Health Care in Germany: Structure, Expenditure, and Prospects

Volker Ulrich

Introduction

GERMANY'S CENTURY-OLD UNIVERSAL HEALTH insurance scheme represents a midpoint in the spectrum of systems that countries have adopted to protect their populations against the financial consequences of illness. Established by Otto von Bismarck in 1883, the German system has been continually extended since to reflect the changing array of diseases and technological progress. [Henke et al. 1994a, p. 7.] Germany today has a comprehensive health care system covering nearly all costs, even including long-term care since 1995.

The German health care system has long been viewed as a model that controls costs and provides nearly all of its citizens with coverage while also maintaining a separate private market to reflect supply and demand for health services. Henke et al. 1994b, p. 252.Note However, the experience of the last three decades has shown that the German system is also faced with mounting health care costs and a steadily increasing share of national income being spent on health care.

As figure 1 shows, German health expenditures as a share of GDP have nearly doubled over the past three decades. In 1960, the share was about 5 percent, whereas the corresponding figure in 1993 was approximately 9 percent. Canadian health expenditures as a share of GDP show a similar time trend, although Canada has devoted a higher share of GDP to health care than Germany, except between 1975 and 1981. It is interesting to note that the shares have been diverging since the end of the 1980s. In Germany, various cost containment measures have been able to rein in spending, while in Canada the corresponding expenditures have been rising. [Comparisons of different health care systems depend to a considerable degree on the international classification of health care expenditures. For further details see OECD 1993, p. 13.] To control health care costs, the German government enacted two major health care reforms in 1989 and 1993 aimed at reducing the structural deficits of the current system. [The last two major pieces of health care legislation are the 1989 and 1993 Health Care Reform Acts. They consist of short-term cost containment policies and long-term structural policies. See also the section below on "Regulating the pharmaceuticals market."]

Click here to view Figure 1: Total Health Expenditure as a Percentage of GDP

This paper outlines the basic structure of the German health care system, analyzes the development of health care expenditures in Germany, and concludes by outlining possible solutions for Germany's health care problems.


Structure of the German health care system

Coverage

In Germany, health insurance is one of the four branches of the social insurance system, [Hoffmeyer 1994, p. 425.] the other three branches being accident insurance, retirement insurance, and unemployment insurance. [Accident insurance is work-related and paid exclusively by employers. The other three branches are financed by contributions from employees as well as employers. More specifically, benefits are financed by an income-related payroll tax, half of which is paid by the employee and half by the employer.] Entitlements of the health system are generous and benefits include primary care, hospital care, dental care, rehabilitation, and preventive care. Even long-term care is now covered by a pay-as-you-go scheme under the umbrella statutory health insurance (SHI) system.

Approximately 88 percent of the German population are insured with one of the compulsory SHI sickness funds (table 1). This is the case with all blue collar workers, white collar workers below a certain income level (1995: DM 5,850 per month), farmers, students, and the unemployed, as well as the family dependents of all these groups. At the same time, over 10 percent of the population are fully covered by private health insurance (PHI). These people are employees with incomes above the assessable ceiling and self-employed persons who have the choice of opting out of the SHI system to join a private insurer. [Pohlmeier and Ulrich 1994, p. 349.]

Click here to view Table 1: Health Insurance Coverage of the German Population: Selected Years

The remaining 2 percent of Germans are mainly civil servants for whom the government pays financial assistance. Only 0.3 percent of the population have no insurance coverage at all, and these uninsured are mainly persons with incomes above the opting-out limit who have decided not to carry health insurance. There is no person in need who is not covered by statutory health insurance. [Henke 1990, p. 253.]

It is obvious from these figures that the German health insurance system is dominated by SHI, with private insurance available to a minor component of the population, more specifically high-income earners. In this context, we should mention that about 4 percent of statutorily insured individuals carry additional insurance with private companies, mainly to guarantee qualitatively better care in the event of an in-patient stay. In this sense, Germany has a two-tier system, though the SHI system is clearly predominant.


Participants

The key participants in the German health care system can be characterized as follows: [Hoffmeyer 1994, p. 432.]

1.Patients, who are members of statutory or private insurance funds;

2.Statutory sickness funds as well as their state and federal associations (table 2). There are about 1,300 autonomous sickness funds in Germany with some 51 million members. The sickness funds with the largest membership are the local funds, which geographically cover the entire country and act as collecting tanks for people for whom statutory insurance is compulsory (i.e., with incomes below the threshold) and the white collar workers' substitute funds operating nationwide;

Click here to view Table 2: Number and Type of Sickness Funds and Private Health Insurance Companies

3.Private health insurers, numbering about 115 in Germany. The 50 companies operating nationwide are joined in the Association of Private Health Insurers and represent the whole private health insurance market, since more than 99 percent of the yield from contributions is apportioned to these companies. Apart from these 50 companies, there are 65 smaller private associations and relief funds which offer mainly supplementary insurance and operate on a solely local basis; [Verband der privaten Krankenversicherer 1994, p. 10.]

4.Ambulatory care, provided predominantly by office-based physicians with resources allocated by collective bargaining between participants (medical associations and sickness funds). The government merely defines the legislative framework for the bargaining process; [Henke et al. 1994b, p. 256.]

5.Hospitals, far more integrated with the administrative system than the ambulatory facilities. The need for and financing of hospitals are determined by state governments: sickness funds cover only current costs; [Henke et al. 1994b, p. 256; Hoffmeyer 1994, p. 451.]

6.Pharmaceuticals producers, numbering approximately 1,200 in 1993 and ranging in size from pharmacies selling drugs under their own names to roughly three dozen multinational companies marketing their products globally. The 10 largest pharmaceutical producers account for 24 percent of sales through pharmacies. In comparison with other industries as well as foreign pharmaceutical markets, the German pharmaceutical market has a fairly low level of producer concentration. This is not true, however, if we look at the sales of particular therapeutic classes, which often have a rather narrow oligopolistic structure. At the end of 1993, 649 hospital pharmacies and 20,648 registered retail pharmacies were selling pharmaceuticals. [Ulrich and Wille 1996, p. 3.] For retail pharmacies, there are two important rules: first, pharmacists are not allowed to own more than one pharmacy, and secondly, a pharmacy must be owned by a pharmacist. These rules preclude the formation of pharmacy chains; and

7.The final key players in the German health system, the Ministries of Labour and Social Affairs in the states and the federal Ministry of Health. On the one hand, the government specifies the legal framework for the SHI system, and the major part of sickness funds' benefits are provided according to this legal framework. On the other hand, the insurance providers are self-governing and possess the administrative autonomy to negotiate with the medical and hospital associations.

An interesting aspect of German health care policy is its approach to controlling expenditures. The revenue-oriented control policy introduced in 1977 has put a "brake on an uninterrupted growth of expenditure." [Advisory Council for the Concerted Action in Health Care 1994, p. 19.] Service financing is subject to sickness fund budget constraints: sickness funds are not permitted to incur debts or keep profits. Revenue-oriented expenditure control aims to stabilize the contribution rate in the SHI system and thus reduce ancillary wage costs in Germany which are relatively high compared with other European countries, the United States, and Japan.

The recent reforms impose controls on health care spending not only through this revenue-oriented policy but also by global budgeting, which sets budget caps on nearly all SHI treatment services. Both instruments-revenue-oriented expenditure control and budget capping-apply only to SHI. These strong regulatory measures can be seen as a timely model for controlling health care expenditures, but they are no substitute for an outcome-oriented health care policy. For this reason, contribution stability and global budgeting can be seen as a type of interim solution that gives politicians time to develop better incentive structures.


Basic Principles

The values underlying the SHI system can be characterized by three principles basic to a social market economy:

•self-administration,

•social partnership, and

•solidarity.

Self-administration means that health care purchasers and providers operate as self-managing private organizations under public law. The second basic principle, social partnership, assumes that both employers and employees share the burden of financing health care. The last principle, solidarity, means that the economically stronger members of society support the weaker members. "It is difficult to imagine circumstances in which it would be politically acceptable to abandon these general principles as part of health care reform policies." [Hoffmeyer 1994, p. 434.]

By contrast, the basic principles underlying the PHI system are the following:

•insurance principle,

•principle of equivalence, and

•personal precaution.

The insurance principle stands for a risk-related contribution rate, i.e. a contribution rate that reflects the medical history of the insured individual. This rate is determined mainly on the basis of age and sex. Under the second principle, equivalence, the contribution rate reflects desired level of coverage without any cross-subsidization. Personal precaution means that each individual is responsible for his or her health capital and points to the relevance of lifestyle variables.

These basic principles have created a very important difference between the two types of health insurance. The PHI system has diversified contribution rates, while in the SHI system, benefits are financed by an income-related payroll tax. In 1995, the average SHI contribution rate was 13.2 percent of labour income, half paid by the employer and the other half by the employee, income being liable to contribution only up to DM 70,200 a year-the assessable income ceiling for 1995. Now unlike PHI premiums, these payroll taxes are independent of individual, medical, or social risks. This means that the relationship between the contribution rate and demand for services is weak, prompting the illusion that medical care is free. Copayments are limited to such items as eyeglasses, physiotherapy services, dentures, prescription drugs, and a per-diem copayment for hospitals. Currently, copayments as a portion of total health expenditures under statutory health insurance approach the 10 percent mark. The high degree of coverage of health care services, with the weak connection between costs and individual payments, generates inflationary effects since both physicians and patients have incentives to maximize the amount of services.

Individuals who voluntarily join a private insurance plan are normally not allowed to re-enter the SHI system if the cross-subsidization effects of SHI change to their advantage. [This may be the case if the number of family dependents increases or if the individual becomes a bad risk for PHI insurers.] Exceptions are allowed for individuals experiencing periods of unemployment, who are automatically insured by a local sickness fund. For both privately and publicly insured individuals, the choice of health insurance company is independent of the employer.


Delivery of services and flow of funding

Ambulatory care

Germany draws a sharp distinction between hospital-based and office-based physicians. Office-based general practitioners provide the population with ambulatory care, prescribe drugs and medical aids, and serve as gatekeepers for specialist referrals and hospitalization. Over the past three decades, the total number of physicians has been steadily increasing (see table 3). In 1993, more than 266,000 physicians were working in various positions in the German health care sector. The number of office-based physicians was 89,000, which indicates a physician/population ratio of 1.18 per thousand inhabitants in the western part of Germany. Approximately 90,000 doctors were employed by hospitals.

Click here to view Table 3: Number of Physician in Various Position in the Western States of Germany, 1970-1993

For care provided to SHI members, physicians are reimbursed on a fee-for-service basis according to a point value scale, the so-called German Uniform Evaluation Standard. This evaluation scale is used for both statutory and private sickness funds. The fee schedule fixes relative prices in terms of point scores assigned to specific services. Price levels (point values) are determined through independent negotiation between the federal and regional organizations of the sickness funds and the corresponding doctor organizations. Although sickness funds and private insurers use the same fee schedule for remunerating ambulatory services, they have different point values. This leads to higher prices for the same services in the PHI system as compared with the SHI system.

Another difference between the SHI and PHI systems is that the physician does not know exactly how much he will earn from his services to SHI patients. The sickness funds and physicians' associations negotiate a fixed budget for ambulatory services every year. This means that the monetary value of a single physician service may decline if physicians are performing too many services in any one category. At present, the price level (point value) is approximately DM 0.09 for local insurance funds and DM 0.11 for substitute funds. The variation results from the different budgets they have negotiated.

By contrast, physicians treating privately insured patients do not suffer from budget caps. Physicians accredited in the PHI system are paid on a fee-for-service basis. These doctors are also allowed to charge fees above the corresponding SHI fees-from 1.7 to 3.5 times the levels paid by the SHI system. [Hoffmeyer 1994, p. 448.] The 1993 Health Care Act limits the growth of the SHI ambulatory budget to the increase in income of statutory sickness fund members and thus in effect introduces a budget cap for ambulatory services. In the medium term, it is planned to remunerate physicians, not for each service, but in line with service categories.


Hospital care

In 1992 there were 3,590 hospitals in Germany, 3,104 in the west and 486 in the east. These can be divided up into hospitals for the acutely ill, special hospitals, and hospitals for long-term illness. As compared with other SHI treatment spending, hospital expenditures have grown disproportionately over the last three decades. This growth is explainable by several factors-medical, technological, and economic. For example, more diseases can now be treated in hospitals, and technological progress has created new diagnosis and treatment possibilities. Economic factors include oversupply of beds, extensive lengths of stay, and retrospective reimbursement methods. [Henke et al. 1994b, p. 257.]

Hospitals can also be divided into the publicly owned and privately owned-private voluntary or private proprietary. Each of these three groups owns approximately one-third of all German hospitals. Almost one-half of all beds are provided by publicly owned hospitals, with one-third in private voluntary hospitals and 20 percent in private proprietary institutions. The owners of public hospitals are states, municipalities, and cities. Private voluntary hospitals are run by churches or other charitable institutions and the proprietary hospitals belong to private companies. [Hoffmeyer 1994, p. 451.]

The traditional remuneration basis for hospitals in Germany is a per-diem rate which is uniform within a hospital and independent of actual diagnosis, amount of care, or length of stay. Rates vary between hospitals depending on size and structure and thus on spectrum of services. The general per-diem rate inevitably leads to tremendous cross-subsidization across medical departments in hospitals. Further, the care-intensive first days in hospitals are subsidized by the last days, which involve mainly "hotel services" instead of expensive treatments. The uniform per-diem rate covers only the hospitals' operating costs: investment expenditures are financed by state governments.

The 1993 Health Care Act introduced several changes in hospital financing. The dual concept of financing, i.e. separate funding of operating and investment costs, was maintained, but the long-standing principle of fully reimbursed operating costs was abolished. Hospitals today bear the risk of not covering their operating costs and their owners have to pay for any deficits. On the other hand, hospitals are allowed to keep any surpluses. Also in 1993, the general per-diem rate was replaced by fee-per-case payments and lump-sum hospital rates. The fee-per-case rates are special rates for well-defined patient groups such as chronically or mentally ill patients or infants in neonatal care. The lump-sum rates are payments for specialized treatment services, e.g. cancer treatment or organ transplants. The new regulations aim to improve efficiency in the in-patient sector, mainly by basing hospital funding on a prospective remuneration system. Between 1993 and 1996, the Health Care Act introduced global budgeting as an interim solution linking hospital expenditures to the income growth rate of SHI members.


Pharmaceutical sector

Retail pharmacies get their pharmaceuticals from wholesalers and not directly from manufacturers. [Henke et al. 1994b, p. 258; Hoffmeyer 1994, p. 459.] However, manufacturers do distribute medicines directly to hospital pharmacies. Methods of distribution and price determination differ completely for retail and hospital pharmacies. Manufacturers often offer hospitals special rebates to entice training doctors to use their products, hoping for advantages from that connection when they set up their own practices later on.

At the manufacturing level, drug prices can be set to reflect prevailing market conditions. However, wholesaler markups are determined by federal law: the maximum markup will vary inversely with a manufacturer's price to produce a diminishing profit curve. Similarly, a retail pharmacist can add another fixed markup to the wholesaler's price. This regulation leads to uniform drug prices in retail pharmacies throughout the country.

The 1989 Health Care Act introduced reference pricing for various types of drugs. Reference prices are administratively fixed reimbursement levels for medicines with identical or similar properties. If an individual wishes to obtain a pharmaceutical priced above the reference level, he or she has to pay the difference between this market price and the official reference price. The efficiency of reference pricing has been a source of controversy, especially because these prices are set by a commission that does not include pharmaceutical industry representatives, only representatives of the sickness funds and physician associations.

Copayments and global budgeting are two other features of funding in the pharmaceuticals market. Copayments were introduced in 1970 in the form of prescription fees, and the copayment structure has changed frequently since then. The 1993 Health Care Act introduced copayments that reflected the package sizes of prescriptions: small packages carry a copayment of DM 3, medium packages DM 5, and large packages DM 7. The 1993 Act also introduced a budget for drugs prescribed by office-based physicians. This budget was set at DM 24 billion for the year 1993, roughly corresponding to 1992 pharmaceuticals spending. If prescription costs exceed the budget, the physicians have to pay for the overrun the following year up to a total of DM 280 million. If pharmaceuticals expenditures exceed the budget by more than DM 280 million, the pharmaceuticals industry is responsible for a further DM 280 million. The budget for medicines has been kept at a comparable level for the years 1994 and 1995.


Expenditure analysis

In 1992, total health expenditures amounted to roughly DM 400 billion: 88 percent of this amount was spent in the western part of the country and 12 percent in the east. The former German Democratic Republic is still in the process of adopting the laws and regulations of the West German health care system. Table 4 shows east-west expenditure ratios by treatment type. On average, the per-capita spending level in the east rose from 49 percent of the western level in 1991 to 72 percent in 1993. There are, however, substantial differences when it comes to specific treatments. For dentures, expenditures in the east were 50 percent above the western level. The lowest expenditure ratio found was that for primary care: here, eastern per-capita expenditures were still 40 percent behind the western level, indicating that the primary care model in the east had not fallen as far behind the western model as had other treatment types.

Click here to view Table 4: East-West Comparison of Expenditure (per capita, persioners included)

Table 5 shows developments in share of spending by treatment type in the SHI and PHI systems since 1970. Actually, the last year for which the Federal Statistical Office provides information is 1991. [There is another database administered by the Ministry of Labour and Social Affairs: however, this data set does not allow for a comparison between SHI and PHI expenditures as it contains information on SHI expenditures only.] The division into 10-year periods shows that structural shifts in SHI occurred mainly between 1970 and 1980, when the shares of primary care (treatment by physicians and dentists) and pharmaceuticals declined and the shares of hospital care, medical aids, and dentures substantially increased. The larger drop in the PHI share of pharmaceutical spending as against SHI was mainly due to the existence of copayments in PHI, which made the demand for pharmaceuticals more price-elastic as compared with SHI.

Click here to view Table 5: Expenditure Share of SHI and PHI by Types of Treatment: Old Länder

By contrast, PHI and SHI have similar remuneration systems for hospital care, which is why hospital care expenditure as a share of total spending increased by approximately the same amount from 1970 to 1980 for both insurance types. Subsequent cost containment policies mainly hardened the budget structure of the German health care sector. As long as health care resources are not allocated through markets, it remains an open question whether a fixed budget structure produces an appropriate and desirable level of health care spending.

When analyzing the PHI figures, it should be kept in mind that differences between the publicly and privately insured and different risk structures impede comparison of the SHI and PHI systems. For this reason, our analysis focusses on the two systems' expenditure structures. In the PHI system, spending on primary care and pharmaceuticals declined as a share of total health spending, whereas the shares of hospital care, medical aids, and dentures grew: a similar trend is seen in the SHI figures. In contrast to SHI, however, PHI spending for dentures and dental care increased substantially: this can be explained by the relatively strong regulation of these treatment types in the SHI system. Another interesting difference concerns pharmaceuticals: while SHI showed only a moderate decline in spending in this sector, the corresponding PHI figure was nearly halved. Analysis also reveals that both SHI and PHI face similar problems with hospital care, which accounts for approximately one-third of all health care spending. What this tells us is that the hospital sector should be the focus of future health care reforms. [In Germany, this is a difficult task because the state governments have authority over the hospital sector and not the federal government which generally puts the reform measures into effect.]


Regulating the pharmaceuticals market

As already mentioned, the recent health care reform acts enshrine two major policies: [Erbsland and Wille 1994, p. 847; Henke et al. 1994b, p. 260; Münnich and Sullivan 1994, p. 22.] short-term cost containment and long-term structural change. The short-term policy aims at keeping the contribution rate constant and can be characterized as a revenue-oriented expenditure policy. The long-term reforms have a broader goal of providing more market-oriented incentives in the health care sector.

With regard to pharmaceuticals reform, reference pricing was introduced in the 1989 Health Care Act for three groups of pharmaceuticals: [Erbsland und Wille 1994, p. 849.]

•group one, pharmaceuticals with identical active substances;

•group two, drugs with pharmaceutic-therapeutic equivalent active substances, especially with chemically related ingredients; and

•group three includes medicines with comparable therapeutic effects, particularly drug combinations.

The Ministry of Health originally hoped that 80 percent of all drugs would be covered by reference prices by the end of 1992 and forecast net savings of DM 2 billion. [Erbsland and Wille 1994, p. 849; Hoffmeyer 1994, p. 464.] Actual developments did not meet these expectations. By January 1, 1993, reference prices had been fixed for:

•86 substances from group one,

•12 substances from group two, and

•3 substance combinations from group three.

At present, reference prices cover only 45 percent of total SHI pharmaceutical expenditures and net savings are estimated at DM 1.1 billion. [Henke et al. 1994b, p. 258; Hoffmeyer 1994, p. 464.] It is expected that the reference pricing system will soon reach its limit as an expenditure control instrument.

The main criticism of the reference pricing system is that it takes only the price component into account, leaving quantity and structural components aside. Table 6 shows that rises in pharmaceutical prices covered by reference pricing had only a small impact on pharmaceutical sales over the last seven years. In each year except 1989 and 1993, the number of prescriptions rose faster than the pharmaceutical price index.

Click here to view Table 6: Component of Expenditure Growth in SHI Pharmaceutical Market

Savings from regulating the prices of medicines were partly offset by substitution effects as physicians altered their prescribing behaviours. Table 6 shows that numbers of prescriptions and the structural component both showed positive growth in all years but 1993. The structural component consists in an inter-drug effect and an intra-drug effect. The inter-drug effect measures changes in sales that result from prescribing different medicines, while the intra-drug effect measures change in expenditure growth for identical medicines when different package sizes, dosage forms, or potencies are chosen. In the majority of years, both effects were positive, indicating a positive contribution to expenditure growth.

In 1993, the Health Care Act introduced a specific budget for medicines. The budget cap caused a substantial decline in both pharmaceuticals volumes and prices. The first year showing negative growth of the structural component was 1993. The negative inter-drug effect in particular shows that physicians were substituting cheaper for more expensive drugs. Compared with reference prices, the introduction of global budgets has achieved more effective and stronger spending cuts. The reason is obvious: budget caps are stronger regulatory measures than reference prices.


Conclusion

Germany is in a period of transition. To contain health care expenditure, cost control interventions have increased over the last three decades. Germany has implemented such long-term macroeconomic measures as revenue-oriented expenditure policy, contribution rate stability, and global budgeting. The middle-term goal, however, is to reduce the structural deficits of the current system, enhance competition, and bring more market elements into SHI. At present, it is unclear whether Germany is moving for more competition or more regulation in its health care sector.


References

Advisory Council for Concerted Action in Health Care (1994), Health Care and Health Insurance 2000, Individual Responsibility, Subsidiarity and Solidarity in a Changing Environment, Expert Opinion Report 1994, Abbreviated Version, Bonn.

Bundesminister für Arbeit und Sozialordnung, Bundesarbeitsblatt, (Ministry of Labour and Social Affairs, Labour Bulletins), various issues.

Erbsland, M. and Wille, E. (1994), "Zu den Effekten von Gesundheitsreform und Gesundheitsstrukturgesetz auf den Arzneimittel-markt," in Die Pharmazeutische Industrie, 56(10), 847-53; 56(11), 941-48.

Henke, K.-D. (1990), "The Federal Republic of Germany," in Scheffler, R.M. and Rossiter, L.F. (eds), Advances in Health Economics and Health Services Research, a Research Annual, Comparative Health Systems: The Future of National Health Care Systems and Economic Analysis, Supplement 1, London, 145-68.

Henke, K.-D. et al. (1994a), "Global Budgeting in Germany: Lessons for the United States," in Health Affairs, 13(4), 7-21.

Henke, K.-D. et al. (1994b), "The German Health Care System: Structures and Changes," in Journal of Clinical Anesthesia, 6, 252-62.

Hoffmeyer, U. (1994), "The Health Care System in Germany," in Hoffmeyer, U. and McCarthy, T.R. (eds), Financing Health Care, Vol. I, Dordrecht, 419-512.

Münnich, F.E. and Sullivan, K. (1994), "The Impact of Recent Legislation Change in Germany," in PharmacoEconomics, 6 (Suppl. 1), 22-27.

OECD (1993), OECD Health Systems, Facts and Trends 1960-1991, Vol. I, Paris.

OECD (1995), Health Data, CREDES, Paris.

Pohlmeier, W. and Ulrich, V. (1994), "An Econometric Model of the Two-Part Decision Process in the Demand for Health," in Journal of Human Resources, 30(2), 339-61.

Statistisches Bundesamt (Federal Statistical Office, 1994), Fachserie 12, Reihe S.2, Ausgaben für Gesundheit 1970-1991, Stuttgart.

Ulrich, V. and Wille, E. (1996), "Expenditures on Drugs and Health Care Reform: The Case of Germany," in PharmacoEconomics, forthcoming.

Verband der privaten Krankerversicherung (Association of Private Health Insurers, 1994), Die private Kranken-versicherung, Zahlenbericht 1993/94, Köln.

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