The health system in Germany comprises public and private institutions and individuals. In comparison with other countries, Germany has an unusually large number of doctors, specialists, therapists, dentists, social workers, medical staff to take care of patients as well as there are sufficient hospital beds. In addition, this also includes employees of other medical specialties and pharmacies with their staff. It is worth noting that approximately one in ten workers (4.2 million out of 80 million inhabitants) is involved in the health sector (Altenstetter, 2003). Moreover, the health care system represents the state (federation, land and communes) and provides medical insurance, accident insurance, care and pension insurance, union health funds. Furthermore, it handles employers, workers, and, last but not least, patients that are partially represented by patients’ associations and private health organizations.
Private enterprises, except for public clinics, offer medical services. In general, “free professions” such as doctors and pharmacists and large private enterprises (for example, pharmaceutical or medical-technical industry) dominate the health sector. Apparently, state plays a secondary role in the provision of medical services in the form of departments of health, public hospitals and university clinics. This paper determines general principles of health care and health insurance in Germany and reviews recent reforms.
Description of the Country
The Federal Republic of Germany is located in the center of Europe. It is a democratic country open to the outside world with a long tradition. Germany has one of the strongest economies in the world and offers powerful innovations in terms of the scientific landscape. At the same time, the country is characterized by creative economy and the lively cultural life. Germany has 82 million people, and about 15 million of them have a migrant background, namely about 7 million people are foreigners, while 8 million individuals have German citizenship. Apparently, a plurality of lifestyles and a variety of ethnic and cultural nuances define the society. Despite changes in society, family remains the most important social unit. Most of residents have a good education, high standard of living and adequate opportunities for the development of personal life (Knox, 2009).
Germany is a land of ideas. It is worth mentioning that central importance is given to education and science, research and development. In Germany, there are about 370 universities for foreign students. Hereby, Germany (after the US and the UK) is the most attractive country for studying. Among European countries, Germany has the highest number of patent applications on a global scale. Therefore, considering that German citizens have a high level of lifestyle, they expect premium health care from the country (Moeller, Breinlinger-O’Reilly, & Elser, 2000).
Overview of Health Care
After reunification in 1991, Germany’s general clinics were closed and transformed into doctors’ offices. Nowadays, public health authorities play no role in the health sector with the exception of disasters and catastrophes. In fact, all university hospitals (clinics) with inpatient treatment remained in the hands of the state. To receive financing, German hospitals sign contracts with insurance companies as well as receive government subsidies from tax revenues. Apparently, numerous legislative reforms in the field of public health were trying to prevent the looming threat of double financing of costly infrastructure (for example, purchase of medical equipment). There were also attempts to unite academic and complementary medicine known in Germany as a new concept of integrative medicine (Moeller, Breinlinger-O’Reilly, & Elser, 2000).
Medical care can be divided into three types. Thus, primary medical and sanitary health care so-called “family medicine” is supported by doctors’ offices, clinics, and other outpatient facilities. In fact, about 90 percent of acute and chronic diseases are treated using this cost-effective and comprehensive system. Secondary health care that is so-called specialized medical services are provided by medical specialists in all fields of medicine who work with patients in the direction of physiotherapy. Apparently, a specialist performs outpatient or inpatient care in a hospital or clinic. In general, this sector of health care includes first aid, intensive care, operating rooms, laboratories, diagnostic radiology, and physiotherapy. With regard to tertiary health care, it is provided in specialized hospitals, clinics, and centers. They provide regions and usually a few cities with particularly complex and expensive services in institutions that handle accidents and disasters, cancer centers, transplantation centers and neonatology (Knox, 2009).
In order to become a doctor in Germany, a person must have higher education in the field of medicine. Enrollment in universities in this specialty program is highly competitive because the position of a doctor is considered to be highly prestigious. Talking about medical training, it covers pre-clinical studies and practical application (Porter & Guth, 2012). Students must complete five years of studying which includes two years of general science, three years of applied science and final year of clinical practice. Furthermore, future specialists must complete first aid training and have three month of nursing experience and four months of internship at the clinic (Knox, 2009).
The Principles of Health Insurance
Social health insurance is available to persons whose annual income does not reach 40 thousand euro. Apparently, this type of insurance provides the diagnosis and prevention of diseases as well as the statutory amount of outpatient and inpatient treatment, provision of medicines and aids, benefits in connection with a temporary disability, termination of pregnancy, and maternity. Insurance contributions provide care for the employees and non-working family members. The fee is dependent on the earnings paid by both employers and the insured themselves. The value of the contribution is not dependent on the number of children within the family (Porter & Guth, 2012).
Private (voluntary) health insurance applies to individuals whose annual income exceeds 40 thousand euro. The risk is calculated for each insured person, taking into account the premium (considering age, state of health and the amount of the desired medical services). In fact, such insured person has the right to choose the time for planned hospitalization, by whom they prefer to be treated taking into consideration doctor’s category (the head of the department or the chief doctor) and the accommodations at the hospital. With private insurance, in comparison to the social where medical services are covered by health insurance, the patient pays for medical care personally and then pays the insurance company’s expenses. In general, it reimburses 70-90% of the costs (Altenstetter, 2003). Repayment is usually made by reducing the fee when renewing the contract. Talking about private insurance, it exists in two forms, namely full and partial. The government manages the system of compulsory insurance of public fund, and since the year 1993, each holder of compulsory insurance is free to choose whether they want to change the annual health insurance fund. Due to increasing competition, the number of such funds has declined significantly, especially over the past few years. Funds can be divided into such following categories as 17 local health insurance funds, 10 trade union funds, 229 sector funds, 19 health insurance funds for employees of large companies, 10 agricultural funds, 1 Maritime Health Insurance Fund, and 1 mining fund (Porter & Guth, 2012).
Comparison of German and the US Health Care
The United States surpasses Germany grounded on the level of modern technology equipment (Shi & Singh, 2013). There are four times more devices for magnetic resonance imaging per million people in the US than in Germany, and the former has twice more CT scanners. The situation would be even worse if Germany did not have a small sector of private health insurance. Even though the share and account of private insurance constitute only a small percentage of total health spending, it exerts pressure on the health insurance companies, forcing them to expand the range and improve the quality of services. At one time, computer tomography was extremely rare so that patients were given access to it only in exceptional cases and after a long wait. Due to this competition, the government has allocated funds for the purchase of additional scanners (Porter & Guth, 2012). Therefore, German medical equipment cannot compete with the one in the US, but in comparison to the rest of the Europe, Germany is one of the leaders.
In comparison with the US health care, Germany shows much more independence. German insurance experiences the smallest amount of control from the state and sometimes, even none. Health care system in the United States is largely dependent on and suffers from regional and local regulations (Johnson & Stoskopf, 2009). Therefore, the US health care system should try to manage its medical care without government’s supervision.
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Current Reforms in German Health Care
Currently, there are three pending reforms in German health care. The first one involves changing the two tariffs for calculating the cost of medical services. Thus, one concerns private insurance, and another one relates to mandatory insurance. The state suggests that hospitals should impose one tariff on both types of insurance, which will greatly affect both sectors. It is worth saying that private insurance companies oppose this reform. The second one is similar and is proposed as an alternative to the first one by the private insurance companies. In calculating the cost of the services, German clinics used the so-called base rate settlement that is unique for each of the clinics. Therefore, this ratio reflects the cost of maintaining the infrastructure of clinical and other institutions that are on the balance of the clinic (it may be the university structure). Hereby, this factor can affect state clinics, which will allow them to hire more advanced staff and better equipment. In this case, the state is against this reform because it will have to invest more money in the public health care. Third reform involves medical specialists. Due to the fact that German doctors are very independent in their work, all of them are members of self-governing professional associations. In fact, these associations solve most of the issues of employment and training of doctors. Apparently, this is the reason why German doctors have more freedom and mobility when choosing their place of work. Moreover, the same high-class specialists can study at several universities and work in several clinics. Thus, the Federal Republic of Germany created the organizational prerequisites for a more personalized medicine (Knox, 2009). The reason doctors oppose this reform is that it will reduce their opportunities for employment and will decrease their level of income.
German health care has a high level of prestige because every tenth citizen is employed in this sector. In fact, only best specialists can become doctors, which creates competition and thorough selection of candidates. Considering that wages of medical personnel are very high, citizens can expect premium health care. Insurance companies and state keep in mind that German population is diverse and demands different types of medical care, which is why this sector is fitting to representatives of all communities. Germany has the highest level of technologies in its medical facilities in case patients may require it.
German health care continues to develop, and what is considered an innovation today, tomorrow will be obsolete, which is not necessarily a good thing for the economy. Nevertheless, in terms of research, Germany surpasses many countries. If the country will be changing politically and socially, it has all advantages to be a leader in the international medical arena. However, experts believe that the German health care system will be discussed in political forums at various levels for a long time because costs continue to rise and the number of patients who are able to afford expensive insurance continues to drop. The population is aging, and it threatens the principle of social solidarity in relation to health care.