latvia
99
Lithuania
98
Poland
98
Spain
97
Finland
97
Portugal
96
Netherlands (2002)
96
Denmark
96
Estonia
95
Slovenia (2002)
93
Germany
91
Luxembourg
91
Sweden (2002)
91
Malta
90
88
Greece (2002)
86
Cyprus
86
France
83
Italy
80
United Kingdom
79
Austria (2002)
78
Ireland
75
Belgium (2002)
60
80
100
Percentage
Note: Countries without data not included.
plans and are subject to the supervision of public health offices. People admitted
to homes for the elderly, homeless or asylum-seekers must present a health
certificate including X-ray.
The well-proved voluntary and educational standards for HIV are applied to
all sexually-transmittable diseases while former, more strict regulations were
abolished. Public health offices are required to strengthen their counselling
services and to provide diagnostic services and treatment in certain cases,
including for example non-compliant tuberculosis patients.
Germany
96
Some state public health services have initiated conferences bringing together
a broad variety of providers, payers, and self-help groups in order to agree on
health targets and better coordinate prevention. In North Rhine-Westphalia,
health conferences have been established through legislation. Several public
health offices have also introduced municipal conferences.
Another forum for improving cooperation among public health services,
office-based physicians, policy-makers and many other stake-holders has been
established at the federal level. The German Forum for Prevention and Health
Pro motion was founded in July 2002 following stake-holder initiatives at the
federal level since 2000 to define health targets and debate ways to strengthen
prevention in round-table discussions. The target of the forums 41 institutional
members is to actively strengthen prevention and health promotion, to promote
the development of broad preventive programmes and information and to
establish sustainable organizational structures capable of fund-raising. Priority
areas of activity are: health promotion in kindergarten, schools and workplaces,
prevention in old age and a comprehensive programme to prevent cardiovascular
diseases (see Health care reforms).
Primary and secondary ambulatory care

Ambulatory health care is mainly provided by private for-profit providers,
including physicians, dentists, pharmacists, physiotherapists, speech and
language therapists, occupational therapists, podologists, and technical
professions (see Human resources). Acute care and long-term care are
commonly provided by non-profit or for-profit providers employing nurses,
assistant nurses, elderly caretakers, social workers and administrative staff
(see Social care).
Patients have free choice of physicians, psychotherapists (since 1999),
dentists, pharmacists, and nursing care providers. They may also choose other
health professionals, however access to reimbursed care is available only
upon referral by a physician. Family practitioners (about half of ambulatory
physicians) are no gatekeepers in Germany, although their coordinating
competencies have been strengthened in recent years.
Of the 304 100 active physicians in 2003, 132 400 worked in ambulatory
care. Of these, a minority of 6600 practised solely for private patients, while
117 600 worked as SHI-affiliated physicians (Table 16) and 8200 as salaried
physician. The majority of physicians have solo practices; only around 25%
share a practice. The practice premises, equipment and personnel are financed
by the physicians. Depreciation of investments is sought through reimbursement
Germany
97
from sickness funds, private health insurers, and to a small but increasing degree
by patients directly.
Solo practices are also the dominant form of ambulatory physician care in
the eastern part, where during the GDR times until 1989 public polyclinics
were the dominant deliverers of ambulatory services, in conjunction with local
community dispensaries and company-based health care services. As part of
the institutional transfer of the old FRG health care system into the new Lnder
in the eastern part, these forms of care were quickly given up in favour of
entrepreneurial solo practices after reunification. Only few polyclinics continued
to exist in the eastern part after reunification, initially on an exemption basis
(see Historical development). Interdisciplinary care has been reintroduced from
2004 at medical treatment centres, which may be owned by companies or
independent professionals but have to be headed by a physician, and comply
with regulations as members of regional physicians associations.
Ambulatory physicians offer almost all specialties; the most frequent ones
are listed in Table 16, together with their development since 1990. The table also
provides information on two aspects linking the ambulatory and the hospital
sector. First, around 5% of all office-based physicians have the right to treat
patients inside the hospital. This is mainly the case for small surgical specialties
in areas where the hospital has so few cases that a physician operating once or
twice a week is sufficient. All other physicians transfer their patients to hospital
physicians for inpatient treatment and receive them back after discharge (for
example, post-surgical care is usually done by office-based physicians). Second,
in addition to the office-based physicians, around 11 000 other physicians are
accredited to treat ambulatory patients. These accredited physicians are mainly
heads of hospital departments who are allowed to offer certain services or to
treat patients during particular times (when practices are closed). Altogether
8% of all hospital physicians had the right to provide ambulatory care to SHI
patients in 2002. On average, more than one internist and nearly one surgeon
per general hospital had an ambulatory accreditation. The accredited hospital
physicians accounted for 0.9% of all those involved in ambulatory SHI care.
Taking reimbursement as a proxy for activity, they still provide around 2%
of all ambulatory services (and the outpatient departments of the university
hospitals around 5%).
Family physician and specialist physician care
The German health care system has traditionally no gatekeeping system; instead
patients are free to select a sickness-fund-affiliated doctor of their choice.
According to the Social Code Book (76 SGB V), sickness fund members
select a family physician who cannot be changed during the quarter relevant
Germany
98
for reimbursement of services for that patient. Since there is no mechanism to

control or reinforce this self-selected gatekeeping, patients frequently choose
office-based specialists directly.
Despite efforts by the federal government to improve the status of family
practice in the ambulatory care sector, the number of office-based specialists
has increased more rapidly than that of general practitioners over the past few
decades, so that GPs dropped to less than 35% of all office-based physicians
in 2002. However, since qualified internists and paediatricians practising as
SHI-affiliated physicians had to decide whether to work as family physicians
(Hausrzte) or as specialists (Fachrzte) ( 73 SGB V), the ratio of specialist
physicians to SHI-affiliated family physicians has increased in recent years.
This also applies to internists or paediatricians starting a new practice. Family
physicians and specialists have different reimbursable service profiles, different
reimbursement pools and, from 2005, separate representation on the board
and in the assembly of regional physicians associations (see Payment of
physicians).
Of the 116 065 SHI-affiliated physicians practising in 2002, 58884 practised
as family physicians (51%) and 57221 as specialists (49%) (Table 16). Among
the family physicians,
31758 were qualified in general practice (physicians holding a specialist
qualification in general practice)
and 11303 worked as practitioners (physicians without any specialist
qualification practising family medicine).
Furthermore, 10336 internists (specialists in internal medicine)
and 5447 paediatricians had opted to practise as family physicians.
Thus, in 2002, 94% of all SHI-affiliated paediatricians and 60% of all SHIaffiliated internists worked as family physicians following policy interventions
to strengthen the professional influence and income of family physicians. While
general practitioners and practitioners accounted for only 38% of all SHIaffiliated physicians, the inclusion of family internists and family paediatricians
shifted the ratio of family physicians to 51% and specialist physicians to 49%.
This ratio had been reached already in 1998 and has not changed since, but
the share of family physicians is expected to decrease again due to higher
retirement rates.
Altogether, the number of office-based SHI-affiliated physicians increased
by 31% between 1990 the baseline year of needs-formula based planning
(Table23) and 2002, with trends varying widely by discipline. While the
number of general practitioners and practitioners increased by 14%, the
Germany
99
number of all physicians with a specialist degree increased three times as much
(Table16).
From 1993, sickness funds were allowed to initiate pilot projects for
gatekeeping systems and to offer their insured a bonus. However, few pilot
projects were introduced and sustained due to various legal barriers, resistance
of the regional physicians associations, and extra costs in the gatekeeping pilots.
Since 2004, sickness funds are obliged to offer the option to enrol in a family
physician care model, with a bonus for complying with the gatekeeping rules.
The first project was negotiated by the regional sickness fund of Saxony-Anhalt
and the regional physicians association and the regional office of the Federal
Family Physicians Organization (BDA). All 1600 family physicians in the
state take part, and all regional fund-insured people above the age of 18 may
take part. Enrolees pay 50% of the physician visit user-fee and may expect
shorter waiting times to see their family physician and support in arranging
appointments with specialists.
The number of visits to ambulatory physicians has increased according to
various surveys in the past decade. Between 1999 and 2002, the average rate of
visits to office-based physicians was reported from 9.5 to 11.5 per year, varying
by survey (48). Physician claims data for 2000 show that SHI-insured patients
generated an average of 7.8 cases per year and thus saw an SHI-affiliated
physician at least 7.8 times a year or more often since a case represents the
first visit per quarter while all subsequent visits at the same physician are not
reflected in the claims data. Data presented in Fig. 10 may rather underestimate
actual outpatient utilization since physicians claims data suggest a higher
number of visits, including to outpatient department of hospitals.
Rescue and emergency care
There are substantial regional variations among the 16 Lnder with respect
to legislation, regulation, organization, purchasing, financing and delivery of
after-hours care, rescue care and emergency care.
Ambulatory physicians provide the major part of urgent care during regular
practice hours or during after-hour services in their practice. Home visits
are provided by the vast majority of family physicians (Hausrzte) as part
of their regular work and in rural areas also at outside regular hours. Only a
few specialists offer home visits. After-hour services are coordinated by the
regional physicians associations. They include telephone counselling, practice
visits and home visits. Increasingly, after-hour services are also offered by
ambulatory physicians at hospitals in the interests of efficiency and good
Germany
100
Table 16.
Specialties and functions of physicians providing ambulatory care in SHI,

19902002
SHI-affiliated physicians in private practiceb
in 1990
Anaesthetists
Dermatologists
Ear-nose-throat
physicians
Gynaecologists
Laboratory specialists
Neurologists/
Psychiatrists
Ophthalmologists
Orthopaedists
Psychotherapists
Radiologists
Surgeons
Urologists
Specialist internists
Family internists
Specialist paediatricians
Family paediatricians
All physicians with a
specialist degree
(incl. Other specialists)
Specialist physiciansc
General practitioners
Practitioners
Family physiciansd
Total (family physicians
+ specialist physicians)
Increase
19902002
in 2002
of these:
with a right
to treat
inpatients
in 2002
Hospital
physicians
with a right
to treat SHI
patients on
ambulatory
basis in
2002
508
2 535
490 %
30 %
2 491
3 308
2 967
7 306
419
32 %
33 %
47 %
3 926
9 702
615
1 509
1 451
3 228
4 092
3 460
842
1 439
2 539
1 744
56 %
27 %
43 %
382 %
68 %
42 %
46 %
5 049
5 201
4 963
3 223
2 424
3 601
2 552
18
575
542
0
534
477
213
133
307
213
512
1 832
220
12720
35%
2 668
24
1 085
100
158
868
78
6 843
265
10 336
81
n. a.
322
5 447
28
19
784
n. a.
5 823
5 723
73
18
191
13 974
10 522
69
286
355
5 914
10 877
5128
13%
50 567
n.a.
44%
n.a.
38 244
14 %
n.a.
n.a.
73 004
57 221
31758
11 303
58 844
88 811
31 %
116 065
Source: Federal Association of SHI Physicians, 2004, 1999 (49,50).

Note: n.a. = not applicable; a very small number, incl. in all specialists and total; b excluding
physicians employed with office-based physicians; c all specialists excluding those practising as
family internist or family paediatrician; d incl. family internists and family paediatricians.
Germany
Fig. 10a.
101
Outpatient contacts per person in the WHO European Region,

Western Europe
Switzerland (1992)
Spain (2001)
Belgium
Israel (2000)
Austria (2001)
Germany (1996)
France (1996)
Denmark (2001)
Italy (1994)
Netherlands
Iceland
United Kingdom (1998)
Finland
Norway (1999)
Portugal (2001)
Sweden (1997)
Luxembourg (1998)
Czech Republic
Slovakia
Hungary
EU-10 average
Croatia (2000)
Estonia
Lithuania
Slovenia
Romania
Poland (2001)
Bulgaria (1999)
Serbia and Montenegro (1999)
Latvia
Turkey (2001)
Malta
Cyprus (2001)
Albania
CIS
Belarus
Ukraine
Russian Federation
CIS-12 average
Uzbekistan
Republic of Moldova
Kazakhstan
Tajikistan
Turkmenistan (1997)
Kyrgyzstan
Azerbaijan
Armenia (2001)
Georgia
11.0
8.7
7.3
7.1
6.7
6.5
6.5
6.2
6.2
6.0
5.6
5.5
5.4
4.2
3.8
3.6
2.8
2.8
14.8
14.5
11.9
8.3
7.0
6.4
6.4
6.4
5.7
5.5
5.4
5.0
4.6
3.0
2.6
2.6
2.5
1.8
1.7
11.4
10.3
9.6
8.8
8.5
6.7
6.2
4.8
4.6
4.5
4.5
1.8
1.6
10
Contacts per person
15
EU-15 average: for member states prior to 1 May 2004; countries without data not included.
Germany
102
Fig. 10b.
Outpatient contacts per person in the European Union,

Czech Republic
14.8
Slovakia
14.5
11.9
Hungary
8.7
Spain (2001)
7.3
Belgium
Austria (2001)
6.7
Germany (1996)
6.5
France (1996)
6.5
Estonia
6.4
6.4
Lithuania
6.4
Slovenia
6.4
Denmark (2001)
6.2
Italy (1994)
6.0
Netherlands
5.6
Poland (2001)
5.5
5.4

Latvia
4.6
Finland
4.2
3.6
Portugal (2001)
Sweden (1997)
2.8
Luxembourg (1998)
2.8
Malta
2.5
1.8
Cyprus (2001)
10
15
Contacts per person

Note: EU: European Union; EU-25 average: for all member states. Countries without data not
included.
Germany
103
hospital-community relations. Patient satisfaction with the accessibility of

family practitioners is relatively high in Germany compared to other European
countries, and home visits seem to be an important factor (51). In rural areas
individual ambulatory physicians also take part in emergency physicians
services in close cooperation with rescue organizations. However, their role in
emergency services has been decreasing.
Emergency physician care is integrated with other types of rescue services,
including non-emergency rescue, fire protection and technical security. Often
non-rescue patient transport is also part of the rescue package. There are
about 360 control and coordination centres for rescue care in Germany, with
uniform telephone numbers and criteria to differentiate between the need for
rescue care or emergency physician care. This integration of rescue services
outside the hospital somehow hinders the full integration of an emergency care
chain. Outside the hospital, mechanisms of regulation, provision and financing
are different from emergency care in the hospital outpatient or inpatient
departments. Outside the hospital, emergency rescue care is usually regulated
by ministries of interior and often integrated with fire and technical security
services. Emergency care at hospitals is regulated, planned and supervised by
the ministries responsible for health at the Lnder level.
Since the second SHI Restructuring Act (1997), planning for emergency
physician service capacities has been clearly allocated to the Lnder, unless
state legislation explicitly delegates the duty to regional physicians association
(as in Bavaria). Non-emergency after-hour care is still delegated to the regional
physicians associations and is thus supervised by the state ministries responsible
for health.
Most Lnder (except for Berlin, for example) delegate the organization and
delivery of rescue care to the municipalities. Within the framework of the state
rescue law, local communities may accredit, regulate and plan for capacities of
integrated public providers (mostly integrated with fire protection) as well as
contracted private rescue providers. Among private providers, priority is clearly
given to non-profit providers over for-profit providers in legislation as well as
practice. Non-emergency transport is usually out-sourced by municipalities.
Private for-profit entrepreneurs play a bigger role here than in the emergency
care market, but welfare organizations still have priority in most states over
private for-profit providers.
Financing rescue care follows a dual principle: while recurrent expenditures
are financed by SHI or private health insurance or out-of pocket, capital
financing is mainly a task of the Lnder. For hospital-based emergency care,
the general rules of hospital financing and planning apply, led by health and
education ministries. For providers outside the hospitals the interior ministries
Germany
104
of interior are responsible for planning and financing. With respect to capital
financing, there are great variations among states: Baden-Wrttemberg finances
investments in buildings, technical and organizational development if these are
part of the rescue plan. Bavaria pays for transport vehicles and major technical
equipment. In North Rhine-Westphalia municipalities finance investments
within their field of responsibility. In Brandenburg depreciation of investment
costs is explicitly enacted as part of (negotiated) service prices.
Recurrent expenditures are financed by SHI or to a lesser extent by
private health insurance. But contracting between SHI and providers outside
the hospital is still rare. Instead a pure reimbursement system on a fee-forservice basis is in place, which may have been crucial in the increase of SHI
expenditures on transport, an item which includes regular patient transfers as
well as ambulance-based emergency and rescue care (Table 15). Co-payments
have traditionally applied to non-emergency transport services, but since
2004, they also relate to emergency transport and services at the hospital. In
addition, non-rescue patient transports have been excluded from SHI. A few
exceptions have been outlined by the Federal Joint Committee, including the
transport of patients with certain severe disabilities or in need of challenging
ambulatory treatments, for example chemotherapy and haemodialysis.Time
standards for reaching patients are established in all states; however, they are
only specified in the legislative text (amended 1999) of Brandenburg (arrival
within 15 minutes).
Secondary and tertiary hospital care

German hospitals have traditionally concentrated on inpatient care; sectoral
borders to ambulatory were strict. While acute hospitals in the hospital plan
provide outpatient emergency care, only university hospitals have formal
outpatient facilities. Day surgery and ambulatory pre- and post-hospital care
have become other fields of increasing activity. Since 2004, hospitals have been
granted additional competencies to provide care to outpatients that require
highly specialized care on a regular basis. Also, participation in integrated care
models offers new opportunities to become active in ambulatory care (see the
separate sections below).
Inpatient care
Planning and regulation of treatment facilities for inpatients are done by
ministries of health and/or science at Lnder level based on the federal legal
Germany
105
framework of the Hospital Financing Act (see Payment of hospitals). This applies
to highly specialized care (for example neurosurgery) as well as secondary
in-patient care. Planning units are institutions, departments and, in certain
Lnder, beds. Contents and methods of the hospital plans differ substantially
among states. Regulation of capacities is planned according to the principles
of need (for specific departments per municipality or county) and performance,
but criteria differ substantially. In recent years several administrations have
sought counselling from research institutes for defining need and interpreting
performance. Several states define capacities as sufficient if the departments
available for one specialty in a given municipality or county had an occupancy
rate of 80% or below. Sickness funds and providers have a say at Lnder hospital
committees, but in the end decisions are taken at the politico-administrative
level. In addition, funds have the right to collectively de-contract a hospital
under certain conditions, but in practice this right is rarely used.
In 2002, there were 2221 hospitals with 547284 beds (6.7 beds per 1000).
Of these, the 274 psychiatric hospitals had 42600 beds and the 1898 general
(or acute) hospitals had 504 684 beds (Table 18). Of the latter 712 were publicly
owned, 758 were private non-profit and 428 private for-profit hospitals, with
bed shares of 54%, 38% and 8% respectively (see Table 8). Beds in university
hospitals accounted for 8.3% of all general and psychiatric hospital beds;
beds in hospitals enlisted in state hospital plans for 88.7%; beds in hospitals
additionally contracted by sickness funds for 1.5% and beds in hospitals without
such contracts that is, purely for privately insured patients for 1.5%. That
is, 97% were enlisted in the hospital plans and entitled to investments from the
Lnder independent of hospital ownership (see Decentralization of the health
care system). But since listed hospitals have no right to have the financing of
(all) the requested investments secured, they often do not receive investments
within the requested time. Decisions on resource allocation depend on political
priorities and the amount of finance available for hospital investments. Hospital
beds per capita and investments per bed vary among Lnder (see Table 28).
Private for-profit hospitals are entitled by the Hospitals Financing Act to
depreciate parts of their investments via the sickness funds reimbursement of
recurrent expenditures (see Payment of hospitals).
Besides acute care, 1343 institutions with 184 635 beds (2.2 beds per 1000)
were dedicated to preventive and rehabilitative care in 2002. Compared to
general hospitals, ownership is very different for preventive and rehabilitative
institutions with 17%, 16% and 67% of beds being public, non-profit and forprofit respectively.
Table 17 shows a substantial shift in the provision of inpatient care. While
the number of beds in homes for elderly and long-term care has more than
doubled between 1991 and 2001, acute and psychiatric hospital care have
Germany
106
been decreased. The corresponding decrease of total hospital beds was partly
offset by an increase in rehabilitative hospitals (for more details see below and
in Social care).
In 2002, the general and psychiatric hospitals workforce amounted to
1038 million people or 850400 full-time equivalents (of which 12% were
physicians), around 4% less than the employment peak reached in 1995 (3).
Compared with 1991, the total of 1 065 million general hospital employees
was virtually the same. Yet the structure of employment shifted during this
period. While maintenance and technical employees decreased by 28% due to
outsourcing, the number of physicians increased by 13%, the number of nurses
by 6%, personnel in medical technical service by 9%, and in functional services
(theatre, day care wards) by 11% (44). The average number of nurses per acute
bed increased from 0.43 in 1992 to 0.48 in 2001(2).
Despite this increase in health care personnel, German acute hospitals still
have relatively low ratios of hospital employees, nurses and physicians per bed
compared to the EU-15 average or other OECD countries (2,45). On average a
full-time working physician had to care for 4 occupied beds; this ratio varied
between 4.7 in Brandenburg and 2.9 in Berlin, with a higher density of university
Table 17.
Number of beds in hospitals and homes (per 100 000 inhabitants), 19912001
Hospital beds
Acute hospital beds
Psychiatric hospital
beds
Nursing & elderly home
beds
1991
1 012
748
1993
966
713
1995
968
691
1997
938
659
1998
930
651
1999
920
644
2000
912
636
2001
901
627
154
132
132
127
127
127
128
127
337
370
370
443
786
819
Source: WHO Regional Office for Europe health for all database, 2004 (5).
hospitals. The ratio of physician full-time equivalents per 10 000 hospital cases
was 66 in 2001, varying between 58 in Brandenburg and Lower-Saxony and
97 in Berlin (3).
Until 1992, the number of hospital beds, inpatient cases, and lengths of
stay had changed gradually and had been foreseen by all parties involved. The
decreasing number of acute hospital beds was largely compensated by beds in
newly opened preventive and rehabilitative institutions. The shorter lengths of
stay were almost equalled by the increasing number of inpatient cases, so that
both the occupancy rate and the number of bed days per capita had remained
stable. The first hospitals faced with restructuring initiatives were those in the
East after reunification, since they had to adapt to the Western standards of
infrastructure, planning and financing.
Germany
107
Although acute hospital beds have been reduced substantially throughout

the last decade, the number of acute hospital beds is still about 50% higher
than the EU-15 average (6.3 vs 4.1 per 1000 in 2001) since capacities were
decreased in other EU countries as well (Fig. 11, Fig. 12).
Since 1993, hospitals in the West and in the East have been faced with a
rapidly changing environment with challenges through fixed budgets, the threat
of deficits, ambulatory surgery, the introduction of prospective payments from
1996, and the introduction of DRGs as the virtually sole system of payment
(see Payment of hospitals). This has changed utilization much more rapidly
than previously.
Table 18 provides more detailed data on the structure and utilization of acute
care in western and eastern Germany. It is apparent that the initially different
figures in the eastern part approached those in the western quite rapidly. Table
19 shows the same for preventive and rehabilitative institutions, where the
adaptation process was even more dramatic. It also shows the considerable
problems in the later part of the 1990s, when a change in social security laws
cut preventive and rehabilitative benefits. The sector has recovered to a large
Fig. 11.
Number of acute hospital beds in Germany, selected countries and EU-15

average, 19902002 (per 1000 population)
8
7
6
5
4
3
2
1
0
1990
1991
1992
1993
France
Norway
EU-15 average
1994
1995
1996
Germany
Switzerland
1997
1998
1999
2000
2001
2002
Netherlands
United Kingdom
Source: WHO Regional Office for Europe Health for all database, June 2004 (5).
Germany
108
Fig. 12a.
Hospital beds in acute hospitals per 1000 population in western Europe,

1990 and 2002 or latest available year (in parentheses)
Monaco (1995)
15.5
7.5
6.3
7.0
6.1
4.9
5.8
7.0
5.6
5.1
4.1
6.1
4.0
6.0
4.0
4.0
4.0
5.1
4.0
4.3
3.7
3.9
3.5
4.2
3.4
3.6
3.3
3.8
3.1
4.0
3.1
3.3
3.0
3.3
3.0
2.4
2.8
2.7
2.4
4.3
2.3
4.1
2.3
2.6
2.2
Germany (1991,2001)
Austria
Belgium (2001)
Luxembourg
Switzerland
Italy (2001)
Greece (2000)
France
Iceland (1996)
Malta (1997,2002)
Denmark
Portugal (1998)
Norway (2001)
Netherlands (2001)
Spain (1997)
Ireland
Andorra (1996,2002)
Finland
Sweden
Israel
1990
2002
12
16
Hospital beds per 1000 population

Note: EU: European Union; EU-15 average: for member states prior to 1 May 2004; countries without data not
included.
Germany
Fig. 12b.
109
Hospital beds in acute hospitals per 1000 population in the European Union,
7.4
6.7
8.1
6.3
7.5
6.3
7.0
6.1
Slovakia
Czech Republic
Germany (1991,2001)
Austria
9.7
Lithuania (1992,2002)
6.0
7.1
5.9
4.9
5.8
7.0
5.6
6.6
5.5
Hungary
Belgium (2001)
Luxembourg
Latvia (1998,2002)
9.2
Estonia
4.5
5.2
4.2
5.0
4.1
4.5
4.1
6.0
4.0
4.0
4.0
5.1
4.0
3.9
3.5
4.2
3.4
3.6
3.3
4.0
3.1
3.3
3.0
3.3
3.0
2.7
2.4
4.3
2.3
4.1
2.3
EU-25 average
Slovenia
Cyprus (2001)
Italy (2001)
Greece (2000)
France
Malta (1997,2002)
Denmark
Portugal (1998)
Netherlands (2001)
Spain (1997)
Ireland
Finland
Sweden
1990
2002
12
Hospital beds per 1000 population

Note: EU: European Union; EU-25 average: for all member states; countries without data not included.
Germany
110
extent, however. These developments in the hospital sector as well as in the

preventive/rehabilitative sector are much less visible if data are combined (see
Table 17).
Between 1991 and 2001, the average length of stay in general and psychiatric
hospitals decreased substantially, from to 14.3 days to 9.8 days in the western
part and from 16.1 to 9.7 days in the eastern part (Table 18). In preventive and
rehabilitative institutions, it fell only by 22% and 23% respectively (Table 19).
During the same period, the number of general and psychiatric hospital cases
per 1000 population rose by 11%, to 20 cases per 100 inhabitants in the western
part and by 38% to 21 cases per 100 inhabitants in the eastern part, resulting
in a decrease in bed days in both parts of the country. Occupancy rates have
decreased in the western part and increased in the eastern part (Table 18). In
preventive and rehabilitative institutions, occupancy rates in the eastern part
had reached the western highpoint of 1995 before occupancy rates in both parts
of the country dropped sharply as a result of the Health Insurance Contribution
Rate Exoneration Act. In summary, after a remarkably short time, almost all
structure, utilization, and expenditure data look very similar in both parts of
the country (see East/West-ratios in Tables 18 and 19).
These data exclude cases admitted only for a few hours. If these shortterm cases are included, as has become standard since 2002, the number of
admissions to general or psychiatric hospitals has increased from 1822 per
10000 inhabitants in 1991 to 2104 in 2001 and 2114 in 2002. Despite the
increase of admissions and the decrease of beds (from 83.2 per 1000 to 67.1
and 66.4) the occupancy rate decreased from 84.1% to 81.1% and 80.1% which
is largely due to a decrease in the average length of stay from 14.0 days to 9.4
days and 9.2 days respectively (52).
Similar to most EU countries, the admission rate to acute (general)
hospitals has increased during the last two decades. The rate of 20.5 per 100
population, documented in 2001, however, ranks above the EU-15 average of
18.1 admissions per 100 population. At the same time, average length of stay
(9.3 days) and occupancy rates (80.1%) are still higher than in most other EU
countries with an average of (7.0 days and 77% respectively) (Table 20).
Hospital outpatient care
Except for university hospitals, hospitals have traditionally provided inpatient
care only. But their scope to provide ambulatory care has been extended
increasingly in the past decade. Since 2003, hospitals may treat patients with
diseases requiring highly specialized treatment on an ongoing basis. Since 2004,
hospitals may also provide care in specialties for which underprovision of care
Germany
Table 18.
111
Inpatient structure and utilization data I: general and psychiatric hospitals in

western and eastern parts of Germany, 19912001
beds/1000
cases/1000
length of stay (days)
West
East
1991
8.19
8.89
1.09
179.3
151.1
0.84
14.3
16.1
1.09
86.0
74.9
0.87
1992
8.02
8.08
1.01
180.4
159.4
0.88
13.9
14.2
1.02
85.3
76.0
0.89
1993
7.80
7.50
0.96
180.3
162.9
0.90
13.2
13.0
0.98
83.9
77.4
0.92
1994
7.68
7.16
0.93
181.9
169.0
0.93
12.7
12.2
0.96
82.7
79.0
0.95
1995
7.55
7.03
0.93
185.4
175.9
0.95
12.2
11.7
0.96
82.0
80.1
0.98
1996
7.30
6.98
0.96
186.8
181.9
0.97
11.5
11.2
0.97
80.3
79.6
0.99
1997
7.12
6.87
0.96
189.4
187.5
0.99
11.1
10.8
0.97
80.7
80.5
1.00
1998
7.01
6.78
0.97
194.4
194.9
1.00
10.8
10.5
0.97
81.8
82.3
1.01
1999
6.91
6.76
0.98
197.5
201.2
1.02
10.4
10.1
0.97
81.7
82.7
1.01
2000
6.84
6.68
0.98
199.9
204.1
1.02
10.2
9.9
0.97
81.3
82.9
1.01
2001
6.70
6.72
1.00
199.6
208.8
1.05
9.8
9.7
0.99
80.4
82.2
1.02
West
East
E/ W
ratio
West
occupancy rate (%)
E/ W
ratio
East
E/ W
ratio
West
East
E/ W
ratio
Source: based on data from the Federal Statistical Office 2003 (52).
Note: From 2002, data include short-time stays and are no longer comparable to previous data
presented here.
Table 19.
Inpatient structure and utilization data II: preventive and rehabilitative

institutions in western and eastern parts of Germany, 19912001
beds/1000
cases/1000
length of stay (days)
West
East
1991
2.06
0.66
0.32
21.4
5.0
0.23
31.0
31.7
1.02
88.4
65.9
0.75
1992
2.09
0.82
0.39
22.0
8.1
0.37
31.1
29.6
0.95
89.8
79.4
0.88
1993
2.13
0.92
0.43
22.4
9.3
0.42
31.1
29.5
0.95
89.5
81.4
0.91
1994
2.28
1.39
0.61
23.3
13.9
0.60
31.3
30.2
0.96
88.0
82.5
0.94
1995
2.34
1.66
0.71
24.3
17.6
0.72
31.1
30.5
0.98
88.7
88.6
1.00
1996
2.39
1.96
0.82
24.1
19.9
0.83
30.2
29.9
0.99
83.2
83.1
1.00
1997
2.33
2.15
0.92
19.4
18.4
0.95
27.5
26.0
0.95
62.6
60.9
0.97
1998
2.30
2.44
1.06
21.1
22.2
1.05
26.5
25.9
0.98
66.4
65.0
0.98
1999
2.27
2.52
1.11
23.1
24.7
1.07
26.0
26.1
1.00
72.5
70.1
0.97
2000
2.25
2.58
1.15
24.5
26.7
1.09
25.7
26.3
1.02
76.5
74.4
0.97
2001
2.24
2.59
1.16
24.8
28.7
1.16
25.5
25.7
1.01
77.4
77.8
1.01
West
East
E/ W
ratio
West
occupancy rate (%)
E/ W
ratio
East
E/ W
ratio
West
East
E/ W
ratio
Source: based on data from the Federal Statistical Office 2003 (52).
Note: From 2002, data include short-time stays and are no longer comparable to previous data
presented here.
is stated by law (for example, pneumology and rheumatology), as recommended

in the Advisory Councils report on over-, under- and misuse in health care
(16). Furthermore, ambulatory care for patients with certain rare diseases and
special forms of disease progression as well as highly specialized services
have been declared areas of hospital activity by the SHI Modernization Act.
The Federal Joint Committee named a few genetic liver diseases and inborn
metabolic disorders in children, and will present criteria on which the selection
Germany
112
Table 20a. Inpatient utilization and performance in acute hospitals in the WHO European
Region, 2002 or latest available year
Hospital beds
per 1000
population
Western Europe
Andorra
Austria
Belgium
Denmark
EU-15 average
Finland
France
Germany
Greece
Iceland
Ireland
Israel
Italy
Luxembourg
Monaco
Netherlands
Norway
Portugal
Spain
Sweden
Switzerland
United Kingdom
Albania
Bulgaria
Croatia
Cyprus
Czech Republic
Estonia
EU-10 average
Hungary
Latvia
Lithuania
Malta
Slovakia
Slovenia
The former Yugoslav Republic of Macedonia
Turkey
CIS
Armenia
Azerbaijan
Belarus
CIS-12 average
Georgia
Kazakhstan
Kyrgyzstan
Republic of Moldova
Russian Federation
Tajikistan
Turkmenistan
Ukraine
Uzbekistan
Admissions per
100 population
Average length
of stay in days
Occupancy
rate (%)
2.8
6.1
5.8a
3.4
4.1
2.3
4.0
6.3a
4.0b
3.7f
3.0
2.2
4.0
5.6
15.5g
3.1a
3.1a
3.3d
3.0e
2.3
4.0
2.4
10.1
28.6
16.9c
17.8a
18.1c
19.9
20.4c
20.5a
15.2d
15.3d
14.1
17.6
15.7a
18.4h
8.8a
16.0a
11.9d
11.5d
15.1
16.3d
21.4f
6.7c
6.0
8.0c
3.8a
7.1c
4.4
5.5c
9.3a
5.7d
6.5
4.1
6.9a
7.7d
7.4a
5.8a
7.3d
7.5d
6.4
9.2
5.0f
70.0c
76.4
79.9d
83.5b
77.9d
74.0g
77.4c
80.1a
84.4
94.0
76.0a
74.3h
58.4a
87.2a
75.5d
76.1d
77.5f
84.6
80.8d
2.8
3.3d
7.6
3.7
4.1a
6.3
4.5
6.0
5.9
5.5
6.0
3.5
6.7
4.1
3.4a
2.1
7.2d
14.8f
13.8
8.1a
19.7
17.2
20.1
22.9
18.0
21.7
11.0
18.1
15.7
8.2a
7.7
9.8d
10.7f
8.7
5.5a
8.5
6.9
7.7
6.9
8.2
4.3
8.8
6.6
8.0a
5.4
62.6c
64.1f
89.6
80.1a
72.1
64.6
72.6
77.8
73.8
83.0
66.2
69.0
53.7a
53.7
3.8
7.7
8.2
3.6
5.1
4.3
4.7
9.5
5.7
6.0e
7.2
5.9
4.7
19.7
4.4
15.5
12.2
13.1
22.2
9.1
12.4
19.2e
8.9
15.3
12.7
7.4
10.9
10.3
9.7
13.5
12.0
11.1e
12.3
31.6a
25.6
88.7h
85.4
82.0a
98.5
86.8
75.1
86.1
55.1
72.1e
89.2
84.5
Notes: a 2001; b 2000; c 1999; d 1998; e 1997; f 1996; g 1995; h 1994; CIS: Commonwealth of independent states; EU: European
Union; EU-10 average: for new member states after 1 May 2004; EU-15 average: for member states prior to 1 May 2004. Countries
without data not included.
Germany
113
Table 20b. Inpatient utilization and performance in acute hospitals in the European
Union, 2002 or latest available year
Hospital
Admissions
Average
beds
Occupancy
per 100
length of
per 1000
rate (%)
population stay in days
population
Austria
6.1
28.6
6.0
76.4
Belgium
5.8a
16.9c
8.0c
79.9d
Cyprus
4.1a
8.1a
5.5a
80.1a
Czech Republic
6.3
19.7
8.5
72.1
Denmark
3.4
17.8a
3.8a
83.5b
Estonia
4.5
17.2
6.9
64.6
EU-25 average
4.2
18.1a
7.0a
77.1a
Finland
2.3
19.9
4.4
74.0g
France
4.0
20.4c
5.5c
77.4c
Germany
6.3a
20.5a
9.3a
80.1a
Greece
4.0b
15.2d
Hungary
5.9
22.9
6.9
77.8
Ireland
3.0
14.1
6.5
84.4
Italy
4.0
15.7a
6.9a
76.0a
Latvia
5.5
18.0
Lithuania
6.0
21.7
8.2
73.8
Luxembourg
5.6
18.4h
7.7d
74.3h
Malta
3.5
11.0
4.3
83.0
Netherlands
3.1a
8.8a
7.4a
58.4a
Portugal
3.3d
11.9d
7.3d
75.5d
Slovakia
6.7
18.1
8.8
66.2
Slovenia
4.1
15.7
6.6
69.0
Spain
3.0e
11.5d
7.5d
76.1d
Sweden
2.3
15.1
6.4
77.5f
United Kingdom
2.4
21.4f
5.0f
80.8d
Notes: a 2001; b 2000; c 1999; d 1998; e 1997; f 1996; g 1995; h 1994; EU: European Union; EU-25
average: for all member states. Countries without data not included.
of hospital-based outpatient care is to be based by 2005. The list of disease

conditions will be reviewed every two years.
The share of hospitals offering pre-inpatient or post-inpatient care has
increased steadily, to 71% in 2002, since their introduction in 1993 (33). More
hospitals in the eastern part (89%) than in the western part (68%) offered this
kind of care in 2002. While hospitals have been allowed to offer surgery on an
ambulatory or day-case basis only since 1993, day-case surgery is not new in
Germany. Due to the separation of the hospital and the ambulatory care sectors,
surgeons, ophthalmologists, orthopaedic surgeons and other specialists in private
practice have performed minor surgery for a long time. Since the 1980s, this
has been supported through the introduction of new items in the Uniform Value
Scale, both to cover additional costs of the operating physician (equipment,
supporting staff etc.) and to cover necessary anaesthesia. In 1991, day surgery
accounted for almost 2% of sickness funds expenditure in the ambulatory care
Germany
114
sector. In 1993, additional items for post-operative care were introduced. The
frequency of these items may be used to estimate the extent to which ambulatory
surgery is taking place in Germany, although they do not allow a distinction
between hospital-based and office-based day surgery since remuneration is
done under the same norms, of the ambulatory care sector.
From 2004, ambulatory surgery is expected to further expand since the
German Hospital Organization and the various federal associations of sickness
funds negotiated a contract widening the range to more than 400 interventions.
For 150 diagnoses ambulatory surgery has become obligatory, unless a physician
explicitly argues for inpatient care. It is estimated that about one third of
operations may be shifted to outpatient care. Ambulatory surgery in hospitals
as well as physicians practices is currently evaluated in benchmarking projects
on a pilot basis. From 2006, ambulatory surgery will be evaluated on a routine
basis by the Federal Office for Quality Assurance as part of an anonymous
benchmarking project with feedback to individual hospitals.
Integrated care
The sectorization of the delivery, financing and decision-making structures of
German health care has increasingly been perceived as a barrier to change. Since
1993, the legal framework allowed for intersectoral pilot projects (paragraphs
6365, Social Code Book V), thus giving sickness funds and providers an
opportunity to test new integrated models of care. Although these regulations
were expanded in each following health care reform, they did not result in
viable concepts or measures. All initiatives in the area of improved cooperation
between individual practices or between the sectors, such as practice networks,
group practices, practice alliances and health care networks, are almost fully
based on pilot projects.
New provisions for so-called integrated care (paragraphs 140 ah, Social
Code Book V) were therefore introduced as part of the Reform Act of SHI 2000.
The aim of these provisions was to improve cooperation between ambulatory
physicians and hospitals on the basis of contracts between sickness funds and
individual providers or groups of providers belonging to different sectors. Due
to legal and financial barriers, only a few initiatives were established on the basis
of these legal provisions. The Act to Reform the Risk Structure Compensation
Scheme provided new incentives for trans-sectoral care in the context of disease
management programmes from 2002.
With the SHI Modernization Act, in force from 2004, integrated care has
been further strengthened and the rules of accountability have been clarified.
Germany
115
The SHI Modernization Act removed barriers to starting integrated care models
which had been enacted when the integrated care was first introduced in 2000:
Integrated care contracts do not need to extend across sectors now, but have to
involve at least different categories of providers within a sector, for example,
family physicians and long-term care providers. Integrated care contracts do
not require the approval of the regional physicians associations. Other sickness
funds or providers may only join the integrated care models if all contract
partners agree. In October 2000, the federal associations of sickness funds and
the Federal Association of SHI Physicians had concluded a general agreement
allowing any fund to join an integrated care model at the beginning of the third
year, but this was perceived by individual sickness funds as a disincentive to
invest in innovative models of care in a competitive market.
Differing also from the 2000 legislation, it stipulates that the principle of
contribution rate stability does not apply to integrated care contracts negotiated
by December 2006. Additionally, sickness funds now have a clear right
(from 20042006) to deduct 1% of the resources for ambulatory physicians
and hospital care once integrated care contracts have been concluded. These
resources may only be used for integrated care purposes in the respective region
of the physicians association and have to be paid back if not fully used. In
addition, expenditures on drugs and medical aids will be adjusted, considering
the morbidity of the patients taking part in integrated care.
Thus, integrated care now represents a separate sector for which financial
resources have to be set aside. It requires that sickness funds negotiate selective
contracts with single providers or a network of providers, i.e. physicians,
hospitals, rehabilitative institutions (see Table 7). While all of them need to
be accredited within their sector, they may provide services across sectors
within the scope of the integrated care contract, e.g. a hospital may provide
outpatient services if it has a joint contract with an ambulatory physician. In
addition, the contracting parties of an integrated care contract may decide to
take over the guarantee of service provision for the insured population from
the regional physicians association(s). The guarantee of service provision may
be shifted to the participating sickness funds and/or to the contracted network
of preferred providers.
Under the new regulations and incentives, integrated care has attracted
substantial interest among hospitals, most of which have been hesitant up to now
to join disease-management programmes. Integrated care contracts concern for
example disease-centred programmes at the interface between acute hospital
care and rehabilitative care, involving office-based specialists physiotherapists
and family physicians.
Germany
116
Social care
Social care is delivered by a broad variety of mainly private organizations
that complement family and lay support for the elderly, children with special
needs, mentally ill and the physically or mentally handicapped. The Lnder
are responsible for planning (and guaranteeing the provision) institutionalized
care and schools for children with special needs. Most providers of institutional
care belong to the six members of the Federal Alliance of Voluntary Welfare
Organizations (see Organizational structure and management). Welfare
organizations have established about 60 000 autonomous institutions with about
1.1 million employees. In social care, they run 50% of old age homes, 80% of
homes for the handicapped and nearly 70% of institutions for youth.
Other typical features of social care in Germany are:
a nearly universal mandatory social insurance for long-term care administered
by sickness funds and private health insurers;
special schools for children with severe learning deficits and behavioural
disorders;
a legal right for children with social problems to personal and family support
services;
a legal quota for employment of the disabled;
a social code book, enforced in 2002, strengthening the individual and
collective rights of disabled and clarifying responsibilities, interrelations
and cooperation of the various payers and providers;
a traditional priority of welfare organizations over for-profit providers, except
for the long-term care sector where non-profit and for-profit providers have
equal status to enhance competition;
traditionally, a strong focus of specialized, comprehensive care for the
severely handicapped in institutions separate from the community;
increasing access to integrated schooling and community-based services,
however with substantial geographic differences among Lnder and urban
vs. rural areas.
Statutory long-term care insurance was introduced in 1994 as Book XI
of the Social Code Book following a 20 year debate about how to secure
financing and access to long-term care in an ageing society with an increasing
burden on municipalities to support elderly care. The statutory long-term care
insurance typically consists of the mandatory social long-term care insurance
Germany
117
and the mandatory private long-term care insurance. Before the introduction
of the statutory long-term care insurance there were certain benefits in the
SHI package for ambulatory long-term care (these were cancelled after the
introduction of the new scheme). However, they were not very generous and
the bulk of long-term care services were financed by social welfare, a public
welfare programme. Significantly, these services were not entitlement-based
on an insurance-relationship, but subject to a means-test and therefore only
paid if the individual or family members could not afford to pay. Private health
insurance schemes also offered insufficient nursing benefits
Starting in 1995, all members of statutory sickness funds (including
pensioners and the unemployed) as well as all people with full-cover private
health insurance were declared mandatory members. This was the first time to
introduce mandatory membership for private health insureds making it the first
statutory insurance with nearly population-wide membership. In January 2003,
70.6 million were covered by mandatory statutory long-term care insurance and
about 8.6 million by mandatory private long-term care insurance (7). The longterm care insurance scheme is administered by the sickness funds (as a separate
entity but without any separate associations) and private health insurers.
The requirement to pay contributions began in January 1995 with ambulatory
benefits available from April of that year. Benefits for care in institutions were
available from July 1996. According to the SHI principles, members and their
employers jointly contribute 1.7% (until June 1996, only 1%) of monthly
gross income, that is, 0.85% each. In order to compensate the employers for
the additional costs, a public holiday was turned into a working day. As an
exception, the Land of Saxony retained the holiday, and the contribution is split
between employee and employer 1.35% to 0.35%. Since 2004, pensioners have
to contribute the entire 1.7% from their pension.
Benefits
In contrast to statutory health insurance, benefits are available upon application
only. The Medical Review Boards (operated jointly by sickness funds and
long-term care funds) evaluate the applicants and place them into one of the
three categories (or deny care). Most of the private health insurers purchase
this service from them. Entitlement to insurance benefits is given when care is
expected to be necessary for at least 6 months (hence long-term care), while
short-term nursing care continues to be funded by the sickness funds, and private
insurers if included in the package. Beneficiaries with a care dependency then
have a choice of receiving monetary benefits or professional nursing care while
staying at home or to receive professional nursing services in nursing homes.
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118
The benefits of long-term care insurance are graded according to type,

frequency and duration of the need for nursing care:
grade I: support is necessary for at least two activities in the areas of body
care, eating and mobility (at least once daily) as well as housekeeping (at
least several times a week) with an overall average duration of at least 90
minutes daily;
grade II: support is necessary at least three times daily with an overall average
duration of at least 3 hours daily;
grade III: support is necessary around the clock including nights with an
overall average duration of at least 5 hours daily.
Monetary support is intended to cover home care delivered by family
members at the following rates: Grade I, 205; Grade II, 410; Grade III, 665
(plus a professional substitute for up to 1432 a year to cover holidays). The
limits for professional ambulatory services delivered on an in-kind basis are
384, 921, and 1432, respectively. In addition, family members serving as
care-givers at home can attend training courses free of charge, and short-term
care is provided during holidays of care-givers. The care-giver is also covered
by statutory accident insurance and statutory retirement insurance, financed by
the sickness fund administering the long-term care insurance of the person in
need. For people choosing institutionalized nursing care, benefits are available
for day or night clinics as well as old age or special nursing care homes. Monthly
benefit limits are 1023, 1279 and 1432 respectively. Higher benefits may
be granted in exceptional cases.
A new development is the option of personal budgets for recipients of
professional ambulatory long-term care. From July 2004, they may spend
their budgetary resources on the provider and service of their choice. The
nominal level of payment has not been changed since the introduction of the
statutory long term care insurance (applying the regular exchange rate from
DM to ), which in fact means a real decrease in cash-benefits and provider
reimbursements.
Of the 813 932 new applications processed by SHI Medical Review Boards
in 2003, 595045 were approved (73%), 190005 (27%) were declined and
28 882 were dealt with in another way. Applicants have a right to challenge
the decision at their sickness fund and may also file a case at social courts.
Altogether, 1.9 million (2.3% of the population) were entitled to benefits from
social long-term care insurance in 2003. Entitlement to social long-term care
concentrated on the elderly but younger age groups were affected as well. Of
the persons entitled to social long-term care, 5% were below 20, 11% between
Germany
119
20 and 55, 6.5% between 55 and 65, 14.7% between 65 and 75, 32.5% between
75 and 85 and 30.7% above the age of 85. Of all entitled persons, more than two
thirds (1.3 million) were cared for at home and less than one third (613274)
received institutionalized care. 49% of entitled persons (calculated from days
of granted benefits) choose monetary benefits only, 9% choose benefits in-kind
(professional care at home) only, 10% choose a combination of both, 27%
choose professional long-term care in nursing homes, 3% choose inpatient
nursing care in homes for disabled, and only 1.7% of the benefit days were
used in form of short-term care, care during holidays or care during day or
night only. The low utilization was partly due to limited capacities, especially
in rural areas (53).
Of the people cared for at home, nearly three quarters (968289) received
cash benefits only and were cared for by family members. More than 90% of
care-givers were women. Recipients of care in nursing homes tended to be older
and have more nursing care needs: 38% were classified grade I, 42% gradeII
and 20% grade III, with the most intensive need for nursing care. The share
of entitled people increased with age, with fewer than 0.6% of entitled people
below the age of 50, 1.7% between 60 and 65, 4.7% between 70 and 75, and
30% 80 and older (54).
Providers and infrastructure
The introduction of long-term care insurance was also associated with an
increase in the number of active nurses and professional old age care-givers,
especially in the ambulatory sector. In 2001, 475 368 employees worked in
accredited nursing homes and 189 567 in ambulatory institutions accredited for
long-term care. Between 1996 and 1999, staff in ambulatory care and inpatient
care increased by 25%, between 1999 and 2001 by 5%. The 70% share of parttime work in ambulatory institutions was higher than the 55% in nursing homes,
nearly half of it in minor part-time jobs (21). The number of people cared for
increased to 48 per ambulatory institution and 69 per nursing home in 2001.
The increase of personnel went along with an increase in nursing homes
but due to mergers a decrease of ambulatory institutions providing long-term
care. Between 1995 and 2001, the number of institutions providing inpatient
long-term care increased from 9.7 to 11.1 per 100 000; the number of ambulatory
providers decreased from 14.3 to 12.8 per 100 000 (56). Of all 674 292 nursing
home beds available for nursing care in 2001 (819 per 100 000; Table 17), 511
028 were available only for long-term care, 2950 only for short-term care and
6963 only for day-care. Other beds were used for multiple functions so that
Germany
120
altogether 618 927 beds were available for long-term care, 107 906 beds for
short-term care, and 91 017 for day care (56). Other structures have developed
much more slowly: there were only 11 ambulatory geriatric rehabilitation
clinics and 10 mobile teams for geriatric rehabilitation for the whole country
in 2000. In addition, the number of specific geriatric beds in acute hospitals or
rehabilitation hospitals doubled from 7 200 in 1993 to 16 100 in 2000 (19 per 100
000) (57). Although slower, the provision of geronto-psychiatric beds, homes
and day clinics has also increased. Overall, the ambulatory care possibilities
for demented and mentally ill seniors is still widely perceived as insufficient
(58), and subject to current reform debates.
Similar to other social care (not health care) sectors, Social Code Book XI
applies the principle of subsidiarity to long-term care, implying that private
non-profit organizations have priority over public institutions to deliver care.
However, the preference for private-for-profit providers over public providers
is an innovation of the statutory long-term-care insurance, and one of several
measures intended to increase competition among providers.
Although the share of privately owned nursing homes has increased at the
expense of public providers since 1994, non-statutory welfare organizations
dominate long-term care services. Of the 9200 nursing homes accredited
in December 2001 to provide nursing care under long-term care insurance
(including day care centres), 56% were owned by non-profit organizations,
36% by private for-profit providers and 8% by public providers, usually
municipalities. Of the 674000 places in nursing homes, 62% were provided
by non-profit providers, 28% by private for-profit providers and 11% by public
providers (59).
Payment
The duty to guarantee access to professional ambulatory long-term care has
been legally entrusted to statutory sickness funds that are responsible for
administering the statutory long-term care scheme (so-called long-term care
funds), while the Lnder guarantee access to institutionalized care. In the case
of long-term care, the principle of dual financing means that investment
expenditures are paid by Lnder have to cover investment costs for institutions
and partly for ambulatory suppliers, while social or private long-term insurers
pay recurrent costs. In contrast to health care (where private providers depreciate
their investments via recurrent costs), the Lnder may also finance investments
for long-term care in the ambulatory sector. The Lnder are also responsible
for planning but they are prohibited from limiting the number of providers in
the ambulatory sector, thus competition is enhanced. Professional care in the
Germany
121
ambulatory sector is paid on a fee-for-service basis while institutionalized care

is based on per diem charges. The prices are negotiated at Lnder level between
long-term care funds and associations of providers delivering nursing care.
Expenditures
Table 21 shows the allocation of resources within statutory long-term care
insurance. In 2003, 32% of expenditures were spent on cash-benefits: to
recipients and to care-givers in form of contributions to statutory insurance
schemes. Compared to 1996, expenditures on cash payments showed a
decreasing trend, expenditures on professional services a rising trend. Virtually
50% of expenditures were for professional care in homes, 15% for professional
nursing care at home, and 3% for other in-kind benefits.
The income of the long-term care funds exceeded their expenditures during
the first three years by 3.4 billion in 1995, 1.2 billion in 1996 and 0.8 billion
in 1997 mainly because funding began earlier than benefit provision but
reached almost a steady state in 1998. Since 2000, expenditures have exceeded
revenues increasingly, amounting to 0.7 billion in 2003 (Table 21). Reserves
are large enough to cover these deficits for the near future, but the discussion of
how to finance long-term care insurance in a sustainable way has started. The
introduction of the statutory long-term insurance led to a substantial decrease
in municipalities expenditures on long-term care. Yet, social welfare still is
required to support the elderly in homes, mainly to finance accommodation
costs not covered by statutory long-term care insurance.
Mental health care
Since a parliamentary committee report in 1975 criticized the institutionalization
and low quality of care for long-term mental illness, mental health care in
the western part shifted gradually to offering community-integrated services.
The situation of mental health care in the eastern part in 1990 was similar to
conditions in the western part before the psychiatric reforms in the 1970s. The
lack of specialized community-integrated services was further aggravated by
staff shortages. Thus, big institutions with 300 to 1800 beds provided relatively
low quality care. Sixty per cent (60%) of inpatients were judged as not needing
hospital care in 1990.
During the process of dehospitalization, the number of hospitals providing
care only for patients with psychiatric and/or neurological illness was decreased
substantially up to the mid of 1990s. Acute psychiatric inpatient care was shifted
to a large degree to psychiatric wards in general (acute) hospitals with beds for
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122
Table 21.
Expenditures and revenues of statutory long-term care insurance in billion

Euroa, 19962003
1996 1997 1998 1999 2000 2001 2002 2003

Expenditures on benefits
10.3
14.3
15.1
15.6
15.9
16.0
16.5
16.6
Cash-benefits
4.4
4.3
4.3
4.2
4.2
4.1
4.2
4.1
Social insurance
contri butions for
caregivers
0.9
1.2
1.2
1.1
1.1
1.0
1.0
1.0
Professional care during
holidays of caregivers
0.1
0.1
0.1
0.1
0.1
0.1
0.1
0.2
Short-term care
0.1
0.1
0.1
0.1
0.1
0.2
0.2
0.2
Day-/ Night care
0.0
0.0
0.1
0.1
0.1
0.1
0.1
0.1
Nursing aids and support
technologies
0.4
0.3
0.4
0.4
0.4
0.4
0.4
0.4
Ambulatory care benefits
in-kind
1.5
1.8
2.0
2.1
2.2
2.3
2.4
2.4
Nursing care in homes
2.7
6.4
6.8
7.2
7.5
7.8
8.0
8.2
Nursing care in homes
for disabled
0.0
0.1
0.2
0.2
0.2
0.2
0.2
0.2
Expenditures of the
medical review board
(50%)b
0.2
0.2
0.2
0.2
0.2
0.3
0.3
0.3
Administration
0.4
0.6
0.6
0.6
0.6
0.6
0.6
0.6
Total expenditures
10.9
15.1
15.9
16.4
16.7
16.9
17.4
17.6
Total revenues
12.0
15.9
16.0
16.3
16.6
16.8
17.0
16.9
Saldoa
+1.2
+0.8
+0.1
-0.0
-0.1
-0.1
-0.4
-0.7
Source: Federal Statistical Office 2004 (38); Federal Ministry of Health and Social Security 2004
(39).
Note: a statutory reserves not included; b the other 50% of medical review board costs are paid
from statutory health insurance contributions.
the mentally ill reduced from 150 000 in the western part of Germany in 1976
to 69 000 in the whole of Germany in 1995 and to 53 916 in 2002. During the
same period the duration of stay in sychiatric hospitals specialized in psychiatry,
psychotherapy and/or neurology was decreased from an average of 152 days in
1976 (western part of Germany only) to 44 days in 1995 and 27 days in 2002
(western and eastern part). Altogether, 396 hospitals (of a total of 2221) had
departments for psychiatric and psychotherapeutic care in 2002. Most of them
(375) also offered day clinics, an option which has been legally available to
non-university hospitals only since 2000. The dehospitalization of long-term
care psychiatric patients was accompanied by an increasing number of hospitals
for preventive/rehabilitative care which lie outside the Lnder hospital plans.
Often owned (often owned by private for-profit providers) these institutions
specialized particularly on the care for patients with addiction problems and
psychosomatic disturbances.
Germany
123
Ambulatory care for the mentally ill children and adults is also supported
by the increasing number of office-based psychiatrists, neurologists,
other physicians with psychotherapist qualifications and psychological
psychotherapists (see Primary and secondary ambulatory care). Since 2000,
psychiatrists have been made coordinators of a new set of benefits called
sociotherapeutic care to encourage SHI-insured chronically mentally ill to utilize
necessary care and to avoid unnecessary hospitalization. Dehospitalization has
led to an increase of specially attended flat-sharing communities and ambulatory
psychosocial centres for crisis intervention, counsseling and social support,
often delivered by non-profit organizations. In addition, public health offices
provide socialpsychiatric services including counsseling, social work, home
visits and crisis intervention, directed particularly at the most disadvantaged
people among the mentally ill. The quantity, comprehensiveness and quality
of ambulatory services varies largely between different local communities
and federal states. Despite advances, psychosocial facilities are often less well
resourced than institutions for somatic care (access to telephone etc.), and
access to occupational rehabilitation and comprehensive social integration is
still considered under-developped.
Care for physically and mentally disabled
Social care for physically and/or mentally disabled is characterized by wellequipped and highly specialized institutions and schools. Although these
comprehensive services are increasingly offered within communities on an
outpatient basis, institutionalized care still plays a major role, especially for
severely disabled people with multiple handicaps.
As with services for the mentally ill, there are a broad variety of private
organizations and local community initiatives offering support for the
handicapped and their families. Yet because of unclear financial responsibilities,
those affected do not have a concrete right to specific community-integrated
services, including kindergartens and schools. This again leads to great regional
differences and under-provision in rural areas.
The reform of Social Code Book IX on rehabilitation in 2001 has increased
the individual and collective rights of the disabled. Personal budgets have been
introduced and coordination centres provide information to the insured, simplify
administrative procedures and coordinate the many actors involved in financing
medical, professional and social rehabilitation as well as disability benefits. A
commissioner for the disabled has been named by the Federal Assembly and
is situated at the Ministry of Health.
Germany
124
Human resources and training

Health care is an important employment sector in Germany, with 4.2 million
residents working in the health sector, accounting for 10.6% of total employment
at the end of 2002, 300 000 in health industries and 3.9 million in health care. Of
these, 1.8 million worked in inpatient care or day-care, 1.7 million in ambulatory
care, 0.2 million in administration and 0.2 million in other institutions. While 1.5
million (37%) worked part-time, 2.6 million (63%) worked full-time. Since 1997
the health care work force has remained virtually stable in numbers of people
but decreased in full-time equivalents (21). While part-time jobs increased,
the full-time job quota decreased from 70% to 66% until 2001, more than the
parallel decrease from 76% to 74% in other economic sectors during the period.
Full-time jobs, mainly in medicine and nursing, started to increase only in 2002,
mainly for physicians and nurses in inpatient care. Table 22 outlines trends in
human resources and training in different professions.
Physicians
Over the past 50 years, the number of physicians has increased steadily. The
average increase, however, has been reduced from 3% in the 1980s and 2% in the
1990s to 1% since 2000 (61). The number of qualified general practitioners, on
the other hand, has decreased, both in relation to the population and especially
in relation to all physicians. However, since an increasing number of internists
and paediatricians followed incentives to focus on practising primary care,
in 2003, 52% of the 116 065 SHI-accredited physicians worked as family
physicians, while 48% were practising as specialists in ambulatory care (see
Primary and secondary ambulatory care).
Of a total of 388 200 physicians in 2003, 304 100 were active a rate of
369 per 100 000 population or one physician per every 271 inhabitants. Of all
active physicians, 145 500 practised in hospitals, 132400 in ambulatory care
(117600 as SHI-accredited physicians, 8200 as employed physicians and 6600
purely for private patients), 10 200 in public health services, administration or
corporatist bodies and 16 000 in other areas, such as the pharmaceutical industry.
According to WHO health for all data, which exclude the latter two groups, the
275167 physicians active in health services accounted for a ratio of 3.4 per
1000 (Table 24), similar to France and the Netherlands (Fig. 14) as well as the
EU-25 average (Fig. 15). Access to medical and dentist studies became more
restricted at the end of 1980s leading to a decrease in graduates from 1994.
Germany
125
According to 99105 of Social Code Book V, needs-based plans have to

be developed to regulate the number of SHI-affiliated office-based physicians.
Originally, the intention was to guarantee that the less common specialties would
also be available in rural areas. Since the 1980s, however, the focus has been
on avoiding over-supply. Since 1993, the Social Code Book has stipulated that
Table 22.
Health care workforce 19922002 (per 100 000 population)
1992 1994 1996 1997 1998 1999 2000

Physicians
284
300
311
313
318
321
326
general practitioners
118
121
115
110
108
106
107
Dentists
70
73
75
76
76
76
77
Pharmacists
53
54
56
57
58
58
58
Nurses
924
938
949
962
Midwives
11
11
11
11
11
11
11
Physicians graduated
13
17
15
11
11
10
10
Dentists graduated
2.4
2.2
1.9
2.0
2.0
2.0
2.0
Pharmacists graduated
2.9
2.9
2.7
2.0
1.9
1.8
1.9
2001
330
106
78
58
973
12
8.5
1.6
1.5
2002
336
106
79
59
new practices may not be opened in areas where supply exceeds 110% of the
average number for a given specialty. Accordingly, the Federal Committee of
Physicians and Sickness Funds developed directives defining these limits. Since
2004, this task has been transferred to the Sub-Committee on Ambulatory Care
of the new Federal Joint Committee (see Planning, regulation and management).
The directives classify all planning areas into one of 10 groups ranging from
large metropolitan areas to rural counties, and define the need per group as the
actual number of physicians working in counties of that group in 1990, divided
by the population. Thus, over-supply is defined as 110% of that figure. Factors
such as age, gender, morbidity or socioeconomic status of the population or
the supply of hospital beds are not taken into account. Due to this definition,
the need for certain specialties varies widely up to a factor of 9 in the case
of psychotherapists since differences are frozen (Table 23).
In early 2003, out of a total of 406 planning areas, 395 were closed to
new surgical practices, 373 to dermatologists, 371 to paediatricians and
399 to specialist internists. However, only 137 areas were closed to family
physicians, meaning that two thirds of all planning areas had not reached the
defined maximum, an increase from the 50% in 1999. In fact, the density of
SHI-affiliated physicians varies greatly between metropolitan areas, lead by
Hamburg, and rural areas. Of the 16 federal states, Hamburg has the highest
and Brandenburg a largely rural state surrounding Berlin has the lowest
rate of family physicians and specialists alike.
Germany
126
Fig. 13.
Number of physicians in Germany, selected European countries and EU-15

average per 1000, 19902002
3.5
2.5
1.5
1
1990
1991
1992
1993
France
Norway
EU-15 average
1994
1995
1996
Germany
Switzerland
1997
1998
1999
2000
2001
2002
Netherlands
United Kingdom
Nurses and other health professions

The number of nurses has increased substantially in the past decades, especially
during the 1990s, when long-term care insurance was introduced and provided
more jobs in ambulatory care (see Social care) (62). From 1997 until 2002, the
number of nurses and midwives together increased from 689000 to 705000,
that is 8.5 per 1000 population in physical persons. When taking into account
part-time work, 635000 nursing posts in full-time equivalents were filled (21).
According to WHO data (5), the number of nurses (9.7 per 1000) ranks well
above the average of both the EU-25 average (7.7) and the EU-15 average (6.8
in 2001) respectively (Fig. 14). Similar to nurses, the number of all other allied
health professionals have increased since 1997, except in health handcraft
professions (21).
An interesting instrument was included in the Health Care Structure Act of
1993, namely the introduction of nursing time standards, through which a daily
documentation of nursing activities put every patient in one of nine categories
with a standardized required nursing time between 52 and 215 minutes per day.
The total number of minutes per ward and per hospital could be calculated into
Germany
127
the nursing staff needed by the unit. Nursing time standards were introduced to
end a period of perceived nursing shortages, on the assumption that new jobs
would be created. However, the Second SHI Restructuring Act abolished the
regulation for the official reason that the standard had led to almost 21000 new
nursing positions between 1993 and 1995, when the law-makers had anticipated
only 13000.
The conditions for independent health care professionals other than
physicians such as physiotherapists or speech and language therapists to be
reimbursed for treating SHI-insured patients are regulated in the Social Code
Book. Section 124 regulates the accreditation of SHI providers, who must
fulfil certain prerequisites (training, practical experience, practice equipment,
contractual agreements) if they want to participate in the care of the insured.
Training
The training of health care professionals is a shared responsibility of the
federal government, state governments and professional associations. Most
current debates arise out of the tension between the various stakeholders.
Table 23.
Needs-based population ratios defined as covering 100% of need per

specialty highest and lowest ratios (defined as one physician per
X population; data from 2003)
Family physiciansa
Specialist internists
Anaesthetists
Dermatologists
Ear-nose-throat
physicians
Gynaecologists
Neurologists/
Psychiatrists
Ophthalmologists
Orthopaedists
Paediatriciansb
Psychotherapists
Radiologists
Surgeons
Urologists
Highest district
ratio
1/1474
1/9574
1/18 383
1/16 996
1/2134
1/44 868
1/137 442
1/60 026
Relative difference
highest/ lowest
1.45
4.69
7.48
3.53
1/16 419
1/6 711
1/42 129
1/14 701
2.57
2.19
1/11 909
1/11 017
1/13 009
1/12 860
1/2577
1/24 333
1/21 008
1/26 017
1/47 439
1/25 778
1/34 214
1/27 809
1/23 106
1/156 813
1/62 036
1/69 695
3.98
2.34
2.63
2.17
8.97
6.44
2.95
2.68
Lowest district ratio
Source: own calculations based on Federal Association of SHI Physicians, 2004 (49).
Note: a including general practitioners, practitioners, and family internists; b including family
paediatricians.
Germany
128
According to the federal structure, the 16 Lnder are generally responsible for
regulating and financing education as well as for registering and supervising
professions, including health professions. However, health professions differ
traditionally from other professions due to the national regulations for their
primary education and the virtual autonomy of the bodies regulating their
specializations (secondary professional education) and continuing education.
National standards for curricula and examinations were introduced in 1871 for
medical studies, 1875 for faculties of pharmacy and 1907 for the nurse training.
Today, uniform curricular frameworks defined by federal law exist for 17 of
23 non-academic health care professions, for example, paediatric nursing,
assistant nursing, midwifery, physiotherapy, speech therapy, technical assistance
or emergency and rescue care. National legislation was also introduced to
harmonize the primary education of elderly care-takers in 2002. In addition, a
new profession, podology, was established by federal law in 2001.
Primary professional education and registration
Primary training of non-academic and academic professionals is basically free
of charge in Germany. However, private schools with course-based training
for therapeutic professions demand fees of about 300 to 700 per month.
Participants of practice-based training in health care institutions such as nursesin-training receive a basic income. University education is financed by the states
while practice-based training at hospitals is basically funded by sickness funds
as part of their financial contracts with individual hospitals.
Many German universities offer a degree in medicine (36), dentistry (31)
and/or pharmacy (23); veterinary medicine is taught at 5 faculties. There are also
many publicly financed facilities for the primary training of nurses and child
nurses, elderly care-takers, who are trained on the job with additional blocks or
days for course-based learning. At the same time, schools for physiotherapists,
masseurs, midwives, dieticians and speech and language therapists are often
private and require fees.
Primary training of most non-academic health professionals requires an
advanced degree after secondary school and usually takes three years. Access to
German universities is usually limited to people with an A-level equivalent (12 or
13 years of school). Academic health education is among the subjects for which
places are distributed centrally according to academic records, waiting times
and special quotas (for example, foreigners or the disabled). Fifteen per cent
(15%) of medical students are accepted by means of interviews at universities.
University studies last between 4 years (pharmacy) and 6 years (medicine).
The curriculum for academic health care professions used to be highly
standardized and organized around three or four main examinations. In 1999, a
Germany
Fig. 14a.
129
Number of physicians and nurses per 1000 population in western Europe,

Monaco (1995,1995)
6.6
Italy (2001, )
16.2
6.1
Greece (2001, 1992)
4.5
Belgium (2002,2001)
4.5
2.6
10.8
Israel
3.7
Denmark
3.6
Norway (2002,2001)
3.6
Iceland
3.6
Switzerland (2002,2000)
3.6
EU-15 average (2001,2000)
3.5
Germany (2002,2001)
3.4
France
3.3
Austria (2002,2001)
3.3
Spain (2000,2000)
3.2
3.7
Portugal (2001,2001)
3.2
3.8
Finland
3.2
Netherlands (2002,2001)
3.1
Andorra
3.0
Sweden (2000,2000)
3.0
Luxembourg
2.6
San Marino (1990,1990)
2.5
Ireland (2001,2000)
2.4
United Kingdom (1993,)
6.0
9.7
20.6
9.0
8.3
6.8
9.7
6.9
Physicians
Nurses
5.9
21.7
13.3
3.2
9.8
7.8
5.1
16.8
1.6
10
15
20
25
Number per 1000 population
Note: EU: European Union; EU-15 average: for member states prior to 1 May 2004; countries
without data not included.
Germany
130
Fig. 14b.
Number of physicians and nurses per 1000 population in the European

Union, 2002 or latest available year (in parentheses)
Italy (2001, )
6.1
Greece (2001, 1992)
4.5
Belgium (2002,2001)
4.5
2.6
10.8
Lithuania
4.0
Denmark
3.6
9.7
Czech Republic
3.5
9.7
EU-25 average (2002,2001)
3.4
Germany (2002,2001)
3.4
France
3.3
Austria (2002,2001)
3.3
Spain (2000,2000)
3.2
3.7
Portugal (2001,2001)
3.2
3.8
Slovakia
3.2
Hungary
3.2
Finland
3.2
Netherlands (2002,2001)
3.1
Estonia
3.1
Sweden (2000,2000)
3.0
Latvia
3.0
5.1
Malta
2.7
5.5
Cyprus (2001,2001)
2.6
Luxembourg
2.6
Ireland (2001,2000)
2.4
Slovenia
2.2
Poland (2001,1990)
2.2
United Kingdom (1993,)
7.8
7.7
9.7
6.9
5.9
Physicians
Nurses
7.1
8.5
21.7
13.3
6.4
9.8
4.2
7.8
16.8
7.2
5.3
1.6
0
10
15
20
Number per 1000 population
Note: EU: European Union; EU-25 average: for all member states.
Germany
25
131
long-sought clause was integrated into the national ordinance for medical studies
allowing individual medical faculties to offer curricula reform while preserving
basic national standards, such as two centralized final examinations. The first
reformed medical curriculum started as a second track at Berlin Humboldt
University in 1999. In autumn 2003, the ordinance was completely changed,
with the political aim of facilitating profound innovations in favour of bedside
teaching, community-based teaching, problem-solving skills and the integration
of basic science and clinical subjects.
Since the beginning of the 1980s cost considerations have motivated health
policy-makers to try to reduce university places for health care studies, while
educators have not generally agreed. Since the early 1990s the number of
graduates in medicine, dentistry and pharmacy has decreased (Table 22).
After graduation, health care professionals are eligible for registration at the
Lnder ministries responsible for health. A regulation that medical graduates
receive full state recognition only after having worked in clinical practice for
18 months was abolished in 2004.
The recent reforms of nurse training (2002), child nursing (2002) and elderly
care-taking (2001) modernized curricula and enhanced elements of preventive
and psychosocial care and community-based practice. The primary training
for elderly care-takers was harmonized for the first time at the federal level
while training standards and requirements had previously varied by state. The
traditionally strong emphasis on social work has been complemented by more
training in nursing skills and sickness-related knowledge, although experience
in geronto-psychiatric nursing has still not become an obligatory part of elderly
care-takers training. Despite initiatives to unify the nursing professions, the
traditional profound dichotomy between them has been preserved by the
recent reforms of primary professional training. Physician assistants and
dental assistants continue to be trained separately in a vocational-type of
training based at physicians practices. Their training was recently broadened
by introducing obligatory rotation and modernized to account for changes in
patient information, practice management and information technologies. The
responsibility for financing nursing schools at hospitals used to be the state
governments, but was shifted largely to sickness funds in 2000. Nurse training
in the future will be financed as a surcharge on DRGs from an inter-hospital
fund (see Payment of hospitals).
Neither a system for monitoring nurses on the basis of professional
qualifications and job positions nor a systematic planning of human resources
according to future needs are in place.
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Secondary professional training (specialization) and continued

education
Medical and veterinary graduates are obliged to specialize if they want to work
as office-based SHI-affiliated physician, while specialization is optional for the
other health care professions. The different federal states recognize a maximum
of 8 specialties in pharmacy, 3 in dentistry, 48 in veterinary medicine, 7 in
psychology and 12 in nursing.
The number of medical specialties increased from 14 in 1924 to 37 in
2003, supplemented by another 52 sub-specialties or additional qualifications.
Based on decisions of the assembly of physician representatives from regional
physician assemblies, the Federal Physicians Chamber issues a model advanced
training regime which is further detailed by the physicians chambers at Lnder
level. For each of these qualifications a minimum length of training, a catalogue
of procedures and skills is detailed in the training regime which may be adjusted
by the physician assemblies at Lnder level. Subsequent to the advanced training
period, physicians must pass an examination of skills and knowledge in the
target qualification.
Practice-based specialization usually takes two or three years in nonacademic and four to six years in academic health care professions. The duration
of specialization in general medicine was increased from three to five years in
1998 in order to strengthen the quality and professional status of future family
practitioners. Yet, general practitioners amounted to only about 20% of the
physicians receiving their specialty diplomas from physicians chambers during
the 1990s. The low generalist/specialist ratio has been interpreted as a result
of lower income prospects (see Payment of physicians), but also of a lack of
training facilities in ambulatory care and lower prestige due to the socialization
of medical doctors in secondary and tertiary hospital care. Therefore, sickness
funds, private health insurers and regional physicians associations have been
obliged since 1999 to finance half of the GP-trainees salaries during the officebased training period (minimum two out of five years). However, in practice,
the subsidy often is the trainees only income, which may explain why in 2003,
of the 12107 physicians obtaining a specialist degree, only 13% were general
practitioners while specialist internists were the largest group (15%) (61).
A high drop-out rate in non-academic professional training and practise
has been interpreted as a result of the employment situation for women, the
relatively low job satisfaction in hierarchical systems and limited prospects for
professional development and social mobility. The shortage of nurses was another
factor motivating the introduction of course-based specialization facilities at
universities of applied sciences during the 1980s. Nursing sciences are offered
by 11 universities for applied sciences and one private university. Part-time or
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133
full-time courses are increasingly offered for other non-medical professions as

well (for example, physiotherapists, speech and language therapists or elderly
care-takers). Polytechnics and private institutions also offer a variety of courses
in areas such as health promotion and hospital management.
Public health was an exclusively medical specialty until 1989, when postgraduate courses were gradually introduced at nine universities, predominantly
in medical faculties. The two-year part-time courses are free of charge and
offer about 300 places to university and polytechnic graduates in medical and
non-medical disciplines. Quality management is another part-time qualification
that has been introduced in recent years at five physicians chambers, private
institutions and some polytechnics.
Since 2004, continuing education has been made obligatory for all health
professionals; evidence of appropriate professional development has to be
presented every five years. In the case of SHI-affiliated physicians, lack
of adequate evidence may lead to a reduction of reimbursement. For other
physicians, psychologists, dentists and pharmacists the responsibility of
regulating, promoting and supervising continuing education lies with the
professional chambers.
Some general issues
Current debates on the education of health care professionals in Germany reflect
the tensions between and within education, health care and professional selfregulation; some issues have been raised for decades. For example, interpersonal
skills and the ability to synthesize knowledge are perceived as under-represented
in nearly all types of health care education compared to factual knowledge,
which has been increased in response to developments and specializations in
medicine. While the practice-based training of health professionals is criticized
as lacking broader educational and pedagogic support for trainees, course-based
education at universities is criticized as preparing students insufficiently for
their future work either in research or in general health care practice.
Some quantitative and qualitative issues have gained particular political
importance during recent health care debates and reforms. The constitutional
right and strong professional and political imperatives to offer free choice of
profession have made restricting access to university education or professional
practice a highly contentious issue. There is now broad agreement in Germany
that health care professionals should be better qualified in primary care, health
promotion, rehabilitative care and interdisciplinary cooperation. However, it has
proved insufficient to add these to the course syllabi while the majority of health
trainees are still nearly exclusively based, trained and specialized in secondary
and tertiary hospitals for acute care. One of the major challenges in health care
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training will therefore be to increase the role, funding and infrastructure of

community-based education.
Pharmaceuticals
Pharmaceutical policy seeks to balance targets of health care and industrial
policy. Health care policy is primarily concerned with safeguarding quality
and safety, improving health and containing costs for SHI. At the same time,
industrial policies seek to protect national labour markets and industries and
their international competitiveness. Regulations concerning the pharmaceutical
market therefore present a dichotomy: On one hand, regulations concerning
pharmaceutical pricing and proof of efficacy remarkably liberal; on the other
hand, the surcharges on ex-factory pharmaceutical prices are extremely
regulated. Only recently have the structure and price regulations in the
pharmaceutical distribution chain been addressed by health policy. Costcontainment has concentrated on the SHI market and has relied especially on
indirect price controls through reference prices since 1989 and on regional
spending caps (19932001). Since then, the pharmaceutical market has been
reorganized stepwise, starting with ad hoc price cuts and rebate measures to
counterbalance the lifting of spending caps which were replaced by practicespecific prescription targets from 2002, coupled with prescription feedback for
individual physicians since 2003. Furthermore, surcharges in the distribution
chain were amended and the pharmacy market was liberalized.
The following sub-sections give an overview of the pharmaceutical market
in 2002, the latest year for which complete data are available. They also outline
the progress of drugs from licensing via distribution, price-regulation to SHI
coverage (an issue which was dealt with under Health Technology Assessment in
the previous version of the HiT (1)). The further sub-sections then concentrate
on regulations such as rebates, reference prices and spending caps which only
apply to the SHI market.
The entire pharmaceutical market
The pharmaceutical industry in Germany is among the most powerful in
developed countries and contributes significantly to the export market. Around
1100 pharmaceutical companies with 114 800 workers operate in Germany
(2002). Of the pharmaceutical industrys total turnover of 23.2 billion in
2002, 11.4 billion was gained in the domestic market and 11.8 billion from
exports (especially the other European Union countries, Japan, Switzerland
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135
and the United States) (63). The globalization of the German pharmaceutical
market is indicated by the tripling of import and export turnover (13.1 billion
in 2001) since 1992. While imported drugs accounted for about 20% of the
pharmaceutical market in Germany in 1992, it accounted for just above 40%
in 2002 (2).
Of the 36.6 billion spent on drugs in 2002 (according to national figures),
31.4 was spent on pharmacies in ambulatory care and 3.0 on acute hospital
care (21). Of the 33.3 billion spent on drugs in pharmacies in 2002, 29.0
billion were spent on prescription drugs and 4.2 billion on over-the-counter
(OTC) medication (2). In real prices, expenditure on OTC drugs increased until
1997 and has decreased since, while prescription drug costs rose continuously.
Private households spent one quarter of their out-of-pocket payments on drugs
in 2001, less than in the mid-1990s when the share was around 30%.
The pharmacy surcharge and tax are among the highest in western European
countries. Of a theoretical end-user price of 100 in 2003 within SHI, drug
manufacturers received about 54.10, wholesalers 5.80 and pharmacists 14.30;
tax accounted for 13.80 and the rebate for sickness funds for 12.50. While
value added tax ranks 2nd lowest among EU-15 countries, value-added taxes
levied upon drugs rank 3rd among EU-15 countries since many governments
provide a reduced tax rates (64). In 2002, the figures based on 100 were: drug
manufacturers 55.90, wholesalers 7.80, pharmacists 17.40, tax 14 and the
rebate of pharmacies to sickness funds to 5.10 (40).
An analysis of prescriptions is undertaken annually by a sickness fund
affiliated institute. Although this report does not provide patient data which could
be used to evaluate appropriateness, it is nevertheless of value for assessment
of trends in physicians prescription behaviour. The report is based on virtually
all drug prescriptions in the ambulatory care sector (GKV-Arzneimittelindex),
and is jointly maintained by several corporatist associations. It does not include
prescriptions paid by private health insurance, drug supply in hospitals or OTC
drugs. The classification of different substances is based on the ATC standard
of the World Health Organization. Until 2000, the report was only based on a
representative sample of 0.4% of all prescriptions covered by sickness funds.
On the basis of expenditure, panel data is projected to 100% of prescriptions.
This methodical change has to be considered when comparing data between
periods before and after 2000.
The gross turnover of pharmacies with SHI prescriptions was 24.9 billion
in 2002. Of this, 2.2 billion (9%) was spent on hand-made pharmaceutical
substances or dressings, nursing care and other products, and 22.7 (91%) was
spent on industrially produced drugs. SHI-insureds were prescribed an average
of 10.9 packages with 430 defined daily doses (DDDs). The prescription rate
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136
varied by age between 100 DDDs in the age group 2025 throughout the year
2002 and 1379 DDDs in the ages 8589. Children under 4 received 209 DDDs
and people over 90 received 1272 DDDs per year (40).
The gross turnover of prescribed medicines per insured was 363 in 2003, of
which 25 was financed by co-payments and 46 by rebates from pharmacies
to sickness funds (but not private insurers), as required by law. Thus, sickness
funds reimbursed an average of 292 per insured in 2003 according to the
physician prescription database called (65). The end-user cost of a prescribed
package in 2003 was 32 on average for SHI-insured people. The average price
was 18 for generics, 17 for reference-priced drugs, 70 for re-imported drugs,
82 for me-too drugs, and 356 for so-called special preparations which are
high-cost medications for certain indications.
SHI-affiliated physicians prescribed an average of 5880 ready preparations
in 235 000 DDDs, with an average turnover of 175 000. The greater part of
prescriptions were issued by general practitioners (54%) and internists (18%)
followed by gynaecologists, ophthalmologists and paediatricians. The turnover
was on average 30 per prescription. The average cost of prescription varied
by specialty between 11 from paediatricians, 27 from general practitioners,
40 from internists, and 68 from urologists, neurologists, psychiatrists and
psychotherapists (40).
Table 24 shows trends in pharmaceutical expenditures of sickness funds,
private health insurers and private households. Of the total pharmaceutical
expenditures in 2002, 70% were spent by statutory health insurance, 6%
by private health insurance, 18% by private households (and not-for profit
organizations), and the remaining 5% by other sources. Most pharmaceutical
expenditures were in ambulatory care. Pharmaceutical cost-containment
measures buffered the rising trends of SHI expenditures on drugs, leading to a
nominal decrease only in 1993 and 1996. As a result of cost-sharing measures,
private household expenditures on pharmaceuticals increased throughout the
1990s, accounting for up to 26% of pharmaceutical expenditures in 1998 but
decreased again to 18% in 2002 (see Out-of-pocket payments).
Licensing
Licensing for new drugs became mandatory only with the 1976 Pharmaceutical
Act (effective from 1978), after it became clear that a significant proportion of
drugs were of unproved effectiveness, and is the most regulated area of medicine
in Germany. The admission of pharmaceuticals for humans onto the market is
the responsibility of the Paul Ehrlich Institute (blood, blood products, sera and
vaccines) and the Federal Institute for Pharmaceuticals and Medical Devices
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137
(all other drugs). The Pharmaceutical Act mandates licensing processes, along
with a set of guidelines issued by the Ministry of Health. Before the act, drugs
had only to be registered with the (former) Federal Health Office. Registration
regulations called for only minor assessments concerning possible toxic effects
and the quality of the preparation. While registered drugs may not be labelled
for specific indications, licensed drugs have to be tested and labelled for certain
indications.
Since 1978, when the Pharmaceutical Act came into effect, approximately
19 000 drugs have been licensed and about 1800 homeopathic remedies have
been registered. A substantial number of drugs registered before the enforcement
of the Pharmaceutical Act are still on the market. These had to apply for
licensing by 30 April 1990 or be removed from the market, which happened
to 70 000 drugs by January 1993. Since a substantial number of drugs did not
have a chance to prove their efficacy, another deadline (31 December 1999) for
submitting licensing applications was established. If a manufacturer renounces
its application for licensing a certain drug, the drug may be marketed until
the end of 2004 without any proof of therapeutic benefit. The Pharmaceutical
Act Amendment (1994) extended the deadline for licensing to December
2005. Altogether 10800 applications for licensing 7300 chemically defined
pharmaceuticals and 3500 homeopathic remedies with indication were handed
in. Of these, 2378 of the former and 955 of the latter had not been evaluated by
June 2004. In addition, 4700 applications for re-registration of homeopathic
drugs without labelling for certain indications were received. These do not fall
under European Union regulation but are performed in Germany.
Licenses are granted to various doses and application forms of drugs, leading
to more than 40 000 items on the drug market. The Red List registry contains
9449 preparations, yet 90% of prescriptions relate to 2300 drugs. Seventy-seven
per cent (77%) of the drugs contained on the Red List were chemically defined
preparations, 11% were phytotherapeutics, 8% homeopathics, and 4% other
drugs in 2003 (63).
The criteria for licensing pharmaceuticals are: scientifically proven safety
and efficacy. This includes a stepwise testing in studies with health humans
(phase I and II) and controlled clinical trials in persons affected by the target
disease (phase III). Based on the EU-wide standard on good clinical practice
an extensive formalization and documentation of study procedures is required.
However, only a marginal beneficial effect needs to be demonstrated with a
small sample in order to fulfil the efficacy criteria, and cost-effectiveness is of
no importance. This has led to the admission of active substances with merely
minor modifications rather than real product innovations. Licensing is, in any
case, limited to five years, after which one needs to apply for an extension.
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Table 24.
Expendituresa on pharmaceuticals, 19922002
Total expenditures on
pharmaceuticals (billion )
by SHI
by private health insurance
by private householdsb
by other sourcesc
on drugs in acute hospitals
(billion )
on drugs from pharmacies
(billion )
Expenditures on drugs from
pharmaciesd (billion )
as % of GDP
by SHI (billion )
as % of GDP
as % of total SHI expenditures
by private health insurance
(billion )
by private householdsb (billion )
on co-payments (a)
by other sourcesc (billion )
1992
1993
1995
1997
1999
2000
2001
2002
25.9
18.7
1.9
4.7
0.6
24.4
16.2
1.0
5.7
1.5
27.0
18.3
1.1
6.1
1.5
28.8
18.7
1.2
7.3
1.6
31.4
21.0
1.7
6.9
1.8
32.4
22.0
1.8
6.6
2.0
35.0
24.2
1.9
6.8
2.1
36.6
25.6
2.1
6.7
2.2
2.3
2.5
2.6
2.7
2.8
2.9
2.9
3.0
22.5
20.8
23.2
24.5
27.0
27.7
30.2
31.4
22.5
1.40
16.6
1.03
16.8
21.1
1.27
14.2
0.86
14.4
23.7
1.32
16.1
0.89
14.2
25.2
1.34
16.4
0.87
14.2
27.8
1.40
18.5
0.94
15.2
28.5
1.40
19.3
0.95
15.5
31.0
1.49
21.4
1.03
16.6
32.2
1.53
22.5
1.07
16.9
0.8
3.9
0.7
1.2
0.9
4.8
1.2
1.0
0.9
5.4
1.5
1.3
1.0
6.3
2.3
1.3
1.5
6.1
2.0
1.7
1.6
5.9
1.8
1.7
1.8
6.1
1.8
1.7
2.0
6.0
1.8
1.7
Source: Federal Statistical Office 2004 (12); Federal Ministry of Health and Social Security 2004
(60).
Note: a data on pharmaceuticals include dressings; b includes expenditures from not-for-profit
organizations but negligible; c includes expenditures from statutory retirement insurance,
Besides regular admission, an accelerated admission process is also possible,

intended for drugs that generate considerable public interest on the basis of their
potential therapeutic value, but lack sufficient data to judge their therapeutic
efficacy. In such cases, it can be decreed that within a certain period data should
be systematically collected on the drugs efficacy in order to reappraise its
therapeutic value. However, this procedure is very rarely adopted.
The accelerated licensing procedure for orphan drugs (those used to treat
very rare diseases) is more often used, and since 2000 may only be initiated at
the European Agency for the Evaluation of Medicinal Products (EMEA). The
mutual recognition procedure is an increasingly used strategy for approval,
in accordance with EC directive 75/319, which came into effect in Germany
on 1 January 1995. Based on this directive, a manufacturer whose drug has
been admitted in another country may also apply for the drugs admission to
Germany which may only be refused by the Federal Institute for Pharmaceuticals
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139
and Medical Devices if a public danger exists. In this case, EMEA enforced
arbitration would be initiated, and eventually adjudicated by the European
Commission.
Homeopathic and anthroposophic drugs are exempted from the licensing
procedures under the Pharmaceutical Act and are subject to registration only.
Registration requirements refer mainly to the quality of the basic products and
the manufacturing process as well as to the durability of the final products.
Registered homeopathic drugs do not need to prove their therapeutic efficacy
unless they are to be licensed for a specific purpose. In this case, a manufacturer
has to apply through the regular admission procedure. The characteristics of the
admission of homeopathic and anthroposophic drugs and fixed combinations
of phytotherapeutics are regulated explicitly in Ministry of Health guidelines.
An exception to this are prescription drugs produced and sold in pharmacies
in quantities of up to 100 units per day and homeopathic drugs produced in
quantities of less than 1000 units per year and drugs currently being tested in
phaseIII clinical trials.
Market admission is not linked to obligatory comprehensive and systematic
post-marketing surveillance. However, physicians and other professionals are
requested to report problems they or their patients encounter with drugs and
medical devices to the Federal Institute, which is required to maintain a database
of all side effects, contraindications and other drug problems. Records are
assessed by medical, pharmacological and toxicological experts, and appropriate
actions are taken, up to withdrawal of the market license.
Distribution of pharmaceuticals
Pharmaceuticals may be dispensed by hospital, institutional and public
pharmacies and, if they are not labelled pharmacy-only, by drug stores and
supermarkets. Public pharmacies are clearly dominant in the distribution: of the
1647 million packages sold in 2002, 93% were sold in pharmacies and only 7%
in drug stores and supermarkets, which accounted for less than 1% of the total
turnover in the pharmaceutical market. Drug stores and supermarkets mainly
sell vitamins, minerals and some phytotherapeutic products, while nicotine
replacement items, homeopathic drugs and anthroposophic drugs, for example,
have to be sold in pharmacies (pharmacy-only OTC).
The average package in 2002 cost 30. Prescription-only medicines
accounted for 79% of the total turnover but only 44% of the packages. The 922
million (56%) OTC sales accounted for 21% of the turnover. Only a small part,
116 million OTC packages (7% of total packages) were sold in drug stores and
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supermarkets while 806 million were sold in pharmacies. Of the 806 million, 560
were self-medication and 278 were prescribed by physicians, some reimbursed
by statutory health insurance, some not (40).
The density of pharmacies is relatively high by international standards
and has slightly increased over the last decade to 26 pharmacies per 100 000
inhabitants in 2002. Public pharmacies are actually all privately owned, operated
by self-employed pharmacists who are mandatory members of pharmacists
chambers, and had a monopoly over drug dispensing in ambulatory care until
2003 and the introduction of e-commerce and extended allowances to hospital
pharmacies, which may also give medications to SHI-insureds if their funds
have negotiated an agreement with the hospital. From August 2002, hospital
pharmacies had already received an allowance to deliver certain medications,
especially chemotherapies, directly to office-based physicians. Office-based
physicians may not dispense medications, with few exceptions. Until 2003,
pharmacists were only allowed to own one pharmacy. Since 2004, they may
run a maximum of four, and the three branch pharmacies must be in the same
or a neighbouring county as the main pharmacy.
Since enforcement of the SHI Modernization Act in 2004, the structure of the
pharmaceutical sector has changed substantially. The market was liberalized
for pharmaceuticals, for example, e-commerce with pharmaceuticals has been
allowed under strictly regulated conditions, pharmacists may operate more than
one pharmacy, and over-the-counter drugs were taken out of the requirement
to charge uniform prices. The internet trade in OTC drugs grew substantially
in the first few months. From January until July 2004, about 600 pharmacies
had obtained licenses to trade drugs via the internet. About 5000 pharmacies
take part in the largest network of internet-based pharmacies (Aponet), which
was established by the Federal Association of Pharmacists Organizations.
By July 2004, 5% of the 3.5 to 5 million client contacts with pharmacies per
day were taking place via the internet. With 175 000 to 200 000 drug orders
per day, this network is by far the largest provider, while the others together
account for 5000 orders per day. Extrapolated, this would account for 4% of total
packages sold in 2002. Yet, in the first months, the liberalization of the pharmacy
market did not lead to price reductions. Although reductions are seen in travel
packages, some lifestyle drugs and selected expensive drugs (to compete with
hospital pharmacies), the overall price level has not (yet) decreased. Likewise,
the removal of fixed prices in the OTC sector did not reduce but rather often
increased prices.
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Price regulation for the entire pharmaceutical market

The regulation of pharmaceutical prices differs between the inpatient sector and
the ambulatory sector. While hospitals may negotiate prices with wholesalers
or manufacturers, the distribution chain and prices are much more regulated in
the pharmacy market. In both sectors, ex-factory prices are basically determined
by manufacturers without either negotiations involving governmental agencies,
direct price controls or profit controls. However, price setting by companies
takes into consideration (price) regulations in other parts of the market, for
example indirect price regulations in form of reference prices, legal minimum
sales from parallel imports. Drug companies have also been obliged to pay
lump sums or give rebate to sickness funds.
The cornerstones of price regulation were hardly changed between 1980
and 2003, but substantially revised with effect from 2004. From 1980 to 2003,
pharmacists and wholesalers were paid by degressively scaled margins as
detailed in the Pharmaceutical Price Ordinance. As the absolute size of the
margin still increased with a products price, there was little incentive for a
pharmacist to dispense a less expensive medicine. The margins for wholesalers
and pharmacists were decreased in 2002. In 2004, the payment of pharmacists
was substantially revised by the SHI Modernization Act (which in this respect
also affected non-SHI patients). This entailed the liberalization of OTC
medication prices and a revision of the price-setting regulations for prescriptiononly drugs. The new Pharmaceutical Price Ordinance for Prescription-only
Pharmaceuticals applies to the entire prescription-only market independent
of the source of payment. It applies to human and animal drugs and to public
pharmacies, but not to institutional pharmacies or to vaccines, blood replacement
and dialysis-related drugs, for which sickness funds negotiate prices with
manufacturers. (Additionally, the competencies of sickness funds to negotiate
volumes and prices for certain other drugs by circumventing pharmacies and/or
wholesalers have been extended since 2004.)
For prescription-only drugs, pharmacists are now paid through a flat-rate
payment of 8.10 plus a fixed margin of 3%. The user price contains an
additional 16% VAT. The margin of 3% is calculated from the manufacturers
price plus the relevant maximum margin for wholesalers (excluding VAT). The
flat-rate was calculated to maintain pharmacists profits. The pharmacists are
happy with this, particularly since price-reducing regulations at manufacturer
and wholesaler level would otherwise have decreased their income in 2004.
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For OTC drugs, pharmacies may now freely determine prices, with the
exception of those still reimbursed by sickness funds, listed among the Federal
Joint Committees exemptions. For SHI-reimbursed OTC preparations, the
previous price-regulations (valid from 2002 until December 2003) with
digressive margins still apply.
Statutory health insurance coverage of pharmaceuticals
The coverage of drugs in the SHI benefit basket is not a straightforward affair.
Unlike many other countries, Germany does not have a positive list of SHIreimbursable pharmaceuticals. The Health Care Structure Act of 1993 had
included a mandate for a positive list to be developed by the Federal Ministry
of Health. This regulation, however, was dropped only weeks before it was
supposed to be put into effect on 1 January 1996. The Federal Minister of
Health decided not to pursue the idea of a positive list and justified this by
citing the successful cost-containment measures in the pharmaceuticals sector,
the otherwise rising costs for chronic patients due to OTC purchases and, most
importantly, the threat to smaller pharmaceutical companies. While this decision
was welcomed by the pharmaceutical industry, it was criticized by both the
sickness funds and the Social Democratic Party. The SHI Reform Act of 2000
again introduced the mandate for a positive list, which the Federal Ministry
of Health, supported by an expert commission, consequentially submitted to
the Federal Council at the end of 2002. However, the opposition, having the
majority in the Council, threatened to reject the proposal. Following opposition
and government negotiations for the SHI Modernization Act, the ministrys
mandate for compiling a positive list was withdrawn again.
Until 2003, market entry for most drugs meant SHI coverage, but there were
a few but important exceptions that were gaining attention:
Drugs for trivial diseases (common colds, drugs for the oral cavity with
the exception of antifungals, laxatives and drugs for motion sickness) are
legally excluded from the benefits package for insureds over 18 years
(34(2) SGB V).
The Social Code Book allows the Minister of Health to exclude inefficient
drugs, that is, those not effective for the desired purpose or combined more
than three drugs, the effect of which cannot be evaluated with certainty (2,
12, 34(3) and 70 SGB V). The evaluation of these drugs takes into account
the peculiarities of homeopathic, anthroposophic and phytotherapeutic drugs.
A negative list according to these principles came into effect on 1October
1991, has been revised several times and contains about 2400 drugs. The
Federal Committee of Physicians and Sickness Funds published the brand
names for these substances.
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The coverage of drugs was also regulated in the pharmaceutical directives of

the Federal Committee, which are legally binding and limit the prescription
of some drugs to certain indications (for example, anabolics to cancer
patients), specify that they may only be used after failed non-pharmaceutical
treatments or in a few cases, disallow any prescription on the account of
sickness funds (for example, drugs to stop smoking).
In mid-1998, the Federal Committee amended its pharmaceutical directives
to exclude drugs for the treatment of erectile dysfunction or improvement of
sexual potency such as Viagra. The Committee argued that varying individual
behaviour does not allow the determination of a standard of disease upon
which to base economic considerations. In its opinion, the responsibility of the
sickness funds ends where personal lifestyle is the primary motive for using
a drug, thus so-called lifestyle drugs are excluded from the benefits package.
This case demonstrated that the criteria for exclusions were less explicit than
for medical technologies (see Health technology assessment), so that decisions
depend on consensus. Accordingly, the Federal Social Court disapproved of
the general exclusion of drugs for the treatment of erectile dysfunction and
instead demanded measures against their misuse. In early 1999, the Federal
Committee passed pharmaceutical directives explicitly stating that the licensing
of pharmaceuticals is a necessary but not sufficient precondition for SHI
coverage. Yet, following various court cases motivated by pharmaceutical
manufacturers, these regulations were never enforced with sanctions, but
were rather recommended as prescription guidelines and updated from time
to time.
Since 2004, the SHI Modernization Act has brought substantial changes to
the coverage by adding two other groups of excluded drugs:
So-called lifestyle drugs have been legally excluded from the benefit
catalogue. The Federal Joint Committee is responsible for defining the exact
extent of this regulation in its pharmaceutical directive.
OTC drugs may no longer be reimbursed by sickness funds except for
children below the age of 12. The task to define exceptions to this general
exclusion has also been delegated to the Federal Joint Committee which
lists OTC drugs and the indications for which they may be prescribed it its
pharmaceutical directive.
The addition of the two groups also affected the two negative lists (for drugs
for trivial diseases and inefficient drugs) and the work of the Federal Joint
Committee. While the two negative lists still exist, they are now considerably
smaller as they are only applicable for prescription-only drugs.
Another issue that has received increasingly attention is the prescription
and SHI coverage of drugs for off-label use, raising concerns about access to
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innovations as well as pharmacovigilance and liability. Generally, drugs not

licensed at all for the German pharmaceutical market or not licensed for the
respective indication may not be prescribed by any physician except under
clinical trial conditions. Sickness funds may not fund clinical research and
may basically not cover prescriptions of unlicensed drugs or for unlicensed
indications. The SHI Modernization Act took internationally a pioneering role by
introducing an expert committee to clarify rules for off-label use. The committee
is affiliated to the Federal Institute of Pharmaceuticals and Medical Devices
and consists of nominated representatives from the Institute, from scientific
medical societies, physicians associations, manufacturers, sickness funds, SHI
medical review boards, and representatives of pharmacists and patient interest
groups. Based on a jurisdiction from the Federal Social Court on criteria for
the access to off-label use drugs, the committee started with defining rules and
conditions for the prescription and SHI-financing of oncological medications
that are not yet licensed for the required indication.
Price regulation for pharmaceuticals covered by statutory health
insurance
Besides the price regulations along the distribution chain that apply to the entire
ambulatory pharmaceutical market, special regulations are in force for sickness
funds, as SHI constitutes the major customer in the pharmacy market. The main
instruments, which are described in turn, are: rebate, reference prices, aut-idem
substitution, and parallel imports.
Pharmacies are obliged to give a rebate, which was 5% until 2001 and was
increased to 6% in 2003. In addition, wholesalers and manufacturers also were
required to give a rebate to SHI since 2002. The rebates of 2003 for SHI from
manufacturers, wholesalers and pharmacists amounted to 3.1 billion or 11.6%
of pharmacy turnover and slowed down the growth of drug expenditures to 2%
but did not decrease overall drug expenditures, as expected (64).
The SHI Modernization Act modified the pharmacy rebate to a flat rate
of 2 per prescription-only drug. From 2005, the rebate will be negotiated
between the federal associations of sickness funds and the Federal Association
of Pharmacists Organizations. For those OTC drugs still paid by SHI (based
on the Federal Joint Committees exemption list), pharmacies have to give a
rebate of 5%. The rebate for manufacturers was transiently set at 16% for SHIcovered drugs in 2004 and contributed substantially to the savings generated for
sickness funds in that year. From 2005, it shall be reduced again to 6% which
is expected to re-induce a substantial increase of drug expenditures.
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Reimbursement of pharmaceuticals has been further regulated by reference

prices since 1989, as a means of exerting indirect price control. The reference
price system establishes an upper limit for sickness fund reimbursements, based
on 35 SGB V, which stipulates that reference prices be defined for drugs with
the same or similar substances or with comparable efficacy. While the Federal
Joint Committee is responsible for the identification and classification of drugs,
the federal associations of sickness funds do the actual reference price-setting.
Reference prices mean that sickness funds only reimburse pharmacies up to a
predefined ceiling and patients pay the difference between the reference price
and the market price. Between 1989 and 1992 no fixed fee co-payment had to be
paid on top of the price differential for the affected drugs. Since 1993 flat-rate
co-payments have to be paid on top of the price differential. It is noteworthy
that because of competition within the reference-price groups and the legal
obligation for physicians to inform patients that they are liable for the price
difference, very few drugs now exceed the reference price.
The Act to Strengthen Solidarity in SHI introduced tighter regulations for the
setting of reference prices, prohibiting them from being higher than the highest
price in the lowest third of the market. For 202 out of a total of 446 drug groups
with reference prices, prices were supposed to be lowered from 1 April 1999 for
a saving of approximately 280 million. However, this reduction was blocked
and reference prices altogether came under legal threat. The pharmaceutical
industry filed several court cases arguing that sickness funds were not authorized
to set (indirect) price controls for patented drugs by including them in the
reference price scheme. Therefore, the Federal Assembly passed the Reference
Price Adjustment Act to transfer the function of adjusting reference prices to
the Ministry of Health. Yet, the Federal Constitutional Court (December 2002)
and the European Court of Justice (early 2004) approved the sickness funds
role in influencing prices in the SHI market, as institutions acting in a publicly
delegated function.
The reference price scheme for pharmaceuticals proved to be an effective
measure for cost-containment. Because of patients attempts to circumvent copayments, demand for pharmaceuticals below the reference price ceiling has
increased, leading to increased competition in the pharmaceutical industry. The
industry has also partly compensated for the lower prices for drugs formerly
above the reference price with above-average increases for non-referencepriced drugs.
The annual savings for sickness funds from the reference price scheme
gradually increased from 1.2 billion in 1996 to 2.1 billion in 2002 (63). In
2003, 61% of SHI prescriptions and 37% of pharmaceutical expenditures were
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for drugs under the reference price scheme (40). The share of prescriptions and
turnover of reference price schemes varied by regional physicians associations,
with turnover ranging from 29% in Hamburg to 38% in the Pfalz region (65).
The Institute for Quality and Efficiency may support the Federal Joint
Committee and federal associations of sickness funds by classifying new
pharmaceuticals according to their degree of innovation and effectiveness with
comparative pharmaceuticals. If the efficacy or safety is superior to existing
drugs, manufacturers will continue to be free to set the prices without regulatory
interference. If they are equal to those of products already on the market, the
new product would be classified into the reference price system, that is, a
patent would no longer secure a reference-price free marketing period. Similar
legislation was abolished in 1996 due to pressure from the pharmaceutical
industry, and was blocked again, as part of the 12th Social Code Book V
Modification Act, by the Federal Council in April 2003 when the Act came
into force. In contrast to earlier government plans, price negotiations for truly
innovative drugs were not introduced; evaluation of drugs is not explicitly
based on cost-effectiveness (but on benefit) and will not provide the basis
for a yes-no decision on SHI coverage but rather on inclusion in the reference
price scheme. The first decisions of the Federal Joint Committee were taken in
July 2004 and enforced in August 2004, referring to statins, sartans, triptans,
and proton-pump inhibitors.
The Pharmaceutical Expenditure Limitation Act had obliged the members
of the Association of Research-Based Pharmaceutical Companies to pay a lump
sum of approximately200 million (the solidarity contribution) in 2003 after
industry had effectively protested against the planned reintroduction of reference
prices for certain patented drugs. Furthermore, the Act sought to promote the
prescription of generics by demanding an update of the price comparison lists
1992 prices.
Until 2001, pharmacists were allowed to substitute for prescribed
preparations only if the physician explicitly allowed or asked for it. The
Pharmaceutical Expenditure Limitation Act (February 2002), following the
lifting of the pharmaceutical budgets, obliged pharmacists to substitute (aut idem
regulation) lower-priced preparations unless the physician explicitly opposed
it. From July 2002 until April 2003, 184 of 680 generic substances (in 15542
preparations) were included stepwise into the aut idem regulation, accounting
for 35% of the prescriptions in the generic market and for 29% of the generic
market turnover (40).
In practice, these regulations for substitutions led to savings of only 48
million, since they mainly applied to the generic market, and the industry
influenced the (upper) price spectrum with dummies. Pharmacists, still receiving
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a percentage per package price, had no financial incentive to substitute.

Furthermore, the Contribution Rate Stabilization Act of 2002 introduced direct
negotiations between sickness funds and manufacturers for further rebates. Yet,
instead of the aspired nominal decrease of e1.4 billion, expenditures increased,
mainly due to the shift to other substances.
In response to these barriers, the SHI Modernization Act simplified the aut
idem regulation and linked it with the reference price system for those substances
for which substitution is possible. Products with replaceable active ingredients
are grouped and the substitution price line is calculated. Subsequently, the
reference prices for those drugs with replaceable active ingredients are amended
and automatically set below the substitution price line.
The Pharmaceutical Expenditure Limitation Act also obliged pharmacists to
generate at least 5.5% of their turnover in 2002 and 7.0% in 2003 by officially
listed parallel imports that can be sold at a lower price than the domestic
equivalent. Although the price difference between domestic products and parallel
imports is shrinking with increasing European Union price convergence, this
regulation is expected to create significant savings for the sickness funds. As a
first result, the market share of parallel imports increased significantly in 2002
(Table 25). In 2003, the turnover from re-imported drugs was 6.8%, ranging
from 5.7% in Bavaria to 8.9% in Berlin. The share of re-imported products was
20% of the turnover in the re-import market, ranging from 16% in the South
Wrttemberg region to 24% in Hamburg and the North Rhine region (65).
Spending caps
Spending caps of varying strictness were a prominent measure to contain
pharmaceutical expenditures from 1993 basically until 2001 (see Table 27).
Since 2002, spending caps have been abolished and replaced by negotiated
targets of cost-control and appropriate prescription. The new initiative is
supported by a long-overdue introduction of a uniform feedback system for drug
prescription, which came into operation for the use of individual ambulatory
physicians only in March 2003.
The spending caps, introduced in 1993, imposed a real reduction in
pharmaceutical expenditure, accounting for 13.7 billion in 1992 (West).
Based on the 1991 expenditure of 12.5 billion, it reduced future spending to
a maximum of 12.2 billion per year. From 1994 to 1997, every single regional
physicians association (West and East) was formally liable for any overspending
with no upper limit, even if total pharmaceutical spending remained below the
cap. At the same time as introducing the spending cap, the reform act imposed
a price cut of 5% for existing drugs not covered by reference pricing and a price
freeze for new drugs, applicable to 1993 and 1994.
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The result of all three cost-containment measures in the Health Care Structure
Act of 1993 i.e. a price moratorium, new cost-sharing regulations and the
expenditure cap in their first year of operation was a reduction of 18.8% in
sickness funds costs for pharmaceuticals. This figure represented a reduction for
the sickness funds of 2.6 billion from 1992s expenditure or 1.2 billion more
than had been required. Of these savings, around 0.5 billion was attributable
to price reductions. Almost another 0.5 billion was the result of the new
cost-sharing regulations. About 60% of the total reduction was attributable to
changes in physicians prescription behaviour. Physicians reduced the number
of prescriptions by 11.2% and increased their prescriptions for generics instead
of the original products.
Between 1994 and 1997, the spending cap levels were subject to regional
negotiations between the associations of sickness funds and the 23 regional
physicians associations in both parts of Germany. Regional caps were exceeded
in some of the 23 regions in 1994 even though national figures remained within
the total (hypothetical) spending cap. Some of the regions also exceeded the
1995 budget and therefore, in September 1996, the sickness funds instigated
proceedings to claim back money from nine regions which have overspent their
budget by up to 11.3%. The regional physicians associations resisted payment,
arguing that they could not effectively manage overall or physician-specific
drug expenditure, due to untimely and unspecified data. Despite the rises in
pharmaceutical expenditure in 1996 when nation-wide spending exceeded
the cap, leading to agreements in several states to even out the overspending in
coming years the spending cap proved to be an effective method of short-term
reduction and long-term modification of pharmaceutical expenditure (66).
With the Second SHI Restructuring Act, the regional spending caps for
pharmaceuticals were abolished from 1998 and were replaced by practicespecific target volumes. Physicians exceeding 125% of the prescription target
were required to compensate the respective sickness fund unless they could
document special requirements of the surgery (Praxisbesonderheiten)
including certain high-cost drugs and certain patient groups for example
patients requiring post-transplantation care or terminally ill patients. If
physicians could proof by documentation that prescriptions were necessary
from a medical point of view and prescribed at a possibly low price they could
evade sanctions altogether or reduce their amount. These prescription targets
for individual practices have basically been maintained since then while the
context for collective responsibilities for drug expenditures was amended by
subsequent reforms.
The Act to Strengthen Solidarity in SHI reintroduced regional spending caps
for pharmaceuticals at the regional level from 1999, initially strictly capped at
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a legally set limit (Table 27). Regional physicians associations became liable
for any over-spending up to 105% of the cap. As a kind of compensation,
debts resulting from the former spending cap were waived. To protest against
the reintroduction of collective liability, several physicians filed constitutional
complaints. The Federal Constitutional Court declined to debate their case
until the threat of collective sanctions for overspending a regional drug budget
had been realized. In fact, collective sanctions have never been executed due
to legal uncertainties to charge persons without individual infringement. Yet,
regional spending caps for pharmaceuticals continued to be met with substantial
resistance.
The Pharmaceutical Budget Redemption Act, enacted at the end of 2001,
re-abolished the legally required spending caps for pharmaceuticals and the
collective liability of physicians for exceeding the regional budgets. Despite
this, the regional physicians associations and the associations of sickness
funds are still required to negotiate a yearly budget and use target volumes
for individual practices. The contractual partners are requested to negotiate an
adequate level of drug budgets since otherwise they can be over-ruled by the
self-governance of statutory health insurance actors at the federal level and
finally by the Federal Assembly. According to the law, negotiations shall take
into consideration among others expected changes due to legal or negotiated
cost-containment measures, regional needs, and shifts in the market including
the entry of innovative drugs or generics. Sanctions for exceeding drug budgets
are not obligatory but the self-governingactors are free to make use of them as
a contractual component. The Act made the introduction of negotiated target
volumes for individual practices and related data management obligatory.
The associations of sickness funds which previously had insisted on regional
spending caps became now obliged to accept the target volumes and lately
to provide prescription feedback to SHI affiliated physicians.
As a first step toward achieving the individual target volumes, each
physicians association subtracts certain types of drugs and drugs for patients
with certain indications from the yearly gross budget. Subsequently it allocates
the remaining budget to different medical specialties, usually on the basis of
prescription volumes of the year before. In most regions the budget of each
specialty is again divided into two sub-budgets, one for the treatment of retirees
and non-retirees, based on the respective prescription volumes of the previous
year. These sub-budgets are finally divided by the number of cases of retirees
and non-retirees, resulting in a target of how much can be prescribed per retired
and non-retired person for each specialty. The targets for individual physicians
for the current year are calculated ex-post by multiplying the total number of
treated cases (retirees and non-retirees) for each physician by the target of each
specialty (66).
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Prescription controls and information

Physicians who exceed their individual target by more than 15% are advised in
written form to critically reconsider their prescription behaviour. The legal limit
for over-prescribing and paying-back has been set at 125% of the individual
target. Those physicians who exceed the target by 25% are asked to justify the
over-prescription. If their arguments are rejected, they are subject to recourse
and usually pay back the difference between the over-prescribed amount and
115% of the target. The amounts paid back by physicians are allocated to the
sickness funds according to the number of cases treated by the physician in
question. For example, in Berlin, 4% of all physicians exceeded their target by
15% to 25%, while 12% of all physicians exceeded their target by more than
25% in 2002. The recourse procedures usually take years. In Berlin for examples,
claim controls relating to prescriptions in 1998 and 1999 were accomplished
only in 2003. Overall amounts of 2.2 million (1998) and 2.4 million (1999)
have been claimed back by the sickness funds, representing 0.3% of the overall
pharmaceutical expenditure in Berlin (66).
Besides the (never realized) threat of collective sanctions and besides the
partly realized threat of individual sanctions for exceeding target volume
controls of individual physicians, two other types of prescription controls
influence physician behaviour: Regular efficiency controls based on a
physicians average amount of prescriptions and sickness funds reclaims from
individual physicians based on so-called other damage. The latter amounted
to 25 000 annually in recent years and refer mainly to the non-compliance with
the Pharmaceutical Directives of the Federal Committee for example due to
prescribing drugs excluded from the benefit catalogue or not licensed for the
respective indication (off-label use).
While controls were enhanced, physicians also received increasingly
prescription feed-back and information from their regional physicians
association, from sickness funds and through their accredited commercial
practice software. Together with the revised target volumes an early information
system was provided to physicians, containing a representative sample of
pharmacies in each region so physicians associations could forecast the
prescription volumes of certain specialist groups and individual physicians.
Those physicians who exceeded the target received the information as an
early warning. Since 2000, every SHI affiliated physician has been informed
about the real prescription behaviour of physicians in the region, based on a
federal information system about SHI-covered prescriptions, abbreviated as
GAmSI (65). Since 2003, they have also received three monthly overviews of
the aggregate prescription volume of their specialist group in the region and
their individual prescription volume. Thus physicians are able to adjust their
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future prescription behaviour according to the provided data. The prescription

feed-back system GAmSI monitors the attainment of negotiated goals. It is
based on indicators that have been agreed at federal level and have up to now
focussed merely on cost-containment purposes rather than on quality, safety
or equity: An increase in the share of prescriptions as well as turnover from
generics and parallel imports and a decrease in the share of disputed drugs and
me-too drugs. In addition, the share of special preparations reflects access
to high-cost drugs for certain diseases.
SHI expenditure and prescription behaviour
Table 25 shows that the above mentioned indicators and a few others have
changed substantially, already since 1992. While prescription volumes reflect
prescription behaviour as well as patients need, figures on SHI turnover
additionally reflect changes in the type and cost of drugs available in the
ambulatory drug market covered by SHI.
While the total number of prescriptions remained at a constant level or even
increased before the introduction of drug budgets in 1993, it clearly decreased
afterwards. The reason is to be found partly in larger packages, induced by
cost-sharing mechanisms (with the overall amount of prescribed daily doses
remaining stable), and partly in a decrease in prescriptions for drugs with
disputed effectiveness between 1992 and 2002. Physicians obviously amended
their prescription behaviour to the new situation due to budgets, sanctions and
prescription information as well as cost-sharing regulations for patients. They
differentiated between drugs of disputed and undisputed effectiveness.
In the period after the introduction of regional spending caps with collective
liability (1993 to 1997), the number of prescribed drugs was reduced at a
compound annual growth rate of -9.8% per year. In the second period of drug
budgets, from 1998 to 2001 allowing a substitution of spending caps by
target volumes with individual liability the number of drugs with disputed
effectiveness did not fall as much in nominal terms as in the first period, but
the yearly reduction according to the compound annual growth rate was even
higher, at -10.3%. In the third period of drug budgets allowing only target
volumes as budgetary regulation the number of prescribed drugs with disputed
effectiveness was again reduced by -7.6% in 2002 (66).
The discouragement of trivial and controversial drugs and the extension
of the negative list is reflected in an absolute and sector share decrease of OTC
between 1997 and 2001, mainly due to price decreases while the number of
packages sold remained remarkably stable throughout these years. A real price
stability for sales of physician-prescribed over-the-counter medications could
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Table 25.
Trends in prescription behaviour for SHI insureds and turnover

in the SHI-pharmacy market, 19922003
Prescriptions (million
packages)
Defined daily doses
(in billion per year)
Value per prescription ()
Disputed drugs
(% of all prescriptions)
Generic prescriptions
(% of potential generic
prescriptions)
Turnover (billion )
Disputed drugsa
Reimported drugsa (a)
Reference-priced drugsa
Genericsa
as % of potential
generic turnover
Ex-patented originalsa
Patented substances
(group A + B + C)a
Me-too preparations
(group C)a
Therapeutically relevant
substances (group B)a
Truly innovative
substances (group A)a
Special preparationsa
1992
1994
1996
1998
1999
2000
2001
2002
2003
1063
915
939
807
783
749
760
761
749
30
16
28
17
29
19
28
23
28
24
28
26
30
28
30
30
31
32
36
32
30
26
23
20
19
18
16
60
17.1
28
29
61
15.8
23
32
63
17.7
20
32
66
18.2
15
1.8
54
31
68
18.8
13
2.2
51
31
71
19.3
10
3.1
50
32
73
21.3
9
4.8
47
30
75
22.7
8
7.1
41
30
75
24.1
7
34b
30.3
44
62
48
66
51
49
56
41
59
40
64
36
66
31
68
32
68
31
12
19
28
29
32
39
38
39
10
15
16
17
19
20
19
11
3
3
5
8
8
12
7
13
8
15
9
15
10
17
11
18
Source: Nink & Schrder, 2004 (64); Schwabe, 2004 (69); (a) Association of Research-based
Pharmaceutical Companies, 2003 (63).
Note: a as percent of turnover in the SHI market for pharmaceuticals (excluding the negligible
turnover from handmade substances); b figure from July 2003.
also be observed from 1987 to 2001 (67), while other data indicate a decrease
in absolute terms from 4 to 3 billion (63).
The changed prescription behaviour of physicians and the following
reduction of drugs with disputed effectiveness also have a significant impact
on SHI expenditures. Data also reveal an increasing readiness of physicians to
prescribe generics, amounting to 75% of all potential generic prescriptions in
2003 (Table 25), one of the highest shares among EU countries and the OECD.
The tendency to prescribe more generics is also expressed in the increasing
turnover of generics as a percentage of their potential market (Table 25). Due to
new product launches, market segments with generic competition decreased, so
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that generic prescription as percentage of the total market remained at around

30% of turnover and even decreased in recent years (Table 25).
The presented results suggest that the introduction of drug budgets in 1993
was associated with decreased prescription of drugs with disputed effectiveness
and increased substitution of generics until 2001, a trend that did not go on
after the legally set spending cap was lifted. These savings were used to replace
former drug therapies by patented therapies, truly innovative substances (group
A), other therapeutically relevant substances (group B) and copies me-too
preparations with no or little additional therapeutic value (group C). Yet, the
shift toward patented substances came at the price of rising drug expenditures.
The value per prescription doubled to 32. The turnover from patented drugs
increased more than turnover from generics or savings related to the omission
of disputed drugs or to the substitution of ex-patented brands aut-idem or by
generics. Turnover from me-too preparations (group C) exceeded turnover from
therapeutically relevant innovations (group A and group B) except for the years
2000 and 2002 (Table 25).
Despite substantial improvement in appropriate and cost-efficient prescribing,
ideal efficiency reserves were estimated for 2002 at 4.1 billion which is 18%
of total SHI spending on ready preparations, of which 1.1 billion was for the
omission of or substitution for disputed drugs, 1.6 billion for the substitution
of analogous preparations of the cheapest brand or generic in the substance
category (group C) and 1.4 billion was for the prescription of 100% generics
(68). A similar overall amount of financial resources was calculated by the
Federal Association of SHI Physicians to be required for avoiding current
estimated under-provision with drugs for certain chronic and rare diseases.
Health technology assessment

Regulation and control of health technologies in Germany was not a major
issue in the past. Although German regulations, especially licensing for
pharmaceuticals (see Pharmaceuticals) and medical devices, meet international
standards, other types of technologies did not receive the attention they deserved.
Since the regulation of health technologies in Germany depends on the structure
and organization of the health care system, when analysing the status quo, the
health care sector, type of technology and the level of regulation have to be
taken into account. While certain aspects are dealt with in other sections as
well (especially regarding pharmaceuticals), a summary of the main issues
follows.
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Registration (Licensing) of medical devices

Since 1 January 1995, the Medical Devices Act (MPG), translating European
Union directives into German law, has been in effect. In conformance with
European Union directives 90/385 (concerning active implant devices such
as pacemakers) and 93/42 (medical products other than those active implant
devices and in vitro diagnostic devices), devices marketed in Germany must
meet the requirements of the Medical Devices Act. In contrast to drugs, medical
products and devices are defined as instruments, appliances, materials and
other products that do not produce their main effect in a pharmacological,
immunological or metabolic way. The licensing of medical devices is the
responsibility of authorized institutions (notified bodies), which require
accreditation through the Federal Ministry of Health. The safety and of technical
suitability of a device are the primary criteria for their market admission. As
opposed to drugs, medical devices do not need to prove that they are beneficial
in terms of potential health gain in order to be marketed. Devices marketed in
Germany are reviewed for safety, and for whether they technically perform as
the manufacturer claims (70).
The European Union Medical Devices Directive 93/42 established a four-part
classification system for medical devices. The rules for classification take into
account the risk associated with the device, its degree of invasiveness, and the
length of time it is in contact with the body. A devices classification determines
the type of assessment the manufacturer must undertake to demonstrate
conformance to the relevant directives requirements. Coverage decisions
about medical devices and mechanisms to steer their diffusion and usage differ
depending on whether they are used directly by patients (medical aids) or as
part of medical or surgical procedures in the ambulatory or hospital sector.
Statutory health insurance coverage of medical aids
Medical aids comprise devices directly used by patients, such as prostheses,
glasses, hearing aids, wheelchairs or respirators. As in care provided by allied
health professionals, insureds are entitled to medical aids unless they are
explicitly excluded from the benefit package through a negative list issued by the
relevant ministry. The Federal Ministry of Labour and Social Affairs (responsible
for SHI at that time) explicitly excluded aids with small or disputed therapeutic
benefit or low selling price (for example, wrist bands). The regulations for the
coverage of non-excluded medical aids are complex and therefore are only
briefly described. The federal associations of the sickness funds publish a
medical aids catalogue, which includes:
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a list of who may be entitled to SHI-paid medical aids

an alphabetical catalogue of all medical aids
a list of the medical aids that can be provided at SHI expense, as decided
by the federal sickness funds associations.
Since 2004 the federal associations are also responsible for selecting the
types of medical aids and prostheses that shall be submitted to reference
prices and define the price limits. Until the end of 2004, reference prices were
set at Lnder level and varied accordingly. Similarly to reference prices of
pharmaceuticals, sickness funds reimburse the cost of covered medical aids
up to the reference price for the specific type of aid. Similarly to reference
prices for drugs, physicians have to inform patients that they are required to
pay costs beyond a reference price limit for the respective type of medical aid
or prosthesis.
Diffusion and usage of medical aids and prostheses is regulated by the
Federal Joint Committee, which issues directives that limit the prescription of
medical aids to the following cases: assuring the success of medical treatment,
prevention of threatened health damage, preventing the health endangerment
of a child, and avoidance or reduction of the risk of long-term care.
Expensive medical devices
Agreements upon the diffusion of expensive medical devices (big ticket
technologies) and their distribution between the ambulatory and hospital sector
has been called a never-ending story. This judgement is the result of various
attempts of corporatist and legislative bodies to improve planning of expensive
medical devices in the light of increasing costs and new types of devices such
as extra corporeal shock-wave lithotripsy. Until 1982, when the Hospital Costcontainment Act came into effect, no regulations concerning expensive medical
devices existed. With this law, it became mandatory for expensive devices to be
subject to hospital planning. Devices that were not part of an agreement could
not be considered in the per diem charges and thus could not be refinanced.
In contrast, notified to the relevant physicians association was sufficient for
expensive devices in the ambulatory care sector. This unequal situation remained
essentially unchanged until the Health Care Reform Act of 1989.
Between 1989 and 1997, regional distribution of expensive medical
equipment for the SHI-covered population was controlled intersectorally by
state-level committees consisting of representatives of the hospitals, physicians
associations, sickness funds and a state representative, who negotiated aspects
of the joint use of devices by third parties, service requirements, population
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Table 26.
High medical technologies per million inhabitants, 19922001
Computed
tomography
ambulatory sector
hospital sector
Magnetic
resonance imaging
ambulatory sector
hospital sector
Positron emission
tomography
ambulatory sector
hospital sector
Coronary
angiography units
ambulatory sector
hospital sector
Lithotripter (hospital
sector)
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
10.4
3.7
7.3
12.9
4.7
8.2
14.7
6.1
8.6
15.6
6.7
9.0
16.4
6.9
9.5
17.1
7.5
10.0
11.0
11.7
12.7
13.3
2.6
1.4
1.2
3.6
2.2
1.4
4.1
2.3
1.8
4.8
2.6
2.3
5.7
2.9
2.8
6.2
3.0
3.2
3.7
4.4
4.9
5.5
0.07
0.12
0.16
0.21
0.01
0.20
0.26
0.30
0.04
0.28
0.44
0.46
3.1
3.4
3.8
4.1
0.4
3.8
4.4
4.7
0.6
4.1
5.4
5.1
1.6
1.7
1.8
1.9
2.0
2.2
2.5
2.8
3.0
3.3
Source: OECD Health Data, 2004 (2); Federal Statistical Office 2002 (11).
density and structure, as well as the operators qualifications. After the Health
Care Structure Act of 1993, the Minister of Health could determine which
devices fell under the committees auspices ( 122 SGB V), but did not do so
and the committees defined expensive medical equipment. On 30 June 1997,
the following devices fell within this definition in almost all states: left heart
catheterization units, computer-tomographs, magnetic resonance imaging
devices, positron-emission tomographs, linear accelerators, tele-cobalt-devices,
high-voltage therapy devices and lithotripters. The 2nd SHI Restructuring Act
abolished the committees effective July, 1997; thus the self-governing bodies are
obliged to guarantee the efficient use of expensive equipment via remuneration
regulations. In effect, this has led to even steeper increases in the number of
expensive medical devices (at least in the hospital sector for which data are
available), since previous site-planning procedures have been annulled.
Table 26 shows the increase in capacities of expensive diagnostic and
therapeutic medical technologies before and after the abolishment of intersectoral
planning of high technologies. Besides increasing capacities in hospital care, a
high density is also found in ambulatory care, reflecting the density of specialists
in secondary ambulatory care in private surgery whose technology investments
Germany
157
are depreciated by reimbursement from statutory and private health insurers

or private households via recurrent services. In the early 1990s, the density of
magnetic resonance imaging was even higher in the ambulatory sector than in
the inpatient sector.
Ambulatory medical treatment
The regulation of access to medical interventions and technologies in the
ambulatory care sector is delegated to joint committees of SHI affiliated
physicians and sickness funds at federal level. Since 2004, the responsible
coverage body is the Federal Joint Committee and its Committee on Ambulatory
Care (see Planning, regulation and management). This Committee has several
sub-committees, one of which is responsible for assessing reimbursable medical
technologies. The predecessor of this was the for Federal Committees Working
Committee on New Diagnostic and Therapeutic Procedures which decided
on the effectiveness of new technologies. Since 1 July 1997, it had also been
responsible for the evaluation and re-evaluation of technologies that were already
covered by statutory health insurance in ambulatory physician care. Until 1997,
the Working Committee worked according to a set of criteria outlined by the
Federal Committee of Physicians and Sickness Funds. New technologies could
only be proposed when they were perceived to be necessary from a physicians
point of view and when enough data were available for their evaluation. The right
to propose was confined to the regional physicians associations, the Federal
Association of SHI Physicians and the federal associations of sickness funds.
Approval required at least one randomized controlled trial, case-control
study, cohort study, or two from the following: time series comparisons, noncontrolled clinical trials, studies showing a change in relevant physiological
parameters, or expert statements based on scientific evidence. This system could
be influenced by a number of factors, not necessarily based on sound scientific
evidence, but rather on interest and opinion. After critiques concerning the
existing procedure and the extension of the committees mandate to evaluate
existing technologies, new directives were passed in October 1997. They were
reviewed in 2004 and now relate not only to services provided by physicians
but also by psychologist psychotherapists, requiring that evaluations be
based on criteria of benefit, medical necessity and efficiency. In addition, the
Sub-Committee on Medical Procedures of the Federal Joint Committee now
performs an explicit prioritization of technologies to be evaluated. The results
are announced publicly and medical associations and possibly individual
experts are invited to submit evidence concerning the three mentioned criteria.
The Sub-Committee then examines the quality of the evidence presented by
the applicant, the medical association(s) and individual experts as well as the
Germany
158
results of its own (literature) searches. Therapeutic procedures were classified

according to five categories following internationally recognized schemes of
evidence-based medicine:
I
randomized controlled trials
IIa other prospective studies
IIb well-designed cohort or case-control studies
IIc temporal or regional comparisons
III other studies and opinions.
Diagnostic procedures are arranged in four categories:
Ia studies demonstrating a benefit in patient outcome
Ib controlled study under routine conditions, allowing the calculation of
sensitivity, specificity and predictive value
II other studies allowing at least the calculation of sensitivity and
specificity
III other studies and opinions.
For both classes of procedures, at least one study with level I evidence is
necessary. Somewhat illogically, however, lower evidence is still accepted for
existing technologies if no level I evidence was available.
Based on the more or less evidence-based assessment of the evidence, the
Federal Joint Committees Sub-Committee on Medical Procedures recommends
whether the technology should be included in the SHI benefit package. In
addition, its predecessor took another type of decision in 2001, when it
concluded that evidence for the efficacy, safety and everyday effectiveness
of acupuncture was not sufficient to decide on SHI coverage, but that a
comprehensive evaluation of these in relation to chronic low back pain, chronic
headache and chronic painful arthrosis of large joints was required. While SHI
may not finance clinical efficacy research, many sickness funds consecutively
launched three major acupuncture pilot projects to evaluate the three indications
on an ongoing basis.
Once a positive decision has been taken to include a technology into the
benefit catalogue of ambulatory physician care, another joint committee at federal
level determines reimbursement issues and requirements for physicians who
want to want to claim reimbursement for the delivery of this technology from
statutory health insurance. This Valuation Committee consists of representatives
from sickness fund associations and the Federal Association of SHI Physicians.
It is charged with determining the relative value of a technology compared to
other technologies in the Uniform Value Scale. Another important task of the
Valuation Committee is the exact definition of a technology and its indications
Germany
159
for use. However, currently only a few of all procedures listed in the Uniform
Value Scale are indication-specific. The committee also determines requirements
that physicians have to fulfil to be eligible for claiming reimbursement, i.e.
specialist qualifications, additional qualifications, technical safety standards,
target groups, frequency of delivery, or documentation requirements.
A re-evaluation of an existing technology may be initiated when frequency
statistics provide evidence for over-utilization or under-utilization of services,
in which case the service in question may be devalued financially in order to
rebalance utilization rates by incentive. In the Valuation Committee, financial
interest and intra-professional distribution conflicts can play a dominant role.
The fee distribution system of the physicians associations partly led to outcomes
unintended by the Federal Committee.
Hospital treatment
Until recently, the introduction of new procedures and technologies was
managed by individual hospitals in the context of budget negotiations with
sickness funds or of applications for capital investment from the Lnder. In 2000,
the then new Committee for Hospital Care was charged with decision-making
on hospital coverage based on health technology assessments. In contrast to its
counterpart for the ambulatory sector, which decides on benefit inclusions and
exclusions, it had to decide only on benefit exclusions. Until 2004 the committee
took only few decisions, affecting mainly rare services. Since 2004, these tasks
are performed by the Hospital Care Committee of the Federal Joint Committee.
The introduction of DRGs as a de facto payment requires a positive definition
of reimbursable benefits. As long as innovations are not integrated into the DRG
system under special reimbursement rules, the reimbursement of innovations
continue to be subject of contracts between individual hospitals and sickness
funds. The demand for sound and rapid assessment of health technologies,
especially of innovative and high cost technologies, is therefore expected to
increase substantially. The SHI Modernization Act stipulates that the Institute
for Quality and Efficiency shall provide evidence at the request of the Federal
Joint Committee or the Federal Ministry of Health.
Discussion
There are still inconsistencies in the various health care sectors with regard
to coverage decisions and the managing of diffusion and usage of health
technologies in Germany. In general, the ambulatory sector still appears to be
much more regulated than the hospital sector. Services provided by allied health
Germany
160
professionals, such as physiotherapy, are explicitly excluded by the government

or are covered through collective contracts.
One initiative, funded by the Federal Ministry of Health, stimulated HTA
activities in Germany from the viewpoint of decision-making at the federal and
corporatist level. As a result of this initiative, the German Scientific Working
Group on Technology Assessment for Health Care produced a set of HTA
reports. The SHI Reform Act of 2000 charged the German Institute for Medical
Documentation and Information (DIMDI) with establishing a database of
relevant HTA results and supporting decision-making processes by the Federal
Committee and other actors.
The establishment of the Institute for Quality and Efficiency in 2004 provides
a further step towards the timely and coordinated use of health technology
assessment and evidence-based medicine. It is to commission health technology
assessments and make recommendations for the inclusion of technologies
in the SHI benefit package, but has no decision-making powers. Decisionmaking on benefit inclusion is performed by the plenary group of the Federal
Joint Committee or one of its five committees (see Planning, regulation and
management). The institute may, but does not have to, delegate tasks in health
technology assessment to the German Institute for Medical Documentation
and Information.
Germany
Financial resource allocation
Third-party budget setting and resource allocation
he German system of health care finance is characterized by multiple

sources, decentralized negotiated allocation and refined, performanceoriented incentives, differing between the ambulatory and inpatient
sectors. The overall flow of finances is outlined in Fig. 15; most of it has been
addressed in previous sections. The main sources of finance are summarized in
Table 9 and discussed in the chapter Health care financing and expenditure. The
pooling of resources and redistribution among sickness funds is discussed in the
section Main source of financing. In 2003, for example, 10.9% of statutory health
insurance revenues were redistributed among funds (Table 11). SHI budgetsetting will be discussed in further detail below (Table 27), while trends in the
allocation of resources by sector have been addressed in the section Health care
expenditure (Table 16). The payment of pharmaceuticals and medical aids has
been discussed in the respective sections of the chapter Health care delivery.
The last end of the flow of finances, the methods of provider payments and
service purchasing are discussed in further detail in the sections below.
Germany does not have one budget for health care. Instead, (the few)
resources available for health care are derived from different ministries. The
same applies to the 16 Lnder. In addition, sickness funds, currently 292, operate
their own budgets autonomously, not counting other social insurance budgets,
or reimbursement through private health insurance companies etc. All tax-based
budgets, at federal as well as Lnder level, are determined by legislatures acting
on proposals from their governments. On the federal level, health care-related
financing is part of the budgets of the Ministries of Health, Defence (military
health care), Interior (police officers and permanent public employees) and
Education and Research. On the Lnder level, health-care financing mainly
Germany
162
Fig. 15.
Financing flow chart of the German health care system, 2002

Voluntary private
Reimbursement of patients
Private health and

long-term care insurers
insurance
premiums 8.4%
Contributions
Payment to providers
Statutory sickness funds
56.9%
Contributions
Payment to providers
Stat. long-term care funds
7.0%
Federal and state

governments
General taxation
7.9%
Investment and
Public health services 0.8%
salaries
Population and
employers
Patients
(+ private nonprofit organizations)
Fee for service

Per diems
Nursing homes 6.9%
12.3%
Co -payments and non reimbursed health expenditure
Ambulatory nursing care

providers 2.7%
Investment
Investment
Acute public, private

non-profit and private
for profit hospitals
27.2%
Per diems, case plus

procedure fees, DRGs
Per diems, case plus
procedure fees, DRGs
Prices
Pharmacies 13.8%
Fee for service
Dentists 6.3%
Ambulatory
care physicians
13.4%
Fee for service (via Dentists associations)

Fee
for
service
Physicians
associations
Mainly
capitation
Fee for service
Source: own compilation based on Federal Statistical Office (12).

Note: Sources of finance not presented in the chart: employers, 4.1% of total expenditure on
health; statutory retirement insurance, 1.8% and statutory accident insurance, 1.7%. Providers
not presented: practices of non-physicians, 2.6% of total expenditure; health sector trade
handicraft, 7.0%; other ambulatory providers, 0.5%; preventive and medical rehabilitative
care institutions, 3.2%; occupational and social rehabilitation providers, 0.6%; transportation
providers, 1.0%; administration, 5.8%; investments, 2.8% and all other providers, 5.0%.
Germany
163
flows from the budgets of the Ministries of Health and Science; the ministries
of interior is involved in the provision of emergency care. The health ministries
cover, for example, capital investments for hospitals which vary greatly among
Lnder (see below) as well as public health services. The science ministries
are responsible for investments, research and medical and dental education at
university hospitals (see Taxes).
Sickness funds do not have fixed predetermined budgets, but have to cover all
the expenses of their insureds. They may not incur deficits and do not generally
receive tax subsidies (except minor ones for elderly farmers and artists and for
so-called non-insurance benefits such as maternity care, since 2004). Sickness
funds carry full financial liability. If expenditures exceed revenues in a given
years, sickness funds are obliged by law to increase their contribution rate, a
decision for which they have autonomy by law (see Main sources of financing).
Only if a fund runs into severe financial problems which threaten its viability,
its respective association is obliged to support it financially.
As mentioned in the section Historical background, the main political goal
in health policy has been to restrict the sickness funds expenditure to a level
where it matches income (or more precisely to limit expenditure growth to
the rate of growth of contributory income in order to keep contribution rates
stable). To that end, sectoral budgets or spending caps were introduced at the
end of the 1980s (Table 27).
Several issues should be kept in mind with respect to resource allocation:
All these SHI budgets are on the providers side, not the payers side.
While some budgets de facto also limit the expenditure of individual funds
(for example, capitation payments to the regional physicians associations
for ambulatory care), others do not have nor intend to have that effect,
since, for example, expenditure under a hospital budget or a pharmaceutical
spending cap is divided between funds according to the actual utilization of
their members. In addition, if private patients are also taken into account,
then the providers budgets are not budgets in the strict sense.
The budgets are based on historical expenditure patterns and not on needsbased formulas. To the end of limiting expenditure, growth rates were limited
by law, or budgets and spending caps were based on actual expenditure
in a previous year (often the year before the legislative act, so as to avoid
any changes after proposing or passing the act). In either case, regional
differences in expenditure remained untouched. The public discussion mainly
concerned caps on pharmaceutical expenditures.
Collective contracting remains the dominant form of purchasing in SHI
ambulatory and long-term care. In 2003, the government had planned to
introduce selective contracting for all ambulatory physician specialists,
Germany
164
Table 27.
Cost-containment through budgets and spending caps, 19892005

Ambulatory care
1989 to
1992
negotiated
regional fixed budgets
Hospitals
negotiated
target budgets at hospital
level
legally set
1995
1998
negotiated regional
spending caps
negotiated regional
fixed budgets
(target volumes
negotiated
target budgets at hospital
level
for individual practice)a

1999
2000
2001
or spending cap
legally set
fixed budgets
at hospital level
1996
1997
no budget
legally set
national spending cap
1993
1994
Pharmaceuticals
negotiated target volumes

for individual practices
legally set regional
spending caps
negotiated regional
spending caps
fixed budgets
negotiated target
budgets
at hospital level
with legally set limit
negotiated regional
spending capsb
legally set
legally set target

budgets at hospital
levelc
negotiated target volumes
negotiated regional
2002
2003
for individual practices

2004
2005
negotiated regional fixed negotiated target

budgets
budgets at hospital
level
at regional level
Note: The darker the background, the more strictly regulated the sector.
a
legally, but not implemented (1997 status was kept);
b
due to the ministerial lifting of spending caps in January 2001, they did not exist for 2001;
c
except for hospitals introducing DRGs already on a voluntary basis.
but this was rejected by the opposition and the medical profession. The
SHI Modernization Act has introduced selective contracting with selected
providers within the framework of family physician and integrative care
models.
Germany
165
Payment of hospitals
Since 1993, and more dramatically since 2004, the German hospital sector has
experienced considerable changes due to fixed budgets, the possibility of deficits
and profits, the introduction of prospective payments methods and increased
opportunities to offer ambulatory treatment. From January 2004, the German
modification of the Australian DRG system is the sole system of financing
recurrent expenditures of acute hospitals except especially for psychiatric care
and certain defined services. It replaces the mix of reimbursements per diem,
per case (mainly elective surgery) and for expensive procedures that existed
between 1993 and 2003.
Investments and planning
Since the 1972 Hospital Financing Act, hospitals are financed by two different
sources: dual financing means financing investments through the Lnder
and running costs through the sickness funds (plus private health insurers).
In order to be eligible for investment costs, hospitals have to be listed in the
hospital plans set by the Lnder. These plans also list the specialties which are
necessary, and even the number of beds per specialty for every hospital. The
numbers of hospitals and beds are planned at a trilateral committee consisting
of representatives from state government, hospitals and sickness funds. The
sickness funds have to contract with any hospital accredited in the hospital plan.
In general sickness funds only pay for acute services of plan-listed hospitals or
university hospitals. With the listing in the hospital plan comes the right to be
paid by sickness funds, although not coverage of full costs.
Investments are in principle covered through taxes and are thus not contained
in the reimbursement. Investments in long-term assets require a case-bycase grant measure and are classified as: construction of hospitals and initial
procurement or replacement of other assets. According to the Hospital Financing
Act, a hospital acquires a legal claim to subsidy only insofar and as along as it
is included in the hospital plan of the Land. The inclusion in the hospital plan
means, on the one hand, that there is a claim to a flat-rate grant for short-term
assets (315 years economic life), and on the other, that the sickness funds
have to finance the hospital care provided by the hospital. It is noteworthy that
listed hospitals do not have a right to have the financing of specific investments
secured. That depends also on the budgetary situation of the responsible ministry
and on political decisions.
Should a hospital not be included in the hospital plan, it still has the
possibility to contract with sickness funds, but no claim to Land investment
Germany
166
financing. Hospitals not fully publicly subsidized can, within a very narrowly
defined framework, refinance investment costs via sickness fund reimbursement
(25).
The share of public investment in hospitals has decreased continuously from
0.24% of GDP in 1992 to 0.15% in 2002, with roughly two thirds spent in the
the western part and one third in the eastern part. Hospitals in the western part
received in average 0.19% of the western GDP in 1991 and 0.12% in 2002.
During the same period, hospitals in the eastern part received comparably
more of the eastern GDP (0.90%0.39%) due to higher grants from the
federal government to upgrade the infrastructure of inpatient facilities, per the
reunification treaty (see Historical background).
Approaches to hospital plans, capacities and investment vary widely among
Lnder (Table 28). Between 1991 and 2001, Berlin reduced its highest-percapita bed numbers by more than 40%, and Mecklenburg-Western Pomerania
reduced its capacities from slightly above to well below average. On the other
hand, due to only modest reductions, Bavaria has moved from well below
average to slightly above per capita, and Bremen and Hamburg have stayed
well above the average.
In international data, preventive and rehabilitative institutions are often
included in hospital data. These institutions, however, are not listed in hospital
plans and receive no Land investment, and have to rely solely on reimbursement
through negotiated contracts (monistic financing).
Recurrent expenditures and cost-containment measures
Sickness funds finance operating costs including medical goods and all
personnel costs, as hospital physicians are salaried employees. They also finance
the replacement of assets with an average economic life of up to three years
or maintenance costs unless parts of the building, operational facilities, and
fittings or external facilities are completely or largely replaced. To cover the
operating costs, wherever possible the individual hospital agrees a budget in
advance for one calendar year with the Lnder associations or representations
of the sickness funds. The heads of medical departments usually have the right
to charge private patients for medical services on top of the hospital charges.
Patients are required to contribute 10 per day for a maximum of 28 days,
mainly for covering part of the hotel services.
Until 1992, the full cost cover principle meant that whatever the hospitals
spent had to be reimbursed. The actual remuneration was done through per-diem
charges retrospectively calculated by the Lnder for each hospital. However,
within each hospital all per diems were equal. The original Hospital Financing
Germany
Table 28.
167
The German Lnder hospital bed numbers 19912001 and capital

investment 2001
Land
Baden-Wrttemberg
Bavaria
Berlin
Brandenburg
Bremen
Hamburg
Hesse
Mecklenburg-Western
Pomerania
Lower Saxony
North Rhine-Westphalia
Rhineland-Palatinate
Saarland
Saxony
Saxony-Anhalt
Schleswig-Holstein
Thuringia
GERMANY
General and psychiatric beds

per 1000 population
(ratio to German average)
1991
2001
6.97 (0.84)
6.04 (0.90)
7.63 (0.92)
6.74 (1.01)
11.57 (1.39)
6.68 (1.00)
8.95 (1.08)
6.22 (0.93)
10.66 (1.28)
9.17 (1.37)
9.16 (1.10)
7.38 (1.10)
7.53 (0.91)
6.34 (0.95)
8.39 (1.01)
7.51 (0.90)
9.19 (1.10)
7.65 (0.92)
8.80 (1.06)
9.06 (1.09)
8.98 (1.08)
6.90 (0.83)
8.79 (1.06)
8.32 (1.00)
6.33 (0.94)
6.02 (0.90)
7.47 (1.11)
6.56 (0.98)
7.07 (1.06)
6.76 (1.01)
7.02 (1.05)
5.87 (0.85)
7.15 (1.07)
6.70 (1.00)
19912001
-13.3%
-11.7%
-42.3%
-30.5%
-14.0%
-19.4%
-15.8%
Capital
investment
in / bed
2001
5 296
7 688
7 737
10 239
4 628
7 933
5 265
-24.6%
-19.8%
-18.7%
-14.2%
-19.7%
-25.4%
-21.8%
-14.9%
-18.7%
-19.5%
11 301
4 793
3 444
5 416
5 716
10 085
10 512
4 693
10 988
6 130
Change
Source: Federal Statistical Office 2003 (52); last column from German Hospital Association,
2004 (71).
Act remained the main legal basis for the hospital sector until 1992 and was
hardly affected by federal cost-containment policies. This was partly due to
the power of the federal states, which had to agree to all decisions affecting
hospitals. Thus, only minor legislation on hospital services was included in the
Health Insurance Cost-containment Amendment Act of 1981, restricting postnatal hospital stay to six days except in the case of medical need, and requiring
hospitals to agree with ambulatory physicians on purchases of large (high
cost) medical technology (see Health technology assessment). The Hospital
Restructuring Act of 1984 introduced negotiated per-diem charges based on
expected costs. Coverage of excess costs was limited de jure, but hospitals
received de facto full compensation through charge adjustments. In addition, the
Act opened up the possibility of including capital costs in per-diem charges if
investments would lower running costs in the medium or long term. From that
time onwards, dual financing also meant dual planning, with the number
of hospitals and hospital beds planned at Land level, while staff numbers and
hospital day numbers were subject to per-diem charge negotiations between
hospitals and sickness funds.
Germany
168
Since the Health Care Reform Act of 1989, hospital and sickness fund
associations have been obliged to negotiate contracts concerning quality
assurance. In addition, the sickness funds gained the right to contract with
additional hospitals and to drop or terminate a contract with a hospital. The
latter process is, however, complicated and therefore happens rarely since
first, the funds have to agree to do it jointly and second, it needs the approval
of the Land government.
The Health Care Structure Act of 1993 was the first major cost-containment
law to affect the hospital sector. This reform was possible since the Social
Democratic Party, which was the opposition in the Federal Assembly but the
ruling party in most states at that time, had agreed to it. The hospital sector
was affected by several new regulations. First of all, increases in sickness fund
expenditure for inpatient treatment were tied to the increase in contributory
incomes for 1993 to 1995. To facilitate this, the full cost-cover principle was
abolished, so the hospitals were allowed to make both profits and run deficits,
and fixed budgets were calculated for each hospital (for budgets see below). The
budgets growth rates were to be based on estimates published in advance by the
Federal Ministry of Health, and retrospectively adjusted for the actual growth
rate. In addition, however, the law allowed several exceptions for higher growth
rates that led to expenditure increases well above what was intended. Second,
nursing time standards were introduced (see Human resources and training).
Since it was calculated that new nurses would have to be employed as a result
of this innovation, a budget exception was allowed. Hospitals were allowed to
offer ambulatory surgery and inpatient care for a few days before and after the
inpatient treatment (see Health care delivery system). The incentives for these
services were initially weak, however, since remuneration was included in the
fixed budgets.
Due to above-average increases in hospital expenditure until 1998, this sector
has been a policy concern for a long time. While expenditure per bed and day
has continued to rise, expenditure per case actually declined in the late 1990s,
indicating that technical efficiency is likely to have increased (Table 29). The
East/West ratios of hospital utilization in Tables 18 and 19 are further indicators
that the health care system in the eastern part has been rapidly assimilated. Yet,
in recent years, hospital expenditures have hardly increased due to legally set
limits for the target budgets. In 2003, budgets were even frozen at 2002 level
except for hospitals which used the option to introduce DRGs already in 2003
and, to a certain degree, for those who introduced working time models to keep
to the European Court rule and corresponding German legislation for on-call
shifts for health care personnel.
Germany
Table 29.
169
Expenditure data for general and psychiatric hospitals in western and

eastern parts of Germany, 19912001
Expenditure/ bed
West
Expenditure/ day
East
E/ W
ratio
0.50
Expenditure/ case
E/ W
ratio
Westa
Easta
E/ W
ratio
199
114
0.60
2 849
1 833
0.64
0.64
219
+10.0%
157
+37.3%
0.72
3 032
+6.5%
2 210
+20.5%
0.73
0.73
236
+7.8%
187
+19.2%
0.79
3 120
+2.9%
2 429
+9.9%
0.78
0.82
250
+6.1%
214
+14.6%
0.85
3 188
+2.2%
2 614
+7 6%
0.82
0.85
269
+7.6%
233
+9.2%
0.87
3 281
+2.9%
2 729
+4.4%
0.83
0.86
284
+5.4%
246
+5.6%
0.87
3 260
0.7%
2 758
+1.1%
0.85
256
+3.8%
2 755
0.1%
0.86
West
East
1991
62 309
31 160
1992
68 232
+9.5%
43 571
+39.8%
1993
72 158
+5.8%
52 708
+21.0%
1994
75 477
+4.6%
61 672
+17.0%
1995
80 569
+6.7%
68 249
+10.7%
1996
83 368
+3.5%
71 834
+5.3%
1997
85 624
+2.7%
75 174
+4.7%
0.88
291
+2.5%
0.88
3 218
1.3%
1998
88 395
+3.2%
78 955
+5.0%
0.89
296
+1.8%
263
+2.7%
0.89
3 187
1.0%
2 747
0.3%
0.86
1999
91 181
+3.2%
81 218
+2.9%
0.89
306
+3.3%
269
+2.4%
0.88
3 191
+0.1%
2 731
0.6%
0.86
2000
93 769
+2.8%
84 343
+3.9%
0.90
315
+3.1%
278
+3.3%
0.88
3 207
+0.5%
2 762
+1.1%
0.86
2001
97 400
+3.9%
87 743
+4.0%
0.90
332
+5.3%
292
+5.2%
0.88
3 269
+2.0%
2 823
+2.2%
0.86
Average rate
of change
19912001
+4.3%
+10.9%
+5.3%
+10.3%
+1.4%
+4.4%
Source: calculation based on Federal Statistical Office, 2003 (55).

Note: a in e and % change to the previous year.
The mix of payment methods

As of the year 1993 hospital services were reimbursed by a two-tier system of
per diem charges: the first component consisted of a hospital-specific basic per
diem covering non-medical costs and a department-specific per diem covering
medical costs including nursing, pharmaceuticals and procedures. The second
component was made mandatory as of 1996: case fees (covering the costs for a
patients entire hospital stay) and procedure fees (paid on top of slightly reduced
per diems) were introduced in order to get a more performance-related payment
method for hospitals. However, case fees and procedure fees accounted for the
reimbursement of less than one quarter of all hospital services until 2002.
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170
Case fees were based on a combination of a certain diagnosis (4-digit ICD-9,

partly separated into elective and emergency) and a specific intervention
(for example, open appendectomy received a case fee different from that for
laparoscopic appendectomy). The case fees were unevenly distributed among
specialties: On the one hand, there were none for medical, paediatric and
psychiatric patients, and on the other hand, more than 50% of gynaecology and
obstetrics cases and approximately two thirds of ophthalmologic cases were
reimbursed via case fees. Procedure fees were only based on an intervention
and more than one procedure fee could be remunerated per case. The more than
70 case fees and the almost 150 procedure fees were originally set through an
ordinance by the Federal Ministry of Health, while the monetary conversion
factor was negotiated at Land level. However, when the number of points was
fixed by the ministry, it assumed a point value of approximately 0.50.
Case fees, procedure fees and per diem charges were all part of the budget
for each particular hospital. These German-style budgets were not budgets in
the sense that the hospital would get an amount of money independent of actual
activity. Instead, the budgets were targets established during the negotiations
between the sickness funds and the hospital until 2003, establishing service
numbers for cases to be reimbursed by case and procedure fees and per diems,
as well as the rate of the latter. If the hospital reached exactly 100% of its
target activity then no financial adjustment had to be made; if actual activity
was higher than the target, it had to pay back a certain part of the extra income
50% of case fees for transplantations, 75% of other case and procedure fees
and 8590% of per diems. In other words, activities above the target were only
reimbursed at 50%, 25% and 1015% respectively. If actual activity was lower
than the target, the hospital received 50% of the difference until 1999, and 40%
of the difference from 2000. This sum was divided according to utilization
among the funds, i.e. actual case fees, procedure fees and per diems are then
higher than originally negotiated.
The introduction of prospective case payments in conjunction with hospital
budgets was expected to induce an increase in technical efficiency and possibly
encourage risk selection by avoiding admission of patients in need of complex
care and early referrals or discharges. Scientific evidence is rather scant with
respect to the impact of the payment method mix on the quality of care. There
is evidence that the overall technical efficiency of the hospital sector improved
after the introduction of appropriate measures: average length of stay decreased
from 13.9 days in 1992 to 12.1 days in 1995 and more substantially from
1996, when case fees were introduced, to 9.8 days in 2001. Despite substantial
decreases in East as well as West German hospitals (Table 18), patients still
stayed a relatively long time in German hospitals in 2001 (Table 20). As Table18
shows, the overall average length of stay decreased during the whole period
Germany
171
covered and was particularly pronounced in the years in which fixed hospital
budgets (1993) and prospective case fees (1996) were introduced. Table 29
shows that costs per case decreased in the period 19961998; however, nothing
can be said about the important question of whether the quality of the output
measure (cases) remained constant. There is some evidence that patients
were transferred more frequently and earlier to rehabilitation clinics and that
costly patients were transferred more frequently to university hospitals, which
themselves have virtually no possibility to transfer costly patients. The average
length of stay decreased disproportionately more in departments where case
fees were applied.
By the end of the 1990s, the existing case payment method with its lack of
risk adjustment and its inherent (though not conclusively documented) incentive
for risk selection came to be regarded as an insufficient basis for expansion
to other, more complex fields of care. Also, the ongoing coexistence of case
payments, fee for special services and per diems was regarded as a barrier to
further efficiency since hospitals could compensate the financial disadvantages
of one payment method by combining it with another.
DRG payment
The governments intention in 1992 to gradually extend the scope of services
reimbursed via case fees to 100% per cent was not realized. The introduction of
a new payment system based on diagnosis-related groups (DRGs) was the most
important reform in the hospital sector since the introduction of the dual hospital
financing in 1972. The SHI Reform Act of 2000 obliged the self-governing
bodies (the German Hospital Organization and the associations of the statutory
sickness funds and private health insurers) to select a universal, performancerelated prospective case fee payment system that takes into account the clinical
severity (case-mix) based on DRGs. It defined the basic characteristics of the
German-type of DRG payment system for acute hospitals: DRGs cover 100%
of (recurrent) cost, are paid by uniform flat-rates and are applied to all services
in acute hospitals with the major exceptions of psychiatry and psychosomatic
medicine. The Act outlined a stepwise approach to making DRGs the only
system, with uniform prices at state level.
The stepwise introduction represented an innovative approach to policy
implementation, which has been characterized as a learning spiral, outlining
long-term roles, objectives and time-frames but allowing governmental actors
and corporatist organizations within the self-governance of SHI to issue and
refine regulations based on the evaluation of the available data and experience.
To a hitherto unforeseen degree, the Federal Ministry of Health was given
and indeed carried out the explicit capacity of substitutive execution if
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172
self-governing corporatist bodies did not fulfil the tasks delegated to them by
law within the defined time schedule. The self-governing bodies opted for the
Australian Refined DRG system 4.1 in June 2000, but could not come to a
consensus on the basic characteristics for the future DRG system, which where
subsequently defined by the Federal Ministry of Health through the Case Fees
Ordinance (based on the Case Fees Act).
According to the First Case Fees Amendment Act of 2003, the introduction
of the DRG-based payment system was to be performed gradually with a
stepwise withdrawal of the mixed payment system (convergence phase).
Thereby, hospitals were given the opportunity to adjust to the transition from
individual budgets based on historical expenditures to a uniform price system
at the state level. The full implementation of the DRG-only price system was
planned for 2007 but was postponed further to 2009 by the Second Case Fees
Amendment Act.
In the pilot phase, selected hospitals introduced the Australian Refined DRGs
without any changes. Based on the experience of about 20 hospitals, DRGs
were recalculated by the Institute for the Payment System in Hospitals. This
technical body was financed jointly by the federal associations of sickness funds
and the German Hospital Organization during the development phase until 2003.
Since 2004, the institute is financed by a surcharge on each DRG documented
by hospitals. This new version was tested by hospitals opting voluntarily for
an early conversion to DRGs in 2003, attracted by the incentive to forego the
required zero-growth of hospital budgets. Since 2004, all general hospitals are
obliged by law to document their activity in the form of DRGs, while they are
still being financed on the basis of negotiated hospital budgets except that in
2004 the calculated units of reimbursement are DRGs (at a hospital-specific
base rate) and no longer per diems.
The German type of DRGs are used in all acute hospitals for all types of
services except for certain defined services and for care in departments of
psychiatry and psychosomatic medicine, where per diem charges continue
to apply for inpatient services as well as pre- and post-hospital care. A DRG
takes into account the diagnosis and its clinical severity, comorbidity and
age of the patient admitted as well as the intervention performed. Due to this
diversification, the number of DRGs increased over the Australian version to
824 in 2004 and 878 in 2005.
The relative weights for the various DRGs are determined on a national
level by presenting the average cost expenditure in relation to a set weight
of 1.0. The sum of all relative weights can be added together and divided by
the number of cases, thus establishing the hospital-specific case-mix index.
Once the DRG system is fully implemented, the equation will be as follows:
Germany
173
the case-mix times the state-wide base rate times the number of cases equals
the hospital reimbursement. In 2004, however, the equation is as follows: the
negotiated budget divided by the product of case-mix times the number of
cases equals the hospital-specific base rate. Currently, hospital-specific base
rates vary substantially, reflecting the large historical funding differences of
hospitals, which will be gradually diminished by the new payment system. For
2004 for example, the average basic case fee was calculated at 2593, varying
from hospitals with a base rate of less than 1000 to hospitals with a base rate
of more than 4000. The base rate of most hospitals ranged between 2000
and 3200.
During the so-called convergence phase, the base rate is adjusted
incrementally from the current hospital-specific rate to a state-wide rate which
will be negotiated in every Land from 2005. According to the regulations
following the Second Case Fees Amendment Act, the base rates in 2005 will be
determined through a 1585 mix of state-wide and hospital-specific base rates,
followed by a 3565 mix in 2006 and a 4555 mix in 2007 and a 2575 mix in
2008, so that a uniform price system at Lnder level will be in force only from
2009. Furthermore, hospitals and sickness funds may negotiate reimbursement
for additional costs in the form of a certain share of the respective DRG. The Act
has again increased the options and clarified the rules for hospitals providing
ambulatory specialist care. In addition, it seeks to improve the situation for
hospitals expected to profit least from the introduction of DRGs: large public
multidisciplinary hospitals and especially university hospitals. Also, surcharges
for training to reduce disadvantages for all training institutions have been
revised. Until 2008, the contracting parties on the Land level must guarantee
the basic principle of contribution rate stability when determining the base rate.
Until the contracting can be shifted to a uniform price, the legal framework of
the price system still requires refinement to shape the incentive effects of the
DRG system (for example, fixed versus ceiling prices and a possible role of
volume rebates).
In addition to the basic DRG rate, the Case Fees Ordinance of the Ministry
of Health of 2002 also defined situations when the DRG is to be modified or
when additional surcharges or deductions apply:
Exceeding the defined upper length of stay will accrue a daily surcharge,
while discharges or referrals to other wards or institutions before the defined
lower length of stay will incur reductions.
The DRG shall also be modified if part of the hospital stay is shortened by
delivering services as part of day-care before a hospital stay or following a
hospital stay (pre-and post-hospital care).
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174
Additional remunerations may be obtained for certain interventions:

The parties contracting on a federal level can agree on payments for services,
service complexes or pharmaceuticals, such as the treatment of patients
with bleeding disorders requiring (expensive) coagulation factors or intercurrent dialysis.
For services not yet covered by DRGs or supplementary payments, case or
day-related payments have been locally agreed in 2003 and 2004.
For payments for new examination and treatment methods, the partners at
federal level issue recommendations, on which local parties will negotiate
from 2005.
Hospitals may also qualify for surcharges or deductions depending on their
infrastructure and functions:
A surcharge for training facilities and training payments as of 1 January2004:
on the Lnder level, a compensation fund administered in trust will be
financed by a surcharge per case by all hospitals in the Land. From these
funds, the teaching hospitals receive contributions for their teaching
facilities.
Other activities incurring surcharges or deductions under federal regulation as
of 1 January 2005 include emergency services, admission of accompanying
people, securing the necessary provision of services or excessively limited
demands for care.
Additional obligatory surcharges have been levied on each DRG for two
systemic activities, quality assurance and the continuous development of the
DRG payment system (at the federal level a surcharge of 0.27 was negotiated
for 2004).
The Case Fees Act and its amendments provide for certain precautions, for
example that hospital operators are obliged to avoid unnecessary hospitalization
and premature transfers for economic reasons and to guarantee correct
accounting. These obligations will be monitored by the SHI Medical Review
Boards which may process samples of current and completed cases. In case
of gross negligence double penalties may apply. Disputes will be dealt with in
joint arbitration committees at the Lnder level.
Up to now, the introduction of DRGs has stimulated intense activities not only
at the federal level but also in hospitals. The number of hospitals documenting
their activities (without being reimbursed) on a DRG-basis increased during
the voluntary period from 284 in January 2003 to 1035 in December 2003,
a bit more than half of all general hospitals. Since then their number increased
only slightly to 1326 in September 2004, i.e. not all hospitals documented
DRGs as required by law. The preparations required substantial investments
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175
in information technologies and controlling activities. Hospitals have gained

more transparency on the range and prices of their services, which probably
affected their output and increased their technical efficiency. Disputes between
hospitals and sickness funds increased during the introduction phase and are one
of the reasons for sickness fund delays in reimbursing hospitals, according to a
survey of the German Hospital Organization (2003), which cites reimbursement
deductions, especially due to referrals and readmission.
Quality assurance and minimal volumes
Traditionally, personnel, technical and physical capacities, professional selfregulation and the control of technical and hygienic security had been perceived
as sufficient to secure quality. The Social Code Book outlines basic quality
requirements of hospitals to be accredited for the hospital plan and to qualify
for reimbursement. Quality assurance in hospitals has changed substantially
during the last decade, shifting from voluntary activities to obligatory tasks.
Requirements for safeguarding quality of processes, and recently of outcomes,
have gradually been increased as outlined in the Social Code Book. Quality
assurance of processes based on documentation was first introduced in the
form of registries in the early 1970s, depending on state legislation concerning
registries for perinatal care and general surgical interventions, for example.
Later registries for high-tech interventions and the use of medical devices
became more common. Their role in actually improving quality of care is not
known, however.
Quality-relevant documentation of case fee procedures, associated with
the introduction of prospective case fees, became a task to be negotiated at
the Lnder level. Since physicians chambers, previously involved in registry
quality measures, were initially not involved, negotiations were delayed and
implementation was weak. A federal working group for quality assurance,
consisting of sickness funds, physicians associations, hospital organizations,
the Federal Physicians Chamber and the German Nursing Council, sought
to improve communication and cooperation in quality initiatives across
professional sectors. The working group built an information system on quality
projects and organized various meetings, but was dissolved in 2004. Its tasks
were delegated to the Federal Joint Committee, where decisions on quality
assurance can be linked more closely to more powerful instruments of contracts,
regulations and reimbursement.
Since 2000, hospitals have been obliged to run internal management
programmes and to negotiate contracts with sickness funds on external quality
assurance measures. Social Code Book V stipulates that quality be an object of
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176
the contracts between purchasers and providers (137). In the contract, providers
are committed to participate in quality assurance measures with special emphasis
on documenting quality indicators in a standard way that allows for comparative
analysis. An independent institute has been established for the inpatient sector
(Federal Office for Quality Assurance, BQS), which assists the contract partners
in choosing and developing the quality indicators to be monitored and collects
the data and presents them in a comparable way. As of now, the contracts oblige
the providers to document quality for a set of surgical procedures (such as hip
replacement and hip fracture surgery, hernia surgery, cataract surgery) and
invasive medical procedures (PTCA, pacemaker implantation). The contract
partners are charged by the legislature to further develop the list of areas for
which quality documentation should be a contractual requirement. The contract
stipulates sanctions for incomplete documentation, that is, for discrepancies
between the number of cases claimed for reimbursement and the number of
cases documented for quality assurance (72).
Publication of the results of quality assurance initiatives became obligatory
in 2000 for nosocomial infections on an anonymous basis. The benchmarking
system with feedback for the participating hospitals and ambulatory surgery
institutions is coordinated by the Robert Koch Institute, and is only slowly
gaining acceptance. From 2005, hospitals are obliged by law to include the
range and volumes (but not outcomes) of their services on their internet
homepages.
From 2000, hospitals were encouraged to take part in certification procedures
by joint initiatives of associations of sickness funds and various hospital
organizations. Two systems of certification combining self-assessment and
visitor assessment were developed, based on the EFQM and European quality
award system, Cum Cert for religious-based hospitals and KTQ (62).
From 2002, minimum services volumes were legally enacted. Contract
partners, i.e. the associations of sickness funds, the German Hospital
Organization and the Federal Physicians Chamber, were required by law to
develop a list of elective services in which there is a clear positive relationship
between volume and quality. For those services, delivery of a predefined
minimum volume will be the condition to become (or to stay) contractable.
Minimum volumes per institution and per individual physician were passed
for the surgical treatment of oesophagus and pancreatic cancer as well as for
kidney, liver and stem cell transplantations in December 2003. From 2004,
hospitals may only be reimbursed for selected interventions if they can show
they have provided the minimum number of these interventions in the previous
year (72).
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177
Payment of physicians
Physicians and other health professionals working in hospitals or institutions for
nursing care or rehabilitation are paid salaries. Public and non-profit providers
usually pay public tariffs, while for- profit providers may pay lower or higher
wages or additional payments. From autumn 2004, junior doctors are granted
the full licensure (approbation) immediately after medical studies, which goes
along with a substantial increase of about 29 000 in the annual gross income
for those working under public service tariffs. Between 1988 and 2003, junior
doctors had been granted a preliminary approbation with restricted competencies
(for example, excluding signing death certificates and medical opinions) and
higher requirements to document continuing education.
Services in ambulatory SHI care or by private physicians, dentists,
pharmacists, midwifes and many other health professionals are subject to
predetermined price schemes or price ranges. The most strictly regulated and
sophisticated reimbursement catalogues have been developed for physicians
and dentists. There are two fee schedules per profession, one for SHI services
and one for private treatments.
Physician payment in statutory health insurance settings
The payment of physicians by SHI is not straightforward, but is subject to a
process involving two major steps. First, the sickness funds make total payments
to the physicians associations for the remuneration of all SHI-affiliated doctors,
in lieu of paying the doctors directly. The total payment is usually negotiated
as a capitation per member or per insured person, covering all services by
all SHI-affiliated physicians of all specialties. Since 2003, sickness funds
pay capita grants to the regional physicians associations depending on the
population of insureds in the region. Until the end of 2002, sickness funds paid
capitations for all their insureds only to one regional physicians association,
namely at the funds headquarters. The regional physicians associations then
settled the reimbursement among themselves. Capitations vary among funds
within a Land and among Lnder. While most substitute funds pay higher than
average capitations, general regional funds and guild funds usually pay lower
than average capitations; capitations of company-based funds vary but taken
together are around average. Second, the physicians associations have to
distribute these total payments among their members according to a Uniform
Value Scale and additional regulations. Prior to payment, the physicians
associations have to check, record and sum up the data that comprise the basis
of these calculations.
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178
All approved medical procedures are listed in the Uniform Value Scale
(EBM). While the coverage decision is made by the Ambulatory Care Committee
of the Federal Joint Committee (see Health technology assessment), a separate
joint committee at the federal level, the Valuation Committee, is responsible
for the Uniform Value Scale. The scale lists all services that can be provided
by physicians for SHI remuneration. Besides the current 147 basic services
(consultations, visits, screening, etc.), the services are ordered by specialty.
The chapter on surgery and orthopaedic surgery currently lists 355 services,
the chapter on ear, nose and throat 97, the chapter on internal medicine87, etc.
Each service is allocated a number of points and lists certain preconditions for
claiming reimbursement, such as particular indications for use or exclusions
of other services during the same visit (Table 30). At the end of each quarter,
every office-based physician invoices the physicians association for the total
number of service points delivered. While physicians receive monthly payments
based on previous figures, their actual reimbursement will depend on a number
of factors:
The total budget negotiated with the sickness funds is divided by the total
number of delivered and reimbursable points for all services within the
regional physicians association, such that the monetary value of each point
cannot be predicted as it depends on the total number of points. The monetary
value is then used to calculate the physicians quarterly remuneration.
The actual reimbursement may be further modified through the Remuneration
Distribution Scale which is different for every physicians association.
Through this measure, minimum and/or maximum point values for the
different specialties or service categories are regulated to adjust for large
variations between specialties.
Between 1997 and 2003, the number of reimbursable points per patient was
limited, varying among specialties and Lnder. These so-called practice
budgets were originally introduced as a measure against the hamster wheel
effect of relative (rather than absolute monetary) point values under fixed
budgets; but had to be abolished following a ruling of the Federal Social
Court which criticized the data basis for the calculations.
Thus, the payment per service may differ from region to region, from quarter
to quarter, and often between specialties within one Land.
The Uniform Value Scale is the backbone of the fee-for-service system for
ambulatory physician services. Some medical interventions are given a specific
number in this tariff list, for example, chiropractic procedures. Many other
interventions, however, may be delivered and then charged under a broader
category of this payment scheme, for example, counselling on a healthy lifestyle.
Not every physician may claim reimbursement for all types of procedures listed
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179
in the Uniform Value Scale; there are specific requirements for reimbursement
of many procedures. Table 30 shows physicians services that contribute a large
part to their reimbursement from SHI.
An analysis of the development of physician reimbursement between 1995
and 2001 shows that due to both higher numbers of physicians and higher levels
of service provision per physician under prospective spending cap conditions
reimbursement remained almost constant per physician and remained almost
constant per service delivered (Table 31).
The above-mentioned limit of points per patient was a partial solution to these
problems. The average annual income from SHI varies from a little more than
64 000 for dermatologists and surgeons to 96 000 for internists (Table 32).
However, in spite of the moderate growth rates in remuneration per physician,
the income of office-based physicians has remained rather high, partly due to
the additional income from sources other than SHI (not included in Table 32).
Particularly, reimbursement from private health insurance (see Private health
insurance) and out-of pocket payments of patients have increased substantially.
Physicians incomes are therefore estimated to be three to five times higher then
the average wage of blue-collar workers and two to three times higher than the
average salary of white-collar workers.
Probably in April 2005, a revised version of the Uniform Value Scale, the
EBM 2000plus, will be introduced. Based on previous experiences with fee-forservice payments and complex fees, it distinguishes clearly between services
of family physicians and specialists. A new feature is that the reimbursement
for services is based on a time value, to better control the plausibility of claims.
The calculated value for the physicians part of the service, set by the Valuation
Committee in December 2003 at 0.77 per minute, is multiplied by the estimated
time required for the physician to provide the service. This amount is added
with a calculatory value for the technical side of the service (/Min x Min). This
value allows for the depreciation of investments and still provides a comparably
strong incentive to provide technical interventions. The EBM 2000plus has been
subject to repeated revisions and negotiations, mainly concerning incentives
for over-provision or under-provision of care but also concerning the balance
of certain specialties and (underprovided) sub-specialties like rheumatological
internal medicine.
According to the SHI Modernization Act, the era of predetermined fixed
budgets is to end in 2006. From 2007, physicians associations will negotiate
morbidity-oriented service volumes with the sickness funds, so that higher
morbidity (probably in the previous year) would increase total remuneration
and therefore the money available per specialty and physician.
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180
Table 30.
Rank
SHI physician fees: top 20 by turnover, with number of points per service,
2002
Service
Number of points
Basic fee per patient

per 3 months
Explanation, planning and

coordination
Consultation fee
50
Family physician basic payment 90
per 3 months
Intensive counselling on the
300 (600 if more than 30 min)
impact of and coping with
illness
5.0%
Home visit
Cost-efficient provision and/or
initiation of lab services
Whole body examination
MRI of head, joints of
extremities
Night, week-end, official holiday
fee
Ultrasound of urogenital organs
MRI of body regions other than
head and joints of extremities
Ultrasound of abdomen
CT of body regions other than
head and joints of extremities
Electrocardiography
Laboratory basic fee
Psychotherapy (long-term,
individual)
Cancer screening women
300 (600 if immediately)

5-240 depending on speciality
1.9%
1.9%
320
1150
1.6%
1.5%
200300
1.4%
400
1150
1.2%
1.1%
520
80
1.1%
0.9%
100250
5110
1450
0.8%
0.8%
0.8%
310 (men: 260)

(+140 cytologic examination)
1850
170
0.8%
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
family physicians: 265 (475 for

retired insureds); specialists:
40420
180
% of payment
for all SHI
physicians
20.8%
4.8%
2.9%
2.2%
Ante-natal care
0.8%
Clinical-neurological basic
0.7%
examination
Source: Federal Association of SHI Physicians, 2004 (49); Federal Associations of SHI
Physicians and federal associations of sickness funds, 2002 (73).
Note: MRI: Magnetic resonance imaging, CT: Computed tomography.
Quality aspects of purchasing

In order to offer special services, mostly invasive procedures or medical imaging
procedures, providers need to fulfil certification requirements, in addition to
being licensed as specialists. This is the case for about 30% of services listed
Germany
Table 31.
181
Indicators for the ambulatory care by SHI-affiliated physicians changes in

the number of physicians, services provided, and remuneration 19802001
(in current prices)
1980a
1985a
1990a
1995a
1996b
1997b
1998b
1999b
2000b
2001b
Change (%)
19962001
number
of SHIaffiliated
physicians
remuneration
for all
physicians
(billion )
55 743
63 056
71 218
88 165
107 071
108 734
110 339
122 604
128 670
128 333
7.4
9.6
12.5
16.7
20.1
20.5
20.6
21.7
22.5
23.2
+20%
+15%
remuneration per
physician
()
132 932
152 404
175 237
189 644
188 100
188 074
186 788
176 830
174 866
180 780
-4%
number of
cases per
SHI insured
and year
Cases
(in million)
expenditure
per casec
()
expenditure
per insured
member ()
252.1
268.3
320.8
400.8
508.8
523.2
532.2
551.3
558.1
564.6
29.4
35.7
38.9
41.7
39.6
39.0
38.7
39.3
40.3
41.1
4.6
4.8
5.5
6.7
7.1
7.3
7.5
7.7
7.8
8.0
209.8
264.9
329.0
412.4
396.3
401.9
406.7
425.7
440.7
455.5
+9%
+4%
+13%
+15%
Source: Federal Association of SHI Physicians, 2004 (49); Wrz, Busse, 2005 (8).
Note: a western part of Germany, b Germany, from 1999 including psychological
psychotherapists; c a case is defined as one or more patient contacts with one and the same
physician per quarter.
in the Uniform Value Scale. Certification is obtained when the facilities fulfil
minimal technical requirements and the providers have undergone additional
training, defined as a minimal number of cases done under supervision.
Organizational requirements are also considered for certification. For example,
a binding cooperation agreement with a heart surgery unit within a certain area
(measured as time to access) is required to obtain certification for ambulatory
PTCA. Specific certificates are required for arthroscopy, dialysis, pacemaker
supervision, ultrasound and laboratory testing, for example. The performance
of other services not only requires a specific qualification, but also evidence
of sufficient experience, indicated as a minimum number of services in the
preceding year, for example 200 colonoscopies or 350 PTCAs (74).
Recertification is needed in order to retain eligible for sickness fund
reimbursement for providing special services within the contracts. Recertification
requirements are fixed in the contracts and vary depending on the service in
question. The different approaches include minimum volumes of procedures
done in a year, or case-verification and evaluation of skills (with thresholds for
sensitivity, for example). Furthermore, the contracts also include agreements
that physicians involve themselves in quality improvement interventions, such
as auditing or supervision with significant event reviews. These requirements
are defined by the Federal Association of SHI Physicians and are contract items
between the sickness funds and the regional physicians associations.
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Table 32.
Remuneration and income from SHI of SHI-affiliated physiciansa

in ambulatory practice, 2001
Dermatologists
Ear-nose-throat
physicians
Gynaecologists
Internists
Neurologists and
psychiatrists
Ophthalmologists
Orthopaedists
Paediatricians
Radiologistsb
Surgeons
Urologists
All specialists
(incl. other specialists)
General practitioners
and practitioners
Totala
Surplus = income
from SHI before tax
()
64 334
SHI remuneration
()
Costs for personnel

and equipment ()
171 100
106 766
192 900
190 600
236 900
111 882
110 357
140 956
81 018
80 243
95 944
151 300
203 300
241 700
188 100
421 200
194 300
204 900
80 643
120 964
148 162
102 138
347 068
129 987
126 014
70 657
82 336
93 538
85 962
74 132
64 131
78 886
205200
124556
80644
171700
192 500
94435
113 190
77265
79 310
Source: Federal Association of SHI Physicians, 2004 (49).

Note: a excluding physicians in joint practices with different specialists and psychological
psychotherapists; b including nuclear medicine specialists.
The reimbursement is further subject to control mechanisms to prevent

over-utilization or false claims. A physician may be subject to a utilization
review at random or if levels of service provision or hospital referrals per capita
are higher than those of colleagues in the same specialty under comparable
circumstances. To escape financial penalties, the physician has to justify the
higher rates of utilization and referral, which may be due to a higher number
of severely ill patients. Utilization review committees and utilization review
arbitration committees with an equal number of physicians and sickness fund
representatives are responsible for these controls.
Private settings
In private delivery settings, payment of health personnel is organized differently.
For physicians and dentists (75), the catalogues for private tariffs are valid in
ambulatory as well as inpatient care, and for patients paying out-of-pocket
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as well as private health insurers. They are based on fee-for-service and are
determined by the Federal Ministry of Health and Social Security which
is advised by Federal Physicians Chamber. In the Catalogue of Tariffs for
Physicians (Gebhrenordnung fr rzte, GO) for example, each procedure
is given a tariff number and a certain number of points. In addition, the single
charge rate and the maximum charge rate are indicated, the latter is usually
set 2.3-fold higher than the single rate, but for certain services physicians may
charge only a 1.7-fold rate. In addition, the catalogue lists the requirements
for reimbursement, such as the duration, performance, documentation or limits
concerning the combination of several tariff numbers. However, the catalogue
does not reflect daily practice very well. For reimbursement purposes, many
services are subsumed under more general items, such as counselling on
preventive self-medication and lifestyle (No. 34; single charge rate: 17.39
and 2.3-fold rate: 40.23) (76).
The list of individual health services (IGEL) presents a selection of
services deliverable on demand of patients. Services presented there may be
offered to patients paying out-of-pocket in addition to the comprehensive range
of SHI benefits. The provision of private services by other health professions
is not regulated specifically by the state. Rather, professional bodies of other
health professions including for example physiotherapists and complementary
therapists issue model tariff lists that patients and therapists can refer to and that
apply if no other prices have been agreed ahead of service delivery (76).
Germany
Health care reforms
he last fifteen years have seen many interventions of the federal

government in health care. A narrative overview of health reforms in
the context of the German reunification is given in the section Historical
development. The following sections give a more detailed account of the political
objectives and contents of health care reform acts since 1989. Another section
reports on reforms planned in the near future. The Christian DemocraticLiberal government (19821998) as well as the Social Democratic-Green
government (since 1998) have both adhered to the basic SHI structures and the
corporatist mode of regulating the health care sector. They partly delegated more
competencies to self-governance. Both governments promoted competition
among sickness funds and intervened increasingly to improve the quality of
health care and innovate its structural division in the delivery, administration
and financing: The Christian Democratic-Liberal government with pilot
projects and structural treaties and the Social Democratic-Green government
with integrated care and the Disease Management Programme. The red-green
government has introduced several reforms and regulations on the modernization
of professional training and infectious diseases that were thought overdue.
Besides that, prime issues of recent major health reforms are nearly all related
to the statutory insurance system. Yet, if one wants to summarize health care
policy in the period from 1988 to 2004, cost containment has been the major
objective. Major political intervention in health care occurred primarily when
the SHI had financial deficits.
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Objectives of health reforms

The major objective: cost containment
The sickness funds and health care providers have been required to pursue a
goal of cost-containment through a policy of contribution rate stability. This
requirement is defined as holding contribution increases level with the rate
of increase of contributory income. The era of cost-containment started in
1977 with the introduction of the Health Insurance Cost-Containment Act,
ending a period of rapid growth in health care expenditure, especially in the
hospital sector. This growth was intentional on the part of politicians in order
to overcome infrastructural deficits and shortcomings caused by the destruction
during the Second World War and an inadequate method of financing hospital
investment.
The basic principle behind German style cost-containment was an
income-oriented expenditure policy to guarantee stable contribution rates.
This was an important objective in a time of economic restructuring and growing
international competition, since the contributions are jointly paid by employers
and employees. Rises in contribution rates therefore became a question of
international competitiveness. A series of cost-containment acts employing
various tools were used, including:
budgets or spending caps for sectors or individual providers
a gradual increase of prospective payment elements in ambulatory and
hospital care
reference prices for pharmaceuticals, extension of a negative list,
introduction (and abolishment) of a positive list, educational approaches to
enhance generic and rational prescribing, and ad hoc price reductions for
manufacturers, wholesalers and pharmacies
reducing the number of hospital beds (rather than hospitals), restrictions
on the number of ambulatory care physicians and on high cost technology
equipment
increased co-payments (both the level and number of services)
exclusion of benefits.
These acts led to a moderation of health care expenditure growth and
stabilized sickness funds expenditures as a proportion of GDP per capita (in the
western part between 6% and 7% since 1975). However, this stability has still
not been adequately acknowledged in discussions about health care expenditure,
since the factor being used by both politicians and employers (and to a much
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lesser extent, the employees/insured) has been the average contribution rate.
This is increasing slowly but regularly (from 10.4% on average in 1975 to
14.3% in 2004), with cost-containment measures having relatively minor and
transient effects. These effects were often even further moderated by exceptional
increases after the publication of new cost-containment proposals and in the
period before the reforms were enforced. The equivalent expenditure curve in
late 1988 became known as Blm belly and in late 2003 as La Ulla wave,
named after the acting ministers of health.
The budgets have been of varying forms and efficacy but have been generally
more successful in containing costs than any of the other supply or demandside measures. Table 27 provides an overview of the rise, fall and resurrection
of budgets and spending caps.
While cost-containment was successful in stabilizing expenditures in
ambulatory medical care and dental care since the 1980s, successes in other
sectors varied: the hospital sector was successfully contained only in the late
1990s. Pharmaceutical expenditures were better contained from 1993 to 2000
than in the ensuing years until strict price and rebate measures were introduced.
Other sectors, such as medical aids or transport/emergency services, were less
effectively curbed.
Since the last Health Care Systems in Transition Profile (1) was published,
the average contribution rate has increased quite steeply, from 13.5% of gross
earnings in 2001 to 14.3% in 2003 and 2004. The last such increase (from 12.4%
to 13.2% between 1991 and 1993) was followed by the Health Care Structure
Act of 1993, the largest and strictest reform act of the 1990s (26). The
problem is that the contribution rate is not based on the total economy but only
on that part on which statutory health insurance contributions are based (i.e.
salaries and wages of people liable to mandatory statutory health insurance).
Over the last 20 years, this income base has increased more slowly than health
expenditure of sickness funds, which has caused debts and consecutively an
increase in the contribution rate.
Other reform objectives
One of the major reforms was the introduction of mandatory insurance for longterm care in 1995 in order to meet the needs of an increasingly ageing society
and relieve private and municipal resources. In addition, some benefits were
legally included into the SHI ambulatory benefit package to address prevention,
patient education, or sociotherapy for the mentally ill. In pursuit of the policy
of rationalization before rationing, access to providers was hardly restricted
and few benefits were excluded, except for the transient exclusion of dentures
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(19971998) for persons born after 1978 and the somewhat more substantial
cuts of the SHI Modernization Act in 2004.
An increase in technical efficiency was sought through budgets and other
cost-containment measures, prospective payment methods (see Payment of
hospitals and Payment of physicians) and introducing competition between
funds or between hospitals and ambulatory services for elective ambulatory
surgery (1993), highly specialized services (2000) and underserved specialties
(2004). This went along with increasingly comprehensive and obligatory
measures to increase the continuity of care and coordination between the hospital
and ambulatory care sectors, and between SHI and rehabilitation. Reforms also
sought to modernize and professionalize the management of sickness funds
(1993) and physicians associations (2005).
To moderate negative effects on equity in financing and access, cost-shifting
measures were accompanied by exemptions for the chronically ill, children and
poor. To decrease adverse effects of fund competition on equity and quality,
repeated reforms were required to improve the risk structure compensation
and adjust the regulatory framework. By introducing increasingly demanding
obligations for quality assurance (inscribed in the Social Code Book in 1989)
policy-makers sought to decrease below-standard care by issuing clinical
guidelines, to strengthen the continuing education of professionals and qualityoriented management in hospitals (1993) and ambulatory physicians practices
(2000). In addition, external quality assurance was made obligatory for hospitals
(2000, accessible to the public from 2004) to provide transparency concerning
any detriment to the quality of care due to new forms of reimbursement.
Health targets and health for all
The German discussion of the World Health Organizations Health for all by
the Year 2000 programme was initially rather short. An extensive book on
the urgent health needs of the population in (West) Germany and subsequent
objectives and targets did not lead to a change in health policies, possibly since
they were published at a time when both the public and the politicians were
preoccupied with unification-related problems. The only visible outcome of the
debate was the mandate contained in the Health Care Reform Act of 1989 that
sickness funds should undertake health promotion activities.
Health objectives and targets gained renewed attention early in 1997 when the
sickness funds were looking for new ways of competing. With health promotion
having been legally abolished at the end of 1996, health care targets were the
only remaining area in which the benefit packages differed between funds.
Health system analysts supported the sickness funds use of health care targets,
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but argued for common targets by which their performance could be judged.
Only one Land (North Rhine-Westphalia) set public health targets, passing a
set of ten in 1994 that followed some of the WHO Health for All targets, but
with more detailed responsibilities of specific institutions and groups. Other
Lnder have initiated their own targets since 19971998 (77.78).
The first encompassing initiative at the federal level to develop and implement
health targets was the 2001 federal ministrys delegation of a coordinating role
to the Society for Social Security Policy and Research (GVG), a consultative
body representing the key actors of the private and social insurance branches.
The multi-stake-holder committees agreed on health targets and clarified the
responsibilities of actors and the means of evaluating progress. The following
major health targets were formulated and published in 2003: to prevent and
treat diabetes, to increase life quality and reduce mortality from breast cancer,
to reduce tobacco consumption, to raise children in a healthy way (nutrition,
exercise and stress management), and to increase the autonomy of patients and
the health competency of citizens (79).
Content of reforms and legislation

Table 33 shows important health care reforms between 1988 and 2004 in
chronological order. Legislation passed since the previous HiT Profile (1) was
published in 2000 is described in more detail. However, it is important to note
that, besides these health care reforms prepared by the Federal Ministry of
Health, numerous acts affected health care.
In fact, health reforms have focused on expenditure control and reorganization
in statutory insurance schemes or the introduction of long-term care. Health care
reforms have until now hardly rarely targeted the revenue side of statutory health
insurance, except e. g. for the SHI Modernization Act that declared all types of
pensions liable to SHI contributions. The income of statutory health insurance
was much more influenced by other social reforms or broader political and
economic reforms that were not initiated by the Ministry of Health, especially
the treaties of German reunification, the introduction of small part-time jobs,
and reforms of statutory unemployment insurance and statutory retirement
insurance.
The treaties of German reunification from 1990 and subsequent legislation
involved statutory insurance schemes in contributing to the attainment of
the overall goal to adapt living standards in the eastern part to those in the
western part. The West-East transfer through SHI was for example increased
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Table 33.
Chronology of health reforms, 19882004
Year passed
1988
1992
1994
1996
1997
1998
1999
2000
2001
2002
2003
2004
Name of the act

Health Care Reform Act of 1989
Health Care Structure Act of 1993
Social Code Book XI (Statutory Long-Term Care Insurance)
Health Insurance Contribution Rate Exoneration Act
First and Second Statutory Health Insurance Restructuring Acts
Act to Strengthen Solidarity in Statutory Health Insurance
Statutory Health Insurance Reform Act of 2000
Act to Equalize Statutory Provisions in Statutory Health Insurance 2001
Infection Protection Act
Social Code Book IX (Rehabilitation and Participation of Disabled People )
Reference Price Adjustment Act
Pharmaceutical Budget Redemption Act
Act to Reform the Risk Structure Compensation Scheme in Statutory Health
Insurance
Act to Newly Regulate Choice of Sickness Funds
Pharmaceutical Expenditure Limitation Act
Case Fees Act
Contribution Rate Stabilization Act
Twelfth Social Code Book V Amendment Act
First Case Fees Amendment Act
Statutory Health Insurance Modernization Act
Act to Adjust the Financing of Dentures
Second Case Fees Amendment Act
by transferring the contributory income level in 1999, the introduction of the

nation-wide risk structure compensation, and the legal obligation to complete
the stepwise adaptation of the quasi-budget for the reimbursement of SHIaffiliated office-based physicians by 2007. Based on these items, the west-east
transfer increased from 0.6 billion in 1999 to 2.9 billion in 2003. In August
2004, the average contribution rate of sickness funds in the eastern part was
lower than in the western part (14.03% versus 14.27%).
While most of these social, political or economic reforms have reduced
resources or increased tasks for SHI, some legislation has led to an increase of
revenues for statutory health insurance. The introduction of minor part-time
jobs (mini-jobs) in 1999, led initially to an increase in contributions, yet the
amendment of the act has led to a decrease of revenues for statutory insurance
schemes.
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Health Care Reform Act of 1989

Many of these reforms built upon cost-containment strategies introduced by the
Health Care Reform Act that came into force on 1 January 1989 in the western
part of Germany. Besides renewing the 1911 social insurance legislation, it
introduced the following:
choice of sickness funds or opting out for blue-collar workers above the
income limit (putting them on par with white-collar workers);
a right for sickness funds to selectively contract with hospitals outside the
hospital plans;
new SHI benefits for home-based nursing care;
health promotion and new preventive services;
differentiation of co-payments for dentures, depending upon regular dental
examinations
no claim bonus models;
reference prices for pharmaceuticals and medical aids;
a negative list for pharmaceuticals based on inefficiency;
public committees to regulate expensive medical technologies jointly in the
ambulatory and hospital sectors;
quality assurance measures;
increased scope for the medical review boards of the sickness funds by
including hospital treatment reviews.
Health Care Structure Act of 1993
The major health care reform of the 1990s, the Health Care Structure Act was
passed through a compromise between the governing Christian DemocraticLiberal coalition and the opposing Social Democrats in 1992 (Lahnstein
Compromise). The act pursued two different strategies to increase clear-cut
cost-containment measures and to introduce more competition to enhance
efficiency, especially between sickness funds and in the hospital sector.
The key elements of the Act were to:
introduce competition between sickness funds with freedom to choose for
most of the insured population (from 1996);
introduce a risk compensation scheme to redistribute contributions among
sickness funds (from 1994);
abolish the full cost cover principle for hospitals;
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introduce a partial prospective payment system for hospitals (case fees and
procedure fees for selected treatments from 1996);
lessen the strict separation of the ambulatory and hospital sectors (making
ambulatory surgery in hospitals possible);
introduce a positive list of pharmaceuticals (from 1996; but the regulation
was abolished in 1995);
introduce fixed budgets or spending caps for the major sectors of health care
(originally limited until 1995);
more tightly restrict the number of ambulatory care physicians;
introduce a random review of ambulatory care physicians reimbursement
claims;
introduce a smart card instead of paper documentation for the insured
population;
increase co-payments and introduce them for reference-priced pharmaceuticals,
differentiated by price (1993) or package volume (from 1994).
The Third Step of health reform (19961997)
After a draft bill failed, the government proceeded with a small-scale act
embedded in a more general act supporting economic growth. The so-called
Health Insurance Contribution Rate Exoneration Act (the majority of which
came into force on 1 January 1997) contained the following measures:
exclusion of dental surgery and dentures from the benefits package for people
born after 1978 (abolished in 1998)
reduction of all contribution rates by 0.4% on 1 January 1997
reduction of benefits for rehabilitative care
increased co-payments for pharmaceuticals and rehabilitative care (partly
lowered in 1999 and 2000)
reduction of health promotion benefits (partly reintroduced in 2000).
The First and Second SHI Restructuring Acts, which followed and came into
force on 1 July 1997 and 1 January 1998, respectively, represented a shift away
from strict cost-containment. The new policy restricted employers contributions
on the one hand and expanded market mechanisms on the other, and increased
the share of private money in the system. In this respect, co-payments were
presented as a means to put new money into the system (and no longer as a
means to decrease utilization). Other measures included the cancellation or
modification of anti-market instruments such as budgets and collective contracts.
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The measures introduced in these two acts included:

the right of patients to negotiate services and ultimately prices for dental
surgery and dentures with dentists and receive only a flat rate from their
sickness fund (from 1998)*
linkage of sickness fund contribution rate increases to an increase in the
fund's co-payments*
the option for sickness funds to introduce no claim bonuses, deductibles
and higher co-payments*
the option for insureds to choose private treatment with reimbursement by
the sickness fund at the contract rate*
cancellation of ambulatory care budgets and pharmaceutical spending caps
(from 1998)*
increased possibilities for non-collective contracts between sickness funds
and providers
transfer of the responsibility for the catalogue of prospective payments from
the Ministry of Health to sickness funds and hospital organizations
abolition of public committees for expensive medical devices
introduction of an annual 10 per insured (not shared with employers) for
restoration and repair of hospitals*
increased co-payments for inpatient care, pharmaceuticals, medical aids,
ambulance transportation and dentures (for those still covered) (partially
abolished in 1998)
a new hospice care benefit
new requirements for HTA in ambulatory care
(Note: * = measures abolished in 1998 (effective 1 January 1999).)
In effect, the 1996/1997 acts broke several traditional rules of the system
such as:
uniform availability of benefits
contributions shared equally between employers and employees
financing depending only on income and not on risk or service utilization
provision of services as benefits-in-kind.
The abolition of these reforms as well as reversal of the trend toward shifting
costs onto patients to the advantage of providers became the most important
part of the health policy programme of the then opposition Social Democrats.
In anticipation of such a policy reversal after the elections, the sickness funds
undermined implementation of the de jure limitation of provider income for
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the sake of cost-containment. They refused to sign contracts but agreed they
would reconsider this standpoint after the election if the government remained
in power. Regarding the instruments addressing the relationship between the
insured and the funds, however, the picture was less clear: some sickness funds
exercised the right to introduce no claims bonuses while deductibles or higher
co-payments were not introduced. Due to public dissatisfaction and the expected
variation in co-payment rates, the government itself postponed enforcement of
its proposal to link increases in contribution rates to higher co-payments.
Act to Strengthen Solidarity in Statutory Health Insurance (1998)
After the change of government in autumn of 1998, the Act to Strengthen
Solidarity in SHI reversed the above-mentioned changes that were not in line
with traditional approaches (marked with an asterisk above). In addition, copayment rates for pharmaceuticals and dentures were lowered and budgets or
spending caps re-introduced for the relevant sectors of health care and in
the case of dental care defined more strictly than ever before. Dental care had
received particular attention in 1998: even though charges were legally limited
for an initial period of three years after privatization of dental care, a large
number of dentists overcharged from the beginning. This behaviour, together
with the restrictions on the benefits package and the offers of new policies by
private insurers contributed to a growing level of public dissatisfaction.
Reform Act of Statutory Health Insurance 2000
After the short-term Act to Strengthen Solidarity in SHI, the government
introduced a new medium- to long-term reform into parliament in June 1999,
which was passed in a modified form in December 1999. The Reform Act of
SHI 2000 took effect in January 2000. Its key features were as follows:
Removal of ineffective or disputed technologies and pharmaceuticals
from the sickness funds benefits catalogue: A number of measures were
introduced, including strengthening health technology assessment through
a new DIMDI unit to inform decision-makers (especially those in the
corporatist institutions) about the effectiveness and cost-effectiveness of
health technologies. The regulations concerning the more or less inactive
Federal Committee of Dentists and Sickness Funds were tightened. This
meant that the ministry could set deadlines for the evaluation of technologies
for inclusion or exclusion from the benefits catalogue. In addition, decisionmaking under corporatist arrangements was extended to the hospital sector
via a Committee for Hospital Care and a Coordinating Committee.
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The measures addressing the benefits catalogue were accompanied by

mandatory treatment guidelines and new quality assurance regulations. For
Pharmaceuticals, the Act re-introduced a positive list of reimbursable
drugs, which was opposed by the pharmaceutical industry, especially the
smaller companies with a high percentage of disputed products. The Federal
Ministry of Health was authorized to issue a positive list upon approval by
the Federal Council. A nine-person commission consisting of experts in
clinical medicine and pharmacology was charged with its preparation.
The co-operation of general practitioners, ambulatory specialists and
hospitals contracts between sickness funds and providers which cross the
line between the ambulatory and the inpatient sectors: For example, a group
of providers could contract with funds to provide both kinds of care. To
promote a (voluntary) gatekeeping function amongst general practitioners,
the act allowed sickness funds to give their members a bonus if they access
specialists via their general practitioner.
Budgets and reimbursement: The financing and reimbursement aspects of
this reform received by far the largest public attention. The Act retained
sectoral budgets which were reduced by the expenditure necessary to
finance care delivered under trans-sectoral contracts. The original proposal
to change to monistic hospital financing failed in the Federal Council. As
far as the reimbursement of the running costs of hospitals was concerned,
the Act included a mandate to introduce a new payment system based on
uniform case fees taking complexities and co-morbidities into account
(see Payment of hospitals). The ambulatory care budgets were to be divided
between primary care physicians and specialists, as determined by the
Valuation Committee.
Change and continuation of policies (20002003)
Since the last version of the Health Care Systems in Transition Profile was
published, in 2000, a broad variety of legislative and regulative measures have
been implemented (Table 33). Primary aims were to cope with increasing
sickness fund deficits, adverse effects of their competition and perceived quality
shortcomings. Also, legal means were required to prepare for the introduction
of diagnosis-related groups (DRGs) in hospitals.
Reforms of the risk structure compensation scheme
The Risk Structure Compensation Mechanism, which redistributes money
among sickness funds to compensate for disparity in members income and
expenditure levels, was transformed fundamentally by two laws. The Act to
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Equalize the Law in Statutory Health Insurance, passed in 1999, standardized

the risk structure compensation mechanism for the whole of Germany from
2001. This led to an increase of the West-East transfer of financial resources.
On the other hand SHIs income basis in the eastern part was broadened by
adjusting the limits for contributions, mandatory membership, and exemption
from co-payment to levels in the western part. Both measures sought to reduce
the high health insurance contribution rates in the eastern part, thereby reducing
obstacles to employment and economy.
The Act to Reform the Risk Structure Compensation Scheme in Statutory
Health Insurance was passed in 2001, following increasing criticism of the
redistribution mechanism of sickness fund revenues as insufficient or unfair.
The impetus for the reform came from two reports from expert groups that
examined the function of the risk structure compensation scheme. Both came
to the conclusion that in principle the scheme was performing well, but there
were still incentives for sickness fund risk selection, since the scheme did not
directly compensate differences in the morbidity structure of the insurance
clientele of a certain sickness fund, but only differences in age, sex, disability,
and income. Therefore the Act added further categories for risk adjustment,
namely the enrolment of chronically ill insureds in specifically regulated
disease management programmes (see Main sources of finance and coverage).
The Act also introduced a high-risk pool effective in 2003 and outlined steps
to introduce a morbidity orientated risk structure compensation scheme as of
the year 2007.
Pharmaceuticals and hospitals: Cost containment and change
In January 2001 the Minister of Health from the Green Party, Andrea Fischer,
resigned over the BSE-crisis, ending a two-year Green tenure in the post.
One of the first things new Social Democratic Minister Ulla Schmidt introduced
was the so-called round-table, consisting (from 2001 to 2002) of representatives
of the physicians, patients, sickness funds, hospitals and industry, meant as
a platform for joint preparation of structural reforms. Perhaps in an effort
to seek consensus, she also announced the cancellation of pharmaceutical
spending caps. Legally, this was done through the Pharmaceutical Budget
Redemption Act, passed late in 2001, which abolished the regional caps in the
ambulatory sector and freed physicians retrospectively from collective liability
for exceeding drug budgets in the previous years. Cost guidelines negotiated
regionally by the self-governing bodies replaced the spending caps. However,
as SHI pharmaceutical expenditures rose by 11% in the first quarter of 2001
alone, the Pharmaceutical Budget Redemption Act had to be accompanied by
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the counter-acting Pharmaceutical Expenditure Limitation Act, with its aut idem
regulation obliging pharmacists to choose the cheapest active substance in a
class of pharmaceuticals. This regulation led to lower-than-calculated savings,
first because pharmaceutical companies partly introduced dummy drugs
(with high prices to increase the lower third on paper) and second because they
often disobeyed the regulation. In a controversial incident, the Association of
Research-Based Pharmaceutical Companies obliged itself to pay a lump sum
of 204.5 million to the sickness funds. In return the government announced a
suspension of general price cuts on certain pharmaceuticals.
The pharmaceutical industry had already filed several court cases arguing
that sickness funds were not authorized to set indirect price controls for patented
drugs by including them in the reference price scheme. Therefore the Federal
Assembly passed the Reference Price Adjustment Act in 2001 to transfer that
function to the Federal Ministry of Health for two years. Meanwhile, however,
both the Federal Constitutional Court (December 2002) and the European Court
of Justice (early 2004) have approved the sickness funds role in determining
reference prices in the SHI market since they act in a publicly delegated function,
and setting reference prices has been redelegated to the federal associations of
sickness funds from 2004.
The Case Fees Act of 2002 specified the regulatory framework and schedule
for the introduction of the DRG reimbursement system, which was to take
place in three phases. In the first phase 20032004 the new case fees were
introduced on a budget neutral basis. This phase was to familiarize hospitals
with the new system, the case fees were not effective as a pricing system, but
rather as units to make up the hospitals negotiated target budgets. In the second
phase 20052006 the individual hospital budgets were gradually to become
adjusted to the case-fee budgets. As of 2007, the case fees were planned to
become effective as a pricing system. The Second Case Fees Amendment Act
prolonged the second phase by two years and postponed the final step to 2009.
The introduction of the DRG-payment system is the most important reform in
the hospital sector since the introduction of dual financing in 1972.
Another element the only lasting one was an increase of the threshold
determining mandatory SHI membership to lower the flight to private health
insurance. This led to a decoupling of the thresholds determining membership
and contributions (the latter remained lower). The 12th SGB V Amendment
Act froze ambulatory and hospital care budgets for 2003, except for hospitals
opting already for documenting according to the DRG system.
Just three months after the government was re-elected in September
2002, it introduced two reform bills with ad hoc austerity measures to reduce
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expenditure. However, the government agreed to strive for more structural

changes, in its coalition agreement (passed in October 2002 and covering the
legislative period 20022006) (81).
The Contribution Rate Stabilization Act, passed by the Federal Assembly
in 2002, mainly targeted pharmaceutical prices by increasing the rebates that
pharmacists have to give to sickness funds for non-reference priced drugs from
5% to 6%. Rebates for SHI were also introduced for manufacturers (6%) and
wholesalers (3%). In addition, direct negotiations between sickness funds and
manufacturers for further rebates were introduced. Yet, instead of the aspired
nominal decrease of 1.4 billion, expenditures increased, mainly due to the shift
to other, often costlier substances. Further elements of the Act were a freeze
on ambulatory and hospital care budgets for 2003, except for hospitals opting
for the DRG system. Another element the only lasting one was an increase
of the threshold determining mandatory SHI membership to lower the flight to
private health insurance. This led to a decoupling of the thresholds determining
membership and contributions (the latter remained lower).
The Statutory Health Insurance Modernization Act (2004)
The passage of the SHI Modernization Act in 2003 ended a one-year decisionmaking process and a five-year polarization of the two biggest political parties,
the Social Democratic Party (SPD) and the Christian Democratic Party (CDU),
over health policy (26). There was a general feeling that reform was needed,
most of all because of increasing expenditure of the SHI contribution rates (on
average from 13.5% of gross income in 2001 to 14.3% in 2003) and perceived
deficiencies in the quality of health care. The Act was a result of a compromise
between the incumbent Social Democratic-Green government and the Christian
Democratic opposition which held a majority in the Federal Council. Its stated
objectives were to improve the efficiency and quality of health care, and to
stabilize SHI contribution rates in order to avoid disincentives for employers
to invest in job-creating activities without rationing.
The legislation was supposed to generate substantial savings for SHI that
were calculated to increase from an expected 9.8 billion in 2004 (about 7% of
the likely expenditure of the sickness funds) to 23 billion by 2007. In 2004, the
bulk of expected savings (4% of current SHI expenditures) shall be achieved by
shifting costs to users and SHI insureds. In comparison, the anticipated savings
from measures targeting health care providers and the pharmaceutical industry
total 1.5 billion in 2004, rising progressively to 3 billion in 2007.
The main elements to achieve the savings or costs-shifts are:
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Some benefits, especially OTC drugs (see below) have been excluded from
the SHI package.
The co-payment requirements have been restructured by (1) introducing
new co-payments, (2) standardizing co-payment levels across sectors, and
(3) revising exemption rules: (1) Co-payments have been newly introduced
for physician contacts in ambulatory care, namely 10 per quarter for the
first contact at a physicians or a dentists office and each contact with other
physicians without referral during the same quarter. (2) Cost-sharing is now
10%, with a minimum of 5 and a maximum of 10 per good or service,
which is generally higher than previously (for details see Complementary
sources of financing). (3) While children under age 18, antenatal care and
preventive services are still exempt from co-payments, the general exemption
of poor people was abolished. Annual co-payments are now limited for every
SHI insured to 2% of annual gross household income at the (documented)
request of the insured; for the chronically ill, the annual financial burden of
co-payments is limited to 1%. Deductions for spouses and children apply.
From 2005, the SHI Modernization Act sought to exclude dentures from
the jointly funded SHI benefit package. As the result of a compromise
between the government and opposition, an additional insurance for
dentures was introduced on a mandatory basis for SHI insureds, paid only
by SHI members (and not by employers), with two options: SHI coverage
at a flat per capita rate including free co-insurance for family members,
after in-kind benefit principles (for example pre-authorization by sickness
funds and administration by regional dentists associations) or private
coverage at rates of the insurers choosing. By the mid-2004, however,
the relatively cheap extra insurance was felt to incur excessive transaction
costs, so a law was passed in the Federal Assembly to keep it inside the SHI
benefit package, financed entirely by the insured through a 0.4% special
contribution, and to cancel the right to the private coverage. According
to the SHI Modernization Act, a special contribution of 0.5% was to be
levied on all SHI members (but not employers) from 2006, roughly equalling
the amount of savings that would be generated by excluding sick pay from
SHI benefits package. A related proposal was dropped early in the policy
process due to controversies.
After the changes regarding dentures, the two special contributions will
be combined into one of 0.9% which will be due from July 2005. At the
same time, the general contribution rate will be lowered by the equivalent
percentage, i.e. employers will save 0.45 percentage points while employees
and other SHI members will face an increase of 0.45 percentage points. Thus,
the longstanding 5050 parity in financing will be changed to approximately
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4654 for employers and members, respectively.

In addition, new sources of income for SHI have been generated, i.e. a
subsidy from the federal budget to cover several benefits relevant to family
policies (see Complementary sources of finance) and by making additional
pensions liable to SHI contributions.
Beyond these highly-publicized cost-containment measures, the SHI
Modernization Act entailed an array of less publicly discussed organizational
reforms to increase the quality of care, efficient coordination and patient
participation.
Especially in the pharmaceutical sector, the Act introduced an array of
different cost-containment measures and substantial structural changes,
including:
the already-mentioned co-payment increases and revision of the exemption
rules;
exclusion of OTC medications from SHI reimbursement, except for certain
named drugs;
reintroduction of reference prices for patented drugs with no or little
therapeutic benefits (as determined by the Federal Joint Committee on the
basis of the evaluation by the Institute for Quality and Efficiency);
increase of rebates that manufacturers have to grant for patented drugs
dispensed to SHI-insured outpatients as long as these are not included in
the reference-price scheme;
the possibility for sickness funds to directly negotiate contracts with drug
manufacturers;
liberalization of price-setting for OTC (leaving fixed prices on prescription
drugs);
introduction of e-commerce;
the possibility for pharmacists to operate three branches of their main
pharmacy within a reasonable distance;
change of the pharmacists surcharge from digressive percentage margins to
a fixed dispensing fee of 8.10 per pack of prescription-only drugs.
To improve the coordination of decision-making across sectors, the Federal
Joint Committee was introduced, taking over functions of the Federal Committee
of Physicians and Sickness Funds, the Federal Committee of Dentists and
Sickness Funds, the Committee for Hospital Care and the Coordinating
Committee. The Federal Joint Committee was also delegated tasks of the
multi-stake-holder body for quality assurance to integrate quality measures into
administrative decisions and to better link them to incentives and sanctions (for
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details see Planning, regulation and management). The Federal Joint Committee
will be assisted by the Institute for Quality and Efficiency, which will evaluate
benefit and risk (but in contrast to previous plans, not cost-effectiveness) of
drugs and other interventions, support the committee in other aspects of its
work and provide evidence-based patient information.
Another aspect of the Act is strengthening the individual and collective
rights of patients by introducing a patients commissioner and giving accredited
organizations representing the rights of the chronically ill a seat in the joint
self-governing structures at the Lnder level, and most visibly in the Federal
Joint Committee, where nine non-voting delegates have the right to participate
in consultations and propose issues.
Various measures of the Act are expected to lead to a diversification of
ambulatory care models via the introduction of a right to establish so-called
medical centres, i.e. multidisciplinary institutions providing ambulatory care.
Under the regulation of regional physicians associations and in competing
with physicians practices, these health centres can offer services in family
medicine, specialist ambulatory care and integrated care. Up to now, only a
few health centres exist in Berlin and Brandenburg as successors of the German
Democratic Republics polyclinics (see Historical development). All sickness
funds are required to offer family practitioner models to better coordinate
services and may include various forms of gatekeeping. Members may, but are
not required to participate.
Integrated care offered by providers of different sectors under a single
contract with a sickness fund has become easier and more attractive. This shall
be financed, at least for 2004 to 2006, by subtracting 1% of the funds available
for ambulatory physician and hospital care. In contrast to the governments
original plans, selective contracting does not apply to all ambulatory specialist
physicians, but only to participants of integrated care projects.
By 2005 smaller regional physicians associations are to be reorganized into
larger units and, more importantly, need to employ full-time managers instead
of the current boards of practising physicians (for sickness funds, this has been
mandatory since 1993). The governments original plan to reorganize the payers
side was withdrawn during the course of negotiations to avoid destabilization
of the institutional framework while funds are charged with increased tasks to
intervene in provision and coordinate care.
A large number of the Acts paragraphs implemented European Union
directives or jurisdiction, for example, the European Union health smart card,
the financing of on-call shifts as working time in hospitals, and information
duties with regard to the geographical origin of dentures. Following the MllerFaur/van Riet decision of the European Court of Justice (C- 385/99) from May
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2003, any insured person may now be reimbursed for ambulatory care received
in any European Union country even if pre-authorization is not sought or if the
provider is not contracted by the respective health service or health insurance. To
avoid discrimination against people seeking care in Germany, these rules now
also apply to all insured (not only the voluntarily insured) within the country.
However, the Act provides several precautions, for example, sickness funds may
apply deductions for administration or shortfalls in co-payments and efficiency
controls before reimbursing their insured. The Act also opens the way for single
sickness funds to contract selectively with providers in other EU-15 countries
within the legal framework for SHI on integrated care models.
The SHI Modernization Act is part of a broader package of fundamental
economic, social and educational reforms called Agenda 2010. The financial
success of the act is being closely monitored by public opinion in Germany,
but also and probably more than ever before by the other European Union
member states. The European Council and the Commission have criticized the
raising of social (health) insurance contributions as a barrier to spurring the
national economy and to reducing the federal government deficit to below 3%
of GDP, as agreed in the Maastricht Treaty.
While the benefit cuts, the co-payments and exemption rules received
substantial sceptical publicity during the first months of the acts implementation,
other more organizational clauses of the reform have received less publicity.
By October 2004, about 170 contracts for integrated care had been negotiated.
Since January 2004, sickness funds have gained substantial savings particularly
due to the increase of co-payments, the reduction of benefits, and rebates in the
drug sector. Yet, contribution rates have not been reduced as much as expected
by federal government, and only a few sickness funds have announced to reduce
the rate in 2005. While the government demands publicly that sickness funds
shall transfer a part of savings to employees and employers, most sickness
funds argue that they need to pay off debts and that expenditures are expected
to rise again in the future to an yet unknown extent.
Since the community-rated flat-rate insurance for dentures, as foreseen by
the SHI Modernization Act for 2005, were considered too expensive concerning
administrative costs and unfair, the governing parties introduced a new Act to
Adjust the Financing of Dentures to the Federal Assembly which was passed
in October 2004. From July 2005 employees will have to pay a special
contribution of 0.4% of their gross income that shall cover expenditures of
dentures, while employers do not have to contribute. In addition, the original
special contribution of 0.5% shall be introduced already in July 2005, making
it a 0.9%-special contribution. At the same time, sickness funds shall become
legally obliged to reduce contribution rates by 0.9 percentage points.
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Future reforms
Further reforms are already under way: The federal government has presented
a framework for a bill to strengthen prevention and better coordinate activities
of the various actors involved. Initiated by the governing coalition the act shall
summarize existing legislation on prevention, clarify responsibilities, reduce
legal barriers, and improve coordination of various actors involved. It shall
become a special section of the Social Code Book besides the social code
books on rehabilitation or statutory health insurance. According to the reform
milestones agreed by the working group, sickness funds, statutory retirement
insurance and statutory accident insurance shall be responsible for financing
the preventive measures envisaged by the bill, i.e. mainly personal services
directed at personal lifestyle with consideration of setting-related approaches.
The bill raised controversy, especially among the actors of the self-governing
structures in statutory health insurance, since federal and state governments are
not required to contribute financially but shall participate in the foundations
governance. One fifth of finances shall be used for population-wide prevention
programmes and given to a federal foundation.
For long-term care insurance the Federal Constitutional Court has demanded
that members with children should pay smaller contributions than members
without children. Two expert commissions dealt with wider questions of
reforming long-term care insurance in the mid of 2003, both suggesting building
a capital stock to achieve sustainable funding. The government-installed
Rrup Commission proposed charging pensioners an extra contribution. The
oppositions Herzog Commission, however, suggested an increased employer
contribution, with employers compensated by the elimination of another public
holiday. In addition, the Herzog Commission wanted to extend the funding base
to all types of income. Otherwise they presented similar recommendations:
long-term care insurance should be maintained as a social insurance financed
by contributions from employers and employees, and should continue to provide
benefits up to a limited amount. These upper limits should be equal regardless
of whether the recipient receives ambulatory or inpatient care (thus replacing
the currently higher limits for inpatient care). Benefits should be adjusted to
inflation and changes in labour costs. People with dementia should qualify
equally for benefits, which would require an extension of the currently somatic
orientation of the definition of need, and the range of services provided.
Another option, suggested in a draft bill by the Ministry of Health, demanded
an extra contribution from insured people without children, combined with
an increase of entitlements and services for demented people. However, in
January 2004, the Chancellors office refused that proposal as unpopular. Thus,
many of the measures are currently being discussed again. Other long-standing
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recommendations of providers and consumer organizations are currently

discussed at the political level, especially ways to strengthen prevention and
rehabilitation within long-term care. A small solution to the courts demands was
passed by the Federal Assembly in 2004 but a wider reform will be postponed
until 2005.
Furthermore, the Federal Assembly has asked federal and state governments
to review the existing risk compensation scheme and develop concepts for
institutional reform on the financing side, including plans that were rejected
during the negotiations for the SHI Modernization Act to facilitate mergers of
the 292 sickness funds, to enable funds to leave their association and join another
one, and to ban new sickness funds until 2007 (after which the risk structure
compensation mechanism is supposed to be based on morbidity criteria).
It is also expected that institutional reforms on the delivery side, especially
alternatives to the current modification of the ambulatory monopoly of regional
physicians associations, will be discussed.
Since 2003 a broad consensus has evolved that the financing of social
insurance branches requires fundamental changes. For health insurance, the
concepts currently vary between broadening the contribution base to all residents
and other types of income (citizen insurance) as supported by the governing
parties and community-rated per-capita premiums, similar to the Swiss model
as favoured by the opposing Christian Democratic Union. Current political
programmes are based on the results of the Rrup Commission, established by
the Chancellor in early 2003 and composed of experts as well as representatives
of employers, trade unions and other groups, and charged with developing
reform proposals for the sustainable financing of the social insurance systems,
including SHI.
As the Commission could not agree on a single proposal, its final report
contained two options. The first one (flat-rate health premiums) recommended
the following elements for SHI:
SHI contributions financed irrespective of income by means of a flat-rate
health premium model (around 200 a month for all adults, with dependant
children still insured without charge);
Taxable payment of the present employers contribution for all employed
people and pensioners irrespective of the form of their health insurance
status as gross wage;
Social compensation as premium subsidies for low-income earners via the
tax system.
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The other model, a contribution-based insurance for the entire population,

also known as citizens insurance, seeks to broaden the SHI contribution
base by:
extending the contribution assessment basis by further types of revenue
(e.g. rents and interest);
raising the contribution assessment limit by about one third, to the level
of the statutory old age pension insurance, currently around 5100 gross
salary per month;
extending mandatory SHI to more groups (civil servants, self-employed and
farmers) by the abolishing the mandatory insurance limit.
For both models, the actual redistributive effect will depend on the extent
of tax subsidies or the threshold for contributions, respectively. According to
original calculations of the Rrup Commission, the citizens insurance model is
projected to provide relief for those with household incomes between 10000
and 40 000 while their suggested model of per-capita premiums would lead to
savings for households earning between 40 000 and 120 000 per year; higher
incomes would not gain due to the necessarily higher taxes. Equal per-capita
premiums would require substantial social transfers and income redistribution
from taxes.
The major political parties are at odds with each other about the future
funding of the health care system. The governing Social Democrats and
Greens are in favour of the citizens insurance scheme and included it into their
programme in autumn 2003. The Free Democratic Party wants to transfer all
SHI funds to private health insurance in a complete privatization of the system.
The Christian Democratic Union (CDU) passed a modified version of flat rate
health premiums at their party congress in December 2003 that would base
reserves for old age on capital cover. The CDU will advocate this model in the
next elections in 2006. However, there is substantial controversy within the
parties, for example, the Christian Socialist Party from Bavaria opposes percapita premiums in favour of a premiums which are still related to income. On
the other hand, the Chancellor has shown substantial reservations about citizens
insurance, as a threat to the private health care industry, which currently insures
9% of the population with comprehensive substitutive insurance and another
9% with supplementary insurance, and a burden to governmental schemes for
officials raised to finance the required social transfers.
Germany
Conclusions
he German system has put more emphasis on free choice, ready

access, high numbers of providers and technological equipment than
on cost effectiveness or cost containment per se (in spite of all the
cost-containment acts that have been passed). The public has supported these
priorities and, if they are used as criteria for assessment, the health care system
appears to work well. Formal waiting lists and explicit rationing decisions are
virtually unknown. These priorities are further supported by the complicated
decision-making processes. While the SHI framework and co-payment levels
are set by federal law, most decisions on the actual contents of the uniform
benefits package and the delivery of curative health services are made through
joint negotiations between the physicians associations and the sickness funds
at both regional and national levels. Cuts therefore require some support from
the sickness funds and the providers.
Although the absolute amount of total health care expenditure has increased
by nearly one half since 1992, it increased by about one tenth as a percentage
of GDP (from 9.9% to 10.9% in 2002) (21) while real annual growth of health
care expenditures ranked below most other OECD countries. This is even
more remarkable, since the statutory long-term care insurance and a number of
new SHI benefits have been introduced. Furthermore, SHI expenditures have
remained relatively stable, increasing from 6.14% of the GDP in 1992 to 6.32%
in 2002. This was due to reforms that primarily sought to prevent sickness fund
expenditure from increasing faster than the income. This goal has led to efforts
to contain costs and the policy of income-oriented expenditure, with the aim
of stabilizing contribution rates. The various stake-holders have managed to
maintain comprehensive health care coverage despite the economic challenges
of reunification, decreasing SHI revenues, and ongoing cost-containment
policies. SHI still covers 88% of the population comprehensively with 57%
of total expenditure. People with social and private health insurance basically
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have ready and equal access to services at all levels, although to a lesser extent
in rural areas.
Substantial changes have been implemented during the last decade to allocate
resources more appropriately to meet the health needs of the population. Longterm care was strengthened most by introducing a branch of social insurance
offering new benefits (though insufficient for dementia) and a rise in the number
of nurses and elderly care-takers as well as ambulatory and in-patient capacities.
New SHI benefits were introduced for patient education, patient information,
sociotherapy for the mentally ill as well as hospice care.
Another achievement is that health and care inequities between the eastern
part and the western part have been reduced substantially since reunification.
Health care of the former German Democratic Republic (GDR) in the eastern
part of Germany was quickly transformed basically by adopting the system of
financing, delivery, decision-making and planning of the old Federal Republic
of Germany (FRG) in the western part. Also, most of the relative eastern deficits
in equipment, building and maintenance standards and nursing home capacities
have been compensated by substantial government investment. Staff capacities
and reimbursement in institutions and ambulatory care have also been increased
close to western levels.
In the last 15 years, life expectancy and most indicators available for health
have improved substantially. This trend was observable in most countries of
the EU, yet the eastern part of the country has experienced one of the most
remarkable increases in life expectancy anywhere in the world. While many
factors have contributed to this success, health care is definitely one of the
important factors. Although several official reports have recently highlighted
the improvements in health status and increase of capacities in the eastern
part, these are still not really appreciated as a success story within Germany.
Rather, the high costs of unification and the disappointment that the economic
situation has not improved as much as initially promised have tended to be the
focus of debate. There may, however, be a reluctance to address these issues
because of the negative connotations among the population in the eastern part
of the dominance in the reform process of western actors and interests, to whom
acceptance of the uniform health insurance or the polyclinic system of the former
GDR would have posed a considerable threat. It is, of course, unknown whether
such acceptance would have produced outcomes as good or better than those
of the current system. The introduction of multi-disciplinary treatment centres
in all parts from 2004 and current debates about a citizens insurance were
received with a kind of satisfaction in the eastern part at certain characteristics
of the GDR health care system not having been completely wrong.
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There is increasing doubt whether the high level of spending on health

translates into good quality care and cost-efficient use of resources. This
discussion was largely stimulated by the World Health Report 2000, which
ranked Germany only at number 25 in health system performance (the efficiency
of goal attainment to financial resources spent). Even though the report was
criticized for its methodological weaknesses, the general conclusion in regard
to Germany appears to be valid (82).
Also the Advisory Council for the Concerted Action in Health Care identified
substantial scope for efficiency gains and quality improvement. Based on a
survey of all major stake-holders in health care including payers, providers, selfhelp groups and government agencies, the expert committee found evidence of
over-use and economic inefficiencies but also for under-use and avoidable harm
from medical care in most common chronic diseases (16). It also demanded that
medical errors be put higher on the agenda and policies be improved (35). In
agreement with many respondents of the survey, the Advisory Council argued
that the sectorization of not only health care delivery but also of financing and
regulation was a major barrier to improving adequacy and efficiency of care.
The following sub-sections, not necessarily sorted by relevance, address
some of the main issues facing the German health care system.
Cost-containment and reimbursement. The gap between expenditures and
income of sickness funds and the future viability of the pay-as-you-go principle
are major political concerns. Germany has the highest level of health care
expenditure in the European Union. It was always comparatively high, but in
1960, its 4.2 % of GDP was closer to the level of the other European Union
countries. Unification was accompanied by a sharp increase from 9.3% of
GDP in 1990 to 10.4% in 1995. This can mostly be explained through a lower
level of income in the eastern Lnder. The high level of expenditure is also
reflected in a nearly steady increase in contribution rates, from around 12% in
1990 to 14.2% in 2004. While cost-containment was successful in stabilizing
expenditures in ambulatory medical and dental care and also hospital care after
1998, spending on care provided by allied health professionals, medical devices
and transport/emergency services was less effectively curbed. Expenditure on
pharmaceuticals increased rapidly in the early 1990s, was effectively controlled
through budgets until 2000, and has increased again.
Cost-containment will therefore remain high on the political agenda. Another
focus will be on the impact of the DRG payment system in hospitals and the
development of appropriate and cost-conscious reimbursement mechanisms for
ambulatory physicians. Particular attention will have to be paid to the interplay
of incentives across levels of care. Increasing capitated elements in primary
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care and new performance-oriented payments in secondary ambulatory care

may hinder utilization at the lowest level of care.
Self-governing structures, accountability and participation.The German health
care system is based on decentralized decision-making and the democratic
legitimization of established actors. Its self-governance has been regarded as
a sound basis for effective negotiations, public trust and safeguards against
unwanted government interference. However, self-governing structures of
professions, providers and sickness funds have increasingly come under scrutiny
to lack transparency and public accountability.
Strengthening the financial income basis. It has been widely recognized by now
that even when cost-containment policies are continued the financing crisis
on the income side would somehow overshadow expenditure crisis. Three facts
are especially relevant to this matter: First, the high level of unemployment
narrows the financial basis of SHI contributions. Second, labour is responsible
for an ever-decreasing share of the national income, while the share of capital
is increasing. These factors result in a relative reduction in the financial flow
to the social insurance system. Third, civil servants and the self-employed are
currently not covered by statutory health insurance.
In conjunction with the other social insurance components (predominately
pensions, long term insurance, unemployment insurance), this has been one
of the primary problems of the German health care system. The particular
construction of the system with solidarity financing, given the demographic and
socioeconomic trends, has led to an increasing proportion of wages contributed
to social insurance, which threatens to increase unemployment and jeopardize
economic growth. Both proposals for a future financing system, i.e. the health
premiums and the citizens insurance, try to tackle this problem, albeit with
differing emphasis on the various components. While the first aims at decoupling
insurance contributions from cost of labour, the latter aims at extending the
contribution base beyond the shrinking contributory basis of employed persons.
More than 120 years after the establishment of a statutory health insurance at
national level the question of a universal coverage of the population is discussed
for the first time. At the same time, in current debates about reforming the
revenue basis, the likely substantial impact on self-governing structures has
hardly been discussed.
Crossing sectoral boundaries of care and allocative efficiency. One weakness
of the German system, the fragmentation of care across sectors, has been
addressed by several recent reforms, such as coordination of SHI, long-term
care insurance and the Social Retirement Insurance (which covers the majority
of rehabilitative care). The separation of ambulatory care and inpatient care
have also been addressed by specific measures including highly specialized
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hospital outpatient clinics, ambulatory surgery at hospitals, dispensing of drugs

for ambulatory care by hospital pharmacies and integrated care models.
The exact extent of the duplication of services and the number of inappropriate
referrals that are either made too early (due to sectoral budgets) or too late (due
to difficulties in communication) are not exactly quantifiable. There is, however,
a broad consensus that there are, at least potentially, negative consequences
for patients. The weak role of primary care and the absence of gatekeepers to
steer the patient through the system are also products of the separation issue.
The sickness funds are ambiguous about this; on the one hand, they claim to
support gatekeeping by family physicians, on the other hand, many of their
disease management programmes and other models may be intended to increase
their own gatekeeping role. The Reform Act of SHI 2000 has addressed these
issues by allowing contracts between the sickness funds and intersectoral
groups of providers and giving the funds the option to introduce gatekeeping
on a voluntary basis. The SHI Modernization Act requires that all funds have
to offer integrated care and spend 1% of their budget on this new sector. In
addition, they now have to offer the option to adapt to a gatekeeping model that
may be combined with various bonus incentives for members.
The future direction of reform is to increase the role of general practitioners,
which requires a strengthening of their position vis--vis office-based specialists,
improvement of training for guiding patients through the system and increased
public awareness of the ability of the general practitioners to guide them.
Office-based specialists, on the other hand, will increasingly have to face
competition with the hospital sector, which is gradually allowed to provide
more ambulatory treatment. While this will open new opportunities for the
hospitals to compensate losses from further reduced inpatient capacities, it will
also aggravate the problem of large, often duplicate capacities for specialized
ambulatory care. Also, it is expected that earlier discharges from acute care will
pose substantial challenges to the ambulatory sector and e.g. institutions for
rehabilitation. Future health care reforms will probably have to deal with this
issue, which will require a consensus of all actors including the Lnder.
Technical progress and health technology assessment. The handling of
innovations is an important question in all sectors of care, and should be
an important target when developing health technology assessment. Some
recent measures to improve quality and expenditure control are associated
with decreased innovation, for example, DRGs and disease management
programmes. The role of HTA can be expected to increase substantially in
supporting decision-making and informing providers and users. While decisionmaking has been integrated on the administrative level in the new Federal Joint
Committee in 2004, the actual coordination of regulations across sectors still
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shows considerable inconsistency in various health care sectors, especially

the licensing, coverage, diffusion and use of technologies. It also remains to
be seen if the new Institute for Quality and Efficiency can play a decisive role
which requires both producing high-quality evidence and being accepted by the
decision-making actors in the Federal Joint Committee and beyond.
Collectivism and competition. Throughout the history of the German SHI,
regulations have become much more uniform. In the late nineteenth century,
individual sickness funds contracted with individual physicians. Later,
individual sickness funds contracted with physicians associations. Then, certain
sickness funds negotiated together but differences remained between the socalled primary funds and the substitute funds. The Health Care Reform Act of
1989 was an attempt to strengthen the purchasers side by standardizing and
centralizing all negotiating procedures while at the same time standardizing the
benefits package. By introducing a risk compensation mechanism, the Health
Care Structure Act of 1993 led to a narrowing of differences in contribution
rates. The Act also introduced free choice of funds for members and therefore
competition among funds. True market competition is not possible, however,
since the sickness funds have to offer nearly the same benefits for very similar
contribution rates; in addition, the range of providers is also the same since
they are contracted collectively. In this situation it is not surprising that funds
particularly the more successful ones in terms of gaining new members are
demanding greater flexibility for selective contracting.
Health policy-makers are cautiously supporting selective contracts while
trying to retain a system with equal access and service quality for all the insured
population. Possibilities for selective contracting are therefore increasing only
gradually, as in the latest SHI Modernization Act, enforced from 2004. The
issue will remain a subject for debate.
Health policy with European dimension. At least since the decisions of the
European Court of Justice in May 2003, it is clear that the free choice of
ambulatory health care goods and services also applies to the German statutory
health care system. Changes in the utilization of cross-border ambulatory care
services are expected to be hardly noticeable to the countrys economy as a
whole, and the few increases will remain restricted to border regions. However,
dental care, elective treatments and certain high-cost drug treatments in EU
countries with lower prices may exert some influence on health expenditure.
In the hospital sector, the treatment of European and international patients is
expected to further increase, especially those from countries with waiting lists.
National health policy-making is expected to increasingly take EU regulations
into account and shape health policy at EU level proactively.
Germany
References
(1)
(2)
(3)
(4)
(5)
(6)
(7)
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List of tables
Table number
Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Table 8.
Table 9.
Table 10.
Table 11.
Table 12.
Table 13.
Table 14.
Table 15.
Table 16.
Table 17.
Table 18.
Table 19.
Title
Macro-economic indicators, 19922002
Trends in health risks, morbidity and mortality, 1991 and 2001
Life expectancy in years at birth in western and eastern parts of Germany,
19492003
Trends in statutory health insurance (SHI), 18852003
Health care personnel and hospital capacities, 18762002
Number of sickness funds in Germany, 19932004 (on 1 January)
Decision-making competencies in German health care by sector, 2004
Development of the public-private mix in ownership of general hospitals,
19902002
Main sources of finance, in percentage of total, 19702002
Trends in financing statutory health insurance (SHI), 19922003
Transfer sums in the risk structure compensation (RSC) scheme absolute
and relative to total SHI expenditure for western and eastern Germany,
19952003
Co-payment/ co-insurance levels in Germany, 19942004
Changes in per capita SHI and PHI expenditure, 19922002 in the western
part of Germany
Trends in health care expenditure, 19702002
Total and SHI expenditures on health by institution as a share of GDP (%)
by type of service, 19922002
Specialties and functions of physicians providing ambulatory care in SHI,
19902002
Number of beds in hospitals and homes (per 100 000 inhabitants),
19912001
Inpatient structure and utilization data I: general and psychiatric hospitals
in western and eastern parts of Germany, 19912001
Inpatient structure and utilization data II: preventive and rehabilitative
institutions in western and eastern parts of Germany, 19912001
Germany
Table number Title

Table 20a.
Inpatient utilization and performance in acute hospitals in the WHO European
Region, 2002 or latest available year
Table 20b.
Inpatient utilization and performance in acute hospitals in the European
Union, 2002 or latest available year
Table 21.
Expenditures and revenues of statutory long-term care insurance in billion
Euro, 1996-2003
Table 22.
Health care workforce, 19912002 (per 100 000 population)
Table 23.
Needs-based population ratios defined as covering 100% of need per
specialty highest and lowest ratios (defined as one physician per X
population; data from 2003)
Table 24.
Expenditures on pharmaceuticals, 19922002
Table 25.
Trends in prescription behaviour for SHI insured and turnover
in the SHI-pharmacy market, 19922003
Table 26.
High medical technologies per million inhabitants, 19922001
Table 27.
Cost-containment through budgets and spending caps, 19892005
Table 28.
The German Lnder hospital bed numbers, 19912001 and capital
investment 2001
Table 29.
Expenditure data for general and psychiatric hospitals in western and eastern
parts of Germany, 19912001
Table 30.
SHI physician fees: top 20 by turnover, with relative point values per service,
2002
Table 31.
Indicators for the ambulatory care by SHI-affiliated physicians changes in
the number of physicians, services provided, and remuneration, 1980-2001
(in current prices)
Table 32.
Remuneration and income from SHI of SHI-affiliated physicians
in ambulatory practice, 2001
Table 33.
Chronology of health reforms, 19882004
List of figures
Fig. number
Fig. 1
Fig. 2
Fig. 3.
Fig. 4
Fig. 5.
Fig. 6a.
Fig. 6b.
Fig. 7a.
Fig. 7b.
Fig. 8a.
Fig. 8b.
Fig. 9a.
Fig. 9b.
Fig. 10a.
Fig. 10b.
Title
Map of Germany and neighbouring countries
Political map of Germany at the level of the Lnder
The organizational relationships of the key actors in the German health care
system, 2005
Average annual contribution rates (%) by sickness fund association,
19822004
Trends in total expenditure on health care in Germany and selected
countries, 19702002 (percentage of GDP)
Total expenditure on health as a % of GDP in the WHO European Region,
Total expenditure on health as a % of GDP in the European Union,
Health care expenditure in US$PPP per capita in the WHO European Region,
Health care expenditure in US$PPP per capita in the European Union,
care expenditure in countries in the WHO European Region,
care expenditure in countries in the European Union,
Levels of immunization for measles in the WHO European Region,
Levels of immunization for measles in the European Union,
Outpatient contacts per person in the WHO European Region,
Outpatient contacts per person in the European Union,
Germany
224
Fig. number
Fig. 11.
Fig. 12a.
Fig. 12b.
Fig. 13
Fig. 14a.
Fig. 14b.
Fig. 15.
Germany
Title
Number of acute hospital beds in Germany and selected countries,
19702002 (per 100 000 population)
Hospital beds in acute hospitals per 1000 population in western Europe,
Hospital beds in acute hospitals per 1000 population in the European Union,
Number of physicians in Germany and selected European countries
per 1000, 19902002
Number of physicians and nurses per 1000 population in the WHO European
Region, 2002 or latest available year (in parentheses)
Number of physicians and nurses per 1000 population in the European
Union, 2002 or latest available year (in parentheses)
Financing flow chart of the German health care system, 2002
Weblinks
Institution
Health care actors at federal level
Federal Assembly
Federal Ministry of Health and Social Security
Federal Institute for Communicable and NonCommunicable Diseases
Federal Institute for Pharmaceuticals and
Medical Devices
Federal Centre for Health Education
German Institute for Medical Documentation
and Information
Federal Insurance Authority
Federal Authority for Financial Services
Supervision
Federal Association of SHI Physicians
Federal Association of SHI Dentists
German Hospital Organization
Federal Association of General Regional
Funds
Federal Association of Substitute Funds
Federal Association of Company-based Funds
Federal Association of Guild Funds
Federal associations of sickness funds
German Council of Disabled Persons
Federal Association Consumers Centres
Association of Private Health Insurance
German Nursing Council
Federal Physicians Chamber
Federal Psychotherapists Chamber
Website
http://www.bundestag.de
http://www.bmgs.bund.de
http://www.rki.de
http://www.bfarm.de
http://www.bzga.de
http://www.dimdi.de
http://www.bva.de
http://www.bafin.de
http://www.g-ba.de
http://www.kbv.de
http://www.kzbv.de
http://www.dkgev.de
http://www.aok-bv.de
http://www.vdak.de
http://www.bkk.de
http://www.ikk.de
http://www.g-k-v.com
http://www.behindertenrat.de
http://www.vzbv.de
http://www.pkv.de
http://www.deutscher-pflegerat.de
http://www.baek.de
http://www.bundespsychotherapeutenkamm
er.org
Germany
226
Institution
Federation of Pharmacists Organizations
Association of Research-based
Pharmaceutical Companies
Federal Association of Pharmaceutical
Manufacturers
Federal Alliance of Voluntary Welfare
Organizations
Association of the Scientific Medical Societies
Federal Office for Quality Assurance
Health targets initiative
German Diagnosis-related Groups
Other national information sources
Federal Health Reporting Database
Federal Statistical Office
Advisory Council for Evaluating the
Development in Health Care
Gesundheitspolitik.net
Dept. Health Care Management, Technische
Universitt Berlin
International information sources
European Observatory on Health Systems
and Policies
WHO Regional Office for Europe health for all
database
Organization for Economic Cooperation and
Development
Health Policy Monitor of the Bertelsmann
Foundation
Germany
Website
http://www.abda.de
http://www.vfa.de
http://www.bah-bonn.de
http://www.bagfw.de
http://www.awmf-online.de
http://www.bqs-online.de
http://www.gesundheitsziele.de
http://www.g-drg.de
http://www.gbe-bund.de
http://www.destatis.de
http://www.svr-gesundheit.de
http://www.gesundheitspolitik.net
http://mig.tu-berlin.de
http://www.observatory.dk
http://www.euro.who.int/hfadb
http://www.oecd.org
http://www.healthpolicymonitor.org/
Glossary
English name
German name
German
abbreviation
1st Case Fees Amendment Act
1. Fallpauschalen-nderungsgesetz
1. FPndG
2nd Case Fees Amendment Act
2. Fallpauschalen-nderungsgesetz
2. FPndG
1st Statutory Health Insurance (SHI)

Restructuring Act
1. GKV-Neuordnungsgesetz
1. NOG
2nd Statutory Health Insurance (SHI)

Restructuring Act
2. GKV-Neuordnungsgesetz
2. NOG
12th Social Code Book V Amendment Act
12. Sozialgesetzbuch-V-nderungsgesetz
Act to Adjust the Financing of Dentures
Gesetz zur Anpassung der Finanzierung von

Zahnersatz
Act to Equalize Statutory Provisions in

Statutory Health Insurance
Gesetz zur Rechtsangleichung in der

gesetzlichen Krankenversicherung
Act to Newly Regulate Choice of Sickness

Funds
Gesetz zur Neuregelung der

Krankenkassenwahlrechte
Act to Reform the Risk Structure

Compensation Scheme in Statutory Health
Insurance
Gesetz zur Reform des

Risikostrukturausgleichs in der GKV
Advisory Council for Evaluating the

Development in Health Care
(previously: Advisory Council for the
Concerted Action in Health Care)
Sachverstndigenrat zur Begutachtung

der Entwicklung im Gesundheitswesen
(frher: fr die Konzertierte Aktion im
Gesundheitswesen)
SVR
Alliance of German Nurses Associations
Arbeitsgemeinschaft Deutscher
Schwesternverbnde
ADS
Association of Independent Voluntary

Welfare Organizations
Deutscher Parittischer Wohlfahrtsverband
DPW
Association of Private Health Insurance
Verband der privaten Krankenversicherung
PKV
Association of Protestant Welfare

Organizations
Diakonisches Werk
Germany
228
English name
German name
German
abbreviation
Association of Research-based
Pharmaceutical Companies
Verband forschender Arzneimittelhersteller
VfA
Association of the Scientific Medical

Societies
Arbeitsgemeinschaft WissenschaftlichMedizinischer Fachgesellschaften
AWMF
Basic Law (= constitution)
Grundgesetz
case fee
Fallpauschale
Commissioner of the Federal Government

for the Concerns of Disabled People
Beauftragter der Bundesregierung fr die

Belange behinderter Menschen

for the Concerns of Patients

Belange der Patientinnen und Patienten

for the Elections in Statutory Insurance

Sozialversicherungswahlen
(the former) Committee for Hospital Care
Ausschuss Krankenhaus
company-based (sickness) funds
Betriebskrankenkassen
BKK
(the former) Concerted Action in Health

Care
Konzertierte Aktion im Gesundheitswesen
KAiG
Contribution Rate Stabilization Act
Beitragssatzsicherungsgesetz 2003
BSSichG
(the former) Coordinating Committee

(between Committee for Hospital Care
and Federal Committee of Physicians and
Sickness Funds)
Koordinierungsausschuss
(regional) dentists association
Kassenzahnrztliche Vereinigung
(regional) dentists chamber
Zahnrztekammer
directive (issued by the Federal Joint

Committee)
Richtlinie (des Gemeinsamen

Bundesausschusses)
farmers (sickness) funds
Landwirtschaftliche Krankenkassen
LKK
Federal Authority for Financial Services

Supervision
Bundesanstalt fr Finanzdienstleistungsaufsicht
BAFin
Federal Alliance of Patient Centres and

Initiatives
Bundesarbeitsgemeinschaft
PatientInnenstellen
BAGP
Federal Alliance of Voluntary Welfare

Organizations
Bundesarbeitsgemeinschaft der Freien

Wohlfahrtspflege
Federal Assembly (Lower Chamber of

Parliament)
Bundestag
Federal Association of Pharmaceutical

Manufacturers
Bundesfachverband der ArzneimittelHersteller
BAH
Federal Association of SHI Dentists
Kassenzahnrztliche Bundesvereinigung
KZBV
Federal Association of SHI Physicians
Kassenrztliche Bundesvereinigung
KBV
Federal Association of the Pharmaceutical

Industry
Bundesverband der Pharmazeutischen

Industrie
BPI
Federal Centre for Health Education
Bundeszentrale fr gesundheitliche
Aufklrung
BZgA
(the former) Federal Committee of

Physicians and Sickness Funds
Bundesausschuss der rzte und

Krankenkassen
Germany
KZV
229
English name
German name
German
abbreviation
Federal Council (Upper Chamber of

Parliament)
Bundesrat
(the former) Federal Health Council
Bundesgesundheitsrat
(the former) Federal Health Office
Bundesgesundheitsamt
BGA
Federal Highway Research Institute
Bundesanstalt fr Straenwesen
BAST
Federal Hospital Reimbursement Ordinance Bundespflegesatzverordnung

Federal Institute for Communicable and
Non-Communicable Diseases (Robert
Koch-Institute)
Robert Koch-Institut
RKI
Federal Institute for Health Protection of

Consumers and Veterinary Medicine
Bundesinstitut fr gesundheitlichen
Verbraucherschutz und Veterinrmedizin
BgVV
Federal Institute for Pharmaceuticals and

Medical Devices
Bundesinstitut fr Arzneimittel und

Medizinprodukte
BfArM
Federal Institute for Sera and Vaccines

(Paul Ehrlich-Institute)
Paul Ehrlich-Institut (Bundesamt fr Sera

und Impfstoffe)
Federal Insurance Authority
Bundesversicherungsamt
BVA
Gemeinsamer Bundesausschuss
G-BA
Federal Ministry of Health
Bundesministerium fr Gesundheit
BMG
Federal Ministry of Health and Social

Security
(abbreviated in the text: Federal Ministry of
Health)
Bundesministerium fr Gesundheit und

Soziale Sicherung
BMGS
Federal Office for Quality Assurance
Bundesgeschftsstelle fr
Qualittssicherung
BQS
Federal Physicians Chamber
Bundsrztekammer
BK
Federal Psychotherapists Chamber
Bundespsychotherapeutenkammer
Federal Republic of Germany (official name

for the old federal states until 1990, since
1990 unified with the new federal states in
the eastern part of Germany)
Bundesrepublik Deutschland
Federal Statistical Office
Statistisches Bundesamt
(the former) Federal Supervisory Office for

the Insurance Sector
Bundesaufsichtsamt fr das
Versicherungswesen
Federation Consumer Centres
Verbraucherzenterale Bundesverband
VZBV
Federation of Pharmacists Organizations
Bundesvereinigung Deutscher
Apothekerverbnde
ABDA
Foundation for the Testing of Consumer

Goods (and Services)
Stiftung Warentest
general regional (sickness) funds
Allgemeine Ortskrankenkassen
AOK
German Alliance Self-Help Groups
Deutsche Arbeitsgemeinschaft
Selbsthilfegruppen
DAG-SH
German Caritas (= Catholic Welfare)

Organization
Deutscher Caritasverband
German Council of Disabled People
Deutscher Behindertenrat
DBR
Germany
230
English name
German name
German
abbreviation
(the former) German Democratic Republic
Deutsche Demokratische Republik
DDR
German Family Physicians Organization
Deutscher Hausrzteverband (frher:

Berufsverband der Allgemeinrzte
Deutschlands Hausrzteverband)
German Forum Prevention and Health

Promotion
Deutsches Forum Prvention und

Gesundheitsfrderung
German Generics Association (previously:

Association of Active Pharmaceutical
Companies)
Deutscher Generikaverband (frher: Verband

aktiver Pharmaunternehmen)
German Hospital Organization
Deutsche Krankenhaus-Gesellschaft
DKG
German Institute for Medical

Documentation and Information
Deutsches Institut fr medizinische

Dokumentation und Information
DIMDI
German Nursing Association
Deutscher Berufsverband fr Pflegeberufe
DBfK
German Nursing Council
Deutscher Pflegerat
DPR
German Organization for Physiotherapy
Deutscher Verband fr Physiotherapie

- Zentralverband der Physiotherapeuten/
Krankengymnasten
ZVK
German Pharmacists Organization
Deutscher Apothekerverband
German Psychotherapist Organization

Professional Organization of Psychological
Psychotherapists
Deutscher Psychotherapeutenverband
Berufsverband Psychologischer
Psychotherapeuten
German Red Cross
Deutsches Rotes Kreuz
guild (sickness) funds
Innungskrankenkassen
IKK
Health Care Reform Act (of 1989)
Gesundheitsreformgesetz
GRG
Health Care Structure Act (of 1993)
Gesundheitsstrukturgesetz
GSG
Health Insurance Contribution Rate

Exoneration Act
Krankenversicherungsbeitragsentlastungsgesetz
Health Insurance Cost-containment Act
Krankenversicherungskostendmpfungsgesetz
Health Insurance Cost-containment

Amendment Act
Krankenversicherungs-Kostendmpfungsergnzungsgesetz
Hospital Cost-containment Act
Krankenhaus-Kostendmpfungsgesetz
Hospital Financing Act
Krankenhausfinanzierungsgesetz
Hospital Restructuring Act
Krankenhausneuordnungsgesetz
Infection Protection Act
Infektionsschutzgesetz
IfSG
Imperial Insurance Regulation
Reichsversicherungsordnung
RVO
Institute for Quality and Efficiency
Institut fr Qualitt und Wirtschaftlichkeit
Institute for the Payment System in

Hospitals
Institut fr das Entgeltsystem im

Krankenhaus
list of pharmaceuticals prescribed in SHI
GKV-Arzneimittelindex
Marburg Union of Employed (Hospital)

Physicians
Marburger Bund - Verband der angestellten

und beamteten rztinnen und rzte
Germany
DPTV
KVKG
KHG
INEK
231
English name
German name
German
abbreviation
Mediation Committee (between Federal

Assembly and Federal Council)
Vermittlungsausschuss
Medical Devices Act
Medizinproduktegesetz
MPG
Medical Devices Ordinance
Medizinprodukteverordnung
MPV
miners (sickness) fund
Bundesknappschaft
Narcotic Drug Commissioner of the Federal

Government
Drogenbeauftragte der Bundesregierung
ordinance (issued by ministries)
Verordnung (von Ministerien)
Organization of Democratic Physicians
Verein Demokratischer rztinnen und rzte
Organization of Ergotherapists
Verband der Ergotherapeuten
Organization of German Doctors

Hartmann Union
Verband der rzte Deutschlands

Hartmannbund
Organization of German Primary Care

Physicians General Practitioners Union
Berufsverband der Allgemeinrzte

Deutschlands Hausrzteverband
Organization of German Psychologists
Berufsverband deutscher Psychologen
Organization of SHI-affiliated Psychological

Psychotherapists
Vereinigung der Kassenpsychotherapeuten
Pharmaceutical Act
Arzneimittelgesetz
AMG
Pharmaceutical Budget Redemption Act
Arzneimittelbudgetablsungsgesetz
ABAG
Pharmaceutical Expenditure Limitation Act
Arzneimittelausgaben-Begrenzungsgesetz
AABG
Pharmaceutical Price Ordinance
Arzneimittelpreisverordnung
AmPreisV
(regional) pharmacists chamber
Apothekerkammer
Physicians Approbation Ordinance
rztliche Approbationsordnung
AppO
(regional) physicians association
Kassenrztliche Vereinigung
KV
(regional) physicians chamber
rztekammer
procedure fee
Sonderentgelt
(regional) psychotherapists chamber
Psychotherapeutenkammer
Reference Price Adjustment Act
Festbetragsanpassungsgesetz
VD
BDP
FBAG
Reform Act of SHI 2000
GKV-Gesundheitsreform 2000
Remuneration Distribution Scale
Honorarverteilungsmastab
sailors (sickness) fund
Seekrankenkasse
SHI Medical Review Board
Medizinischer Dienst der

Krankenversicherung
MDK
Social Code Book V (Statutory Health

Insurance)
Sozialgesetzbuch V (Gesetzliche
Krankenversicherung)
SGB V
Social Code Book IX (Rehabilitation and

Participation of Disabled People )
Sozialgesetzbuch IX (Rehabilitation und

Teilhabe behinderter Menschen)
SGB IX
Social Code Book XI (Statutory Long-term

Care Insurance)
Sozialgesetzbuch XI (Soziale
Pflegeversicherung)
SGB XI
State(s)
Land (Plural: Lnder)
HVM
Germany
232
English name
German name
German
abbreviation
statutory health insurance (SHI)
Gesetzliche Krankenversicherung
GKV
Statutory Health Insurance (SHI)

Modernization Act
GKV-Modernisierungsgesetz
Soziale Pflegeversicherung
substitute funds
Ersatzkassen
Uniform Value Scale
Einheitlicher Bewertungsmastab
Valuation Committee
Bewertungsausschuss
Welfare Organization of the Jews in

Germany
Zentralwohlfahrtsstelle der Juden in

Deutschland
Workers Welfare Organization
Arbeiterwohlfahrt
(the former) Working Group Quality

Assurance
Arbeitsgemeinschaft Qualittssicherung
SPV
EBM
AQS
Note: For reasons of international comparability, the names of institutions used in the ensuing text do not
necessarily reflect the English names that institutions use themselves. This glossary updates and extends the
glossary of the HiT Germany 2004.
Germany
The Health care systems in transition

profiles
A series of the European Observatory on Health
Systems and Policies
he Health care systems in transition (HiT) country profiles provide an

analytical description of each health care system and of reform initiatives
in progress or under development. They aim to provide relevant
comparative information to support policy-makers and analysts in the develop
ment of health care systems and reforms in the countries of the European Region
and beyond. The HiT profiles are building blocks that can be used:
to learn in detail about different approaches to the financing, organization
and delivery of health care services;
to describe accurately the process, content and implementation of health
care reform programmes;
to highlight common challenges and areas that require more in-depth
analysis; and
to provide a tool for the dissemination of information on health systems and
the exchange of experiences of reform strategies between policy-makers and
analysts in countries of the WHO European Region.
How to obtain a HiT

All HiT country profiles are available in PDF
format on www.observatory.dk, where you can
also join our listserve for monthly updates of the
activities of the European Observatory on Health
Systems and Policies, including new HiTs,
books in our co-published series with Open
University Press (English), policy briefs, the
EuroObserver newsletter and the EuroHealth
journal. If you would like to order a paper copy
of a HiT, please write to:
The publications of
the European Observatory
on Health Systems and
Policies are available on
www.euro.who.int/observatory
[email protected]
Germany
234
HiT country profiles published to date:

Albania (1999, 2002a,g)
Andorra (2004)
Armenia (1996, 2001g)
Australia (2002)
Austria (2001e)
Azerbaijan (1996, 2004)
Belarus (1997)
Belgium (2000)
Bosnia and Herzegovina (2002g)
Bulgaria (1999, 2003b)
Canada (1996)
Croatia (1999)
Cyprus (2004)
Czech Republic (1996, 2000)
Key
Denmark (2001)
Estonia (1996, 2000, 2004)
All HiTs are available in English.
Finland (1996, 2002)
When noted, they are also available
France (2004c)
in other languages:
a
Georgia (2002d,g)

Albanian
e
e
b
Germany (2000 , 2004 )

Bulgarian
c
Greece (1996)

French
d
Hungary (1999, 2004)

Georgian
e
Iceland (2003)

German
f
Israel (2003)

Romanian
g
Italy (2001)

Russian

h
Kazakhstan (1999g)
Spanish
i
Kyrgyzstan (1996, 2000g)

Turkish
Latvia (1996, 2001)
Lithuania (1996, 2000)
Luxembourg (1999)
Malta (1999)
Netherlands (2004)
New Zealand (2002)
Norway (2000)
Poland (1999)
Portugal (1999, 2004)
Republic of Moldova (1996, 2002g)
Romania (1996, 2000f)
Russian Federation (1998, 2003g)
Slovakia (1996, 2000, 2004)
Slovenia (1996, 2002)
Spain (1996, 2000h)
Sweden (1996, 2001)
Switzerland (2000)
Tajikistan (1996, 2000)
Turkey (1996, 2002g,i)
Turkmenistan (1996, 2000)
Ukraine (2004g)
United Kingdom of Great Britain and Northern Ireland (1999g)
Uzbekistan (2001g)
Germany

Health Care Systems in Transition

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Health Care Systems

The European Observatory on Health Systems and Policies is a partnership

[email protected] (for copies of publications)

ISSN 1020-9077 Vol. 6 No. 9

he Health Care Systems in Transition (HiT) profiles are country-based

European Observatory on Health Systems and Policies

source, quantitative data on health services are based on a number of different

he Health Care Systems in Transition profile on Germany 2004 was

European Observatory on Health Systems and Policies

Introduction and historical background

he Federal Republic of Germany is situated in central Europe and covers

European Observatory on Health Systems and Policies

Source: The World Factbook, 2004.

principles embodied in the national constitution (known as the Basic Law or