The German health care system is supported and self-managed by many institutions and actors. We provide information on which organisations play a role, how the care system is structured and how it has developed.
In Germany, the care system is divided into three areas: There is outpatient care, the hospital sector and outpatient and inpatient rehabilitation facilities.
The actors in the health care system include associations and interest groups representing the various providers and occupational groups, health insurance companies, quality assurance institutions, the Ministry of Health, as well as patient organisations and self-help groups.
Four Basic principles of the pension system
The health care system in Germany is based on four basic principles:
- Compulsory insurance: All citizens are obliged to be insured in a statutory health insurance fund – as long as they do not earn more than a certain amount gross (“compulsory insurance limit”). Those who earn more can take out private health insurance. This means that every German pays into the health system. Currently, the contribution is 15 to 18 percent of gross income.
- Contribution financing: Health care is mainly financed by contributions from health-insured citizens and employers. Subsidies from tax revenues are added. By way of comparison, state health systems such as those in the UK or Sweden use tax revenues. In market economy systems such as the USA, many citizens have to pay for treatment costs and loss of earnings due to illness themselves or take out private insurance.
- Principle of solidarity: In the “solidarity community” of the health care system, all those with statutory health insurance jointly bear the personal risk of the costs arising from an illness. Every legally insured person has the same right to medical care and continued payment of wages during an illness – regardless of his or her income and thus contributions. The level of contributions depends on income. In this way, rich people pay for poor people and healthy people pay for sick people. However, contributions are only calculated as a percentage up to a certain income level (the “income threshold”). All those who earn more pay the same maximum amount.
- Principle of self-administration: The state decides on the framework conditions for medical care. However, the further organisation and financing of the individual medical services is the task of so-called self-administration in the health care system. This is carried out jointly by representatives of doctors and dentists, psychotherapists, hospitals, health insurance companies and the insured. The highest body of self-administration within the framework of the statutory health insurance system is the Federal Joint Committee.
A bit of history: The five branches of social security
The foundations of the German health system date back to the Middle Ages. At that time, for example, craftsmen were organized in so-called guilds. They already had pre-forms of solidary health insurance: all members of a guild paid contributions into a common fund. This made it possible to support individual members if they were in need due to illness, for example. Since the beginning of industrialisation, for example, there have been factory workers’ health insurance funds. The various forms of social security were unified by social policy at the end of the 19th century, the so-called Bismarckian social legislation. Health insurance was the first to be introduced in 1883. Initially, it was primarily intended to cover workers in industry, crafts and small businesses when they became ill.
All insured persons received a legal right to free medical treatment and medicines as well as sickness and death benefits. At that time, about 10 percent of the population had health insurance – today it is almost 100 percent!!!
The introduction of health insurance in 1883 was followed by statutory accident insurance (1884) and pension insurance (1889). In 1927, unemployment insurance was introduced for manual workers and salaried employees. Accident insurance covers, among other things, medical benefits in the event of work-related accidents and occupational diseases as well as cash benefits in the event of work-related disability and death. Accident insurance is also compulsory, but is financed solely by employer contributions.
The statutory pension insurance is financed in equal parts by contributions from employees and employers. It pays old-age pensions, disability pensions and rehabilitation benefits for those in gainful employment.
It was not until 1995 that the fifth branch of the social insurance system was introduced: long-term care insurance. It covers a share of the costs for care and nursing if someone becomes in need of care.
The legal requirements for the five branches of social security can be found in the social security code books.
Health system structure and actors
At the federal level, the Federal Ministry of Health (BMG) shapes health policy. Among other things, it prepares laws and draws up administrative regulations for the activities of self-administration in the health care system. The BMG also supervises a number of institutions and authorities that deal with overarching health issues. These include the Federal Institute for Drugs and Medical Devices (BfArM) and the Paul Ehrlich Institute (PEI). The BfArM is, among other things, responsible for the approval of drugs. The tasks of the PEI include the approval of vaccines, for example.
Within the framework of statutory health insurance, the Federal Joint Committee (G-BA) is the supreme decision-making body of joint self-administration in the health care system. It consists of representatives of doctors, dentists and psychotherapists, the statutory health insurance funds, hospitals and patients. As the central organ of self-government at federal level, the Federal Joint Committee decides, among other things, which medical services are paid for by the statutory health insurance funds and in what form they are provided.
Important providers, institutions and associations in the healthcare sector are:
Health insurance companies
The statutory health insurance funds have the duty to insure citizens and ensure that they receive medical services. To this end, they conclude contracts with a large number of institutions and organisations, including the associations of panel doctors and panel dentists, as well as associations of doctors, hospitals and pharmacists. The association of all statutory health insurance funds at the federal level is called the “GKV-Spitzenverband”. It assumes legally defined tasks and represents the interests of the various health insurance funds. The private health insurance companies offer their customers either full, partial or supplementary insurance. Their representative body is the “PKV Association”.
Associations of statutory health insurance physicians and dentists
All doctors and psychological psychotherapists who settle accounts with the statutory health insurance scheme are organised in the federal states in associations of panel doctors (KV), dentists in associations of panel dentists (KZV). The responsible associations at the federal level are the Kassenärztliche Bundesvereinigung (KBV) and the Kassenzahnärztliche Bundesvereinigung (KZBV). The tasks of the associations are defined by law.
The German Hospital Association (DKG) represents central and regional associations of the various hospital operators such as cities and municipalities, churches, non-profit associations and other private operators.
Chambers of doctors, dentists, psychotherapists and pharmacists
At the level of the federal states all physicians, dentists, psychotherapists and pharmacists are compulsory members of their respective state chamber. The tasks of the chambers include monitoring professional obligations and compliance with the X-ray and radiation ordinance. They are responsible for the recognition of the profession, the specialist examination as well as the assessment and arbitration in case of allegations of treatment errors. The state chambers have formed corresponding federal chambers at the federal level.
Public Health Service (ÖGD)
The task of the ÖGD is to protect the population from health hazards. It is mainly the municipal health offices that take care of hygiene in community facilities, infection prevention and general health promotion. They also offer counselling and help, for example with psychosocial problems.
Associations of pharmacists
Pharmacies are responsible for dispensing medicines to consumers. Pharmacists also have the task of providing information and advice on medicines. In order to ensure care, their associations must conclude contracts with the GKV-Spitzenverband and the health insurance funds.
Non-medical healthcare professionals
Last but not least, there are many so-called non-physician health care professions. These include, for example, physiotherapists, speech therapists, caretakers or midwives. Insofar as they offer health insurance services, their associations also conclude contracts with the GKV-Spitzenverband and the health insurance funds.
Patient organisations and self-help
Many people have joined together to form self-help groups and patient organisations that advise and support patients. Various patient organisations also represent patients’ interests in health policy issues.
Outpatient care in Germany is mainly provided by registered doctors in private practice, freelance doctors, dentists, psychotherapists and specialists from non-physician health care professions. Most doctors and dentists have a “health insurance fund licence”, i.e. they treat people with statutory health insurance.
Most people first go to their family doctor when they are ill or have a health problem. General practitioners are general practitioners, general practitioners, internists or paediatricians and adolescents. In the case of special medical problems, they refer patients to an appropriate specialist practice, for example for gynaecology (gynaecology) or for skin diseases (dermatology). However, it is also possible to go directly to a special medical specialist.
In addition to their membership in the respective association of panel doctors or panel dentists, general practitioners, specialists and dentists each have their own associations representing their specific professional interests.
In addition to individual practices, there are many group practices or medical care centres in Germany in which two or more doctors and specialists from non-physician health care professions work together. Such large practices can often offer services that are otherwise only available in hospitals, such as special examinations or outpatient operations. This is why they are sometimes called “practice clinics”.
Outpatient care also includes outpatient treatment in hospital or psychiatric institutions.
Most hospitals in Germany provide treatment to those with statutory and private health insurance. The large hospitals usually have public sponsors, i.e. federal states and municipalities. Non-profit or denominational hospitals are run by non-profit organizations such as the Red Cross or churches. There are also many clinics run by private companies. Some of them only accept private patients. They usually have comparatively few beds, and many are specialized in certain areas.
If a longer stay in hospital is necessary, this is called “inpatient treatment”. In this case, those with statutory health insurance also have to make a co-payment for accommodation and meals. This is recorded in the “hospital contract” between patient and clinic before treatment.
In addition to inpatient care in hospitals, there is also the area of inpatient medical rehabilitation. In rehabilitation facilities, treatments are offered that help people to become independent and able to perform well again after a serious illness and intensive therapy. Among other things, physiotherapeutic treatments, psychological care and support in using aids are offered. Such treatment often follows a stay in hospital, for example after an operation. Last but not least, there are rehabilitation facilities for mental and addiction disorders.