Monday, November 10, 2008

Germany - OECD Summary

Summaries of summaries of healthcare systems based on the Commonwealth Fund reports.
Author(s) of the originals are:
Karsten Vrangbaek, Isabelle Durand-Zaleski, Reinhard Busse, Niek Klazinga, Sean Boyle, and Anders Anell

• Germany's system is based on public or social health insurance (SHI)
• SHI is mandatory for those with income less than €48,000 (this is about 75 to 80% of the population)
• The top quintile of income earners can opt in or out of SHI; 75% of these high earners opt in. (This matches up interestingly with the quintiles in the US, with the top 5% in Germany opting out of SHI it sounds like.)
• Also civil servants and the self-employed are excluded from SHI and make up the bulk of the 10% of privately insured individuals. (I don't understand the rationale of excluding the self-employed or, for that matter, civil servants except that I presume they just get these benefits paid for by the government anyway.)
• SHI covers the usual healthcare plus dental and drugs and more.
• Cost-sharing occurs through co-pays for outpatient visits, drugs and dental care. Apparently this is new since 2004. Cost-sharing max-out is 2% of income. Out-of-pocket expenses account for 13.8% of total health expenditure.
• SHI is operated by over 200 competing health insurers and these are called "Sickness Funds".
• The Sickness Funds are all autonomous and nonprofit but regulated.
• Funding comes from the employer at 8% of gross up to €43,000 and from the employee at 7% of gross.
• For those not in SHI, the sickness funds set rates but in 2009 the government will collect and regulate this as well. After 2009 the government will distribute to sickness funds based upon risk adjustment mix of their clients.
• Interestingly, private health insurance rates cannot change once you have been accepted into the plan.
• Private health insurance accounts for less than 10% of the total health expenditure of Germany.
• Physicians receive fee for service plus "fees per time period" (the latter sounds like capitation). Just a note here to refer to the NPR story about the fee-for-service money running out towards the end of every quarter
• Hospital-based physicians are salaried.
• Hospitals are split up into about 1/2 public, 1/3 private nonprofit and 1/6 private for-profit. The latter for-profit segment is apparently growing at this time.
• Hospital reimbursement is now a DRG based.

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