HEALTH SYSTEM

Government role

Statutory health insurance system, with 124 competing SHI insurers (“sickness funds” in a national exchange); high-income people can opt out for private coverage

Public system financing

Employer/employee earmarked payroll tax; general tax revenue.

Private insurance role

~11% opt out from statutory insurance and buy substitutive coverage; some complementary (minor benefit exclusions from statutory scheme, co payments) and supplementary coverage (improved amenities).

Provider ownership

Primary care: Private

Hospitals: Public (~48% of beds); private nonprofit (~35%); private for-profit (~17%)

Provider payment

Primary care payment: Fee-for-service

Hospital payment: Case-based payment (includes physician costs)

Primary care role

Registration with GP required: No

Gatekeeper: Generally no, present in specific programs by sickness funds.

HOW IS THE MEDICAL SERVICE ORGANIZED

Primary care

Many of the GPs work in their own practices. Most of them employ doctor’s assistants. Of the total outpatient physicians roughly half work as GP and half as specialists.
Individuals have freedom of choice among GPs. Registration with a family physician is not required and the GP has no formal gatekeeping function.
Social Health Insurance accredited GPs are nomrally reimbursed on a fee-per.service basis according to a uniform fee schedule. For provate patients GPS also get a fee-for-service but the tarifs are usually higher.
Pay for performance has not yet been established.

Outpatient specialist care

In respect of accessibility and payments of outpatient specialist the same applies as for the GP (see above).

Direct payments to providers

Social Health Insurance physicians in outpatient care bill their regional associations on the basis of a uniform fee schedule. They in return receive the money from the sickness fund. Co-payments on the other hand are paid directly to the provider.
In case of private health insurance the patient pays up front and submits the claim for reimbursement.

After hours care

The regional associations of Social Health Insurance accredited physicians organize the after-hour-care, their physicians are obliged to provide it in their practices. In some regions (e.g. Berlin) it is delegated to hospitals.
The patient receives a report which he can give to his GP.
The after-hours-assistance is also available through a nationwide hotline.

Hospitals

About half of the hospital beds are to be found in public hospitals. The number of private hospitals has been increasing over the last years.
The hospitals are typically staffed with employed physicians that are paid a salary. They are typically not allowed to treat outpatient. Senior doctors are allowed to treat privately insured patients on a fee-for-service basis.
Inpatient care is paid per admission through a diagnosis-related-group (DRGs) system. Currently there are about 1.200 DRG categories used which also cover the physician costs.
Also for inpatient treatment a pay for performance method has not yet been implemented.

Mental Health Care

Acute psychiatric inpatient care is mostly provider by psychiatric wards in general acute hospitals. Qualified GPs can provide basic psychosomatic services.

Long-term Care

Long term care insurance in compulsory and is usually provided by the same insurer as the one offering health insurance coverage.
Both home care and institutional care are provided almost exclusively by private not-for-profit and for-profit providers. Medical services or palliative care in a hospice are covered by Social Health Insurance. The number of facilities offering palliative or hospice care has significantly grown over the last few years.