As one would expect of the richest country in Europe, Germany offers high quality healthcare, from primary care through to high-tech hospitals and good provision for chronic disease and old age.
It all dates back to Otto von Bismarck, the “Iron Chancellor” who established Germany’s social welfare system in the 1870s. He was reported to have said it was immoral to benefit from sickness, and that “insurance should be on the mutual principle (so that the healthy pay as much as the sick) and no dividends or profits should be derived by private persons”.
One could argue that these high-minded principles exist more in the imagination than reality. But Bismarck’s broad idea of a range of statutory health insurers, independent of providers, competing against each other, holds good. Insurers (also known as sick funds or mutuals) are financed by contributions from employers and employees.
The “Bismarck system” operates across most of Europe, including Austria, Netherlands, France and Switzerland, all with well-rated healthcare. The NHS’s “Beveridge system,” free at point of use and taxpayer funded, may be much loved by the British people, but arguably does not match the Bismarck system in medical outcomes and aspects of patient satisfaction.
Waits in Germany remain close to nonexistent – even if economic pressures apply, as with all Western countries with ageing populations. If you suffer cancer or need certain operations, your insurer may have to pay for a lengthy stay at a salubrious “rehab centre” in the Black Forest.
YOU GET WHAT YOU PAY FOR
With Germany spending 11 per cent of its (considerable) GDP on healthcare, one would expect good health outcomes. They are respectable, with life expectancy at 77 for men and 83 for women. The yardstick of a nation’s healthcare efficiency, infant mortality, is four per 1,000 live births, a satisfactory figure for a country with high numbers of less well-off immigrants.
GERMANY FEELS THE SQUEEZE
The German state is as vulnerable as the UK, America or other European states to the problems of mounting healthcare bills. Indeed, it is particularly exposed because of a shrinking and ageing workforce, and falling birth rates.
That is why Chancellor Angela Merkel defied heavy opposition to push through wide-ranging changes to the state health system in 2010. One aim was to limit ever-rising taxes on employers (who to that point jointly funded the system through equal contributions). That represented a barrier to taking on staff, in turn aggravating unemployment.
Another aim was to throw the onus of meeting rising healthcare bills on insurers, and ultimately, policyholders.
WHAT THE CHANGES MEAN
From January 2011, employers have to pay 15.5 per cent of their income towards healthcare. (The previous rate was 14.9 per cent). This is a huge proportion of income by comparison with other countries, but it should be remembered that the cover is for cradle-to-grave service.
But the 15.5 per cent employers’ rate is fixed in law and frozen long term. The sums raised are ultimately distributed among scores of state registered health insurers, many quite small and trade-union based. The idea is that by freezing the employers’ income-related contribution rate, the onus falls on insurers to cope with future cost rises. Insurers will either increase premiums – arguably the most likely scenario – or slash overheads and tighten efficiency.
As with all insurance-based health schemes, the individual needs to weigh up premium against benefits. As a German government spokesman puts it: “The premium, which has to be paid by all members of a health insurance fund, is a transparent price signal. It allows the insured to compare the price and the benefit package and choose the fund with the best price-performance ratio.”
Some relief exists for people trapped in an insurance fund that hikes premiums unreasonably. If the average additional premium exceeds two per cent of a policyholder’s income, the individual is reimbursed by the state. To avoid bureaucracy, compensation is paid indirectly, by lowering the income-related contribution rate of the person in question. To cover these costs, €2 billion has been made available until 2014.
If a health fund has to levy an additional premium, or increase its premium, it must notify its members of their right to cancel their membership. Members are allowed to leave their old fund and join a new one within two months of an additional premium coming into force.
Since 2007, expatriates in Germany, along with every German citizen, have been obliged to buy cover with a registered insurer.
The problem is that an expat who travels widely on business almost certainly also needs international medical insurance. The individual is thus doubly insured, an expensive option.
The element of compulsion applies even in a case of an EU expatriate, say, who is living in Germany for a short spell. He or she still has to buy cover from a German insurer, but may not wish to drop existing cover. This would seem the only way of guarding against becoming uninsurable for any chronic condition that occurs when German state cover lapses, and the expat policyholder wishes to move to his home country, or elsewhere.
Is the system anti-competitive, as it excludes foreign insurers? Probably, except that exceptions may be made for expatriates with high-level comprehensive insurance. If you earn more than €4,000 a month, you can take out private insurance and drop state-approved cover. Your policy needs to be at least as thorough as German public health insurance, which includes provision for chronic disease and elderly care.
The German embassy in London describes the question of using foreign insurers as “complex”. A spokesman said: “A British national working in Germany can, in principle, take out private health insurance in the UK, but would have to prove to his employer in Germany that his health insurance covers the mandatory minimum the German public health insurance would cover.”
As well as matching German state insurance in terms of benefits, the employer would need a certificate by the employee’s British health insurer guaranteeing that this was the case. “Without this certificate, the employer would automatically be obliged to register the employee with a public health insurer.”
The spokesman added: “One important factor where private health insurance has to match public health insurance in Germany is an adequate old-age provision.
“Foreign insurance companies that want to offer private health insurance in Germany usually start a German business to provide services that are in full accordance with the German Insurance Contract Act, such as AXA Germany.”
Expats on higher salaries, or those who want wider geographical cover, may find it cheaper to buy international private medical insurance.
As ever, premiums vary by around 100 per cent, but no two plans are ever strictly comparable. Among the least expensive in a list of insurers provided by Stephen Walker, of Medical Insurance Services in Brighton, is AxaPPP.
A 25-year-old man can get comprehensive cover for a year from Axa for £789 (budget plan, covering in-patient only, is £617). Other providers under £1,000 for a year’s cover for the same individual are InterGlobal at £890 (budget £581) and IMG at £915 (budget £470). The IMG premiums include a 15 per cent starter discount.
For a couple 34 and 31 in Germany seeking comprehensive cover, annual premiums under £2,000 come from AxaPPP at £1,943 (budget £1,519) and IMG because of a 15 per cent starter discount. IMG’s Global Select plan is £1,928 (budget £1,047).
Also competitive is Aviva International Solutions. For the couple 34/31, its comprehensive plan costs £2,522 a year (budget £1,766). The annual premium for Bupa’s Classic is £3,967 (budget £2,156).
PROOF OF THE PUDDING?
If the Merkel reforms work, the chancellor can thank her 19th century predecessor for bequeathing a system that makes competition possible.
Mrs Merkel needs success because the reforms prompted a steep fall in her poll ratings. She was roundly attacked by opposition parties, trade unions and insurers. They claimed the reforms were aimed more at raising money than cutting costs.
But Germany has at least made a serious attempt to tackle a problem that is afflicting every Western nation. Each is trying a different approach. That’s a sure sign that no one nation has the answer to the spiralling health costs of an increasingly greying and demanding populace
The Telegraph Expat
Under Obamacare, the U.S. healthcare system is starting to look more like Germany's. Here's what Germans do right—and how Americans could do even better.
The German health insurance and social security system is administered by the several companies. There are two different types of German Health Insurance. “Gesetzliche Krankenkasse” or state health insurance is the most common. “Private Krankenkasse” is private health insurance.
The German Medical Association (Bundesärztekammer) is the central organisation in the system of medical self-administration in Germany. As the joint association of the State Chambers of Physicians (Landesärztekammer),
From the UK newspaper The Guardian:
Looking at different countries' healthcare systems is like looking at the NHS in a circus mirror: the main elements are all there, but it's a different image. There are differences between almost all countries' organisational structures, along with the way their 'insurance' system is administered, usually for historical reasons. And while European citizens can use other countries' public healthcare under the European health insurance card scheme, attempts to join systems up (such as patient records) are at an early stage.
An interesting aspect of this is how similar the administration of these countries is to the UK's pre-1974 NHS structure, which evolved because of county council involvement. English councils will soon be involved in public health, and could have more significant powers depending on how the NHS
What differs, however, is the way treatment is controlled at the point of care, and how the patient pays and is reimbursed. In some countries, this has profound implications for the unemployed or homeless, although most doctors will treat first and organise the paperwork afterwards.
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Belgium's healthcare system is rated by Expatica.com, a UK expatriates web site, as having one of the best healthcare systems in Europe. Dating from 1945, its quality is largely down to its sponsorship by competing mutuals, and provisioned by a mixture of state and non-profit hospitals. Each mutual is funded by the state, the funding dependent on its membership numbers.
Like the system in France, citizens pay and swipe a health card at the point of care. They are then reimbursed between 50% and 75% of the costs by their mutuelle/mutualiteit scheme. Some GPs and hospitals have local arrangements with mutuals to reduce payments at the point of care.
Also as in France, most citizens also sign up for mutual insurance to top up their healthcare reimbursements (complimentaire).
As in Germany, Belgian citizens can visit any healthcare establishment they wish - quite literally walking in off the street, although referrals from private or practice-linked GPs are increasingly being used, and language pays a major part in choices.
Almost all dentists in Belgium are private, with only partial patient/state reimbursements complicating the landscape.
Healthcare insurance is a part of the Belgian social security system, meaning that citizens must join a health insurance fund mutuelle (mutualiti) or ziekenfonds (mutualiteit) and pay through payroll or bank deductions.
Hospitals and GP clinics are private and typically managed by universities, religious organisations or mutuals. Most cities have a choice of a social welfare hospital and a religious hospital.
The former are highly regulated and will treat regardless of the patient's ability to pay. The latter tend to have a more middle class atmosphere and are generally associated with 'better' treatment.
Like the UK, France a two-tier healthcare system, with a state-run equivalent of the NHS - Couverture Maladie Universelle (CMU) - and the private sector. In 2000, the World Health Organisation said it ran the best national healthcare system.
In many ways, the CMU operates as a mirror-image of the planned NHS reformed system in organisational terms, with hospitals acting as the centre of healthcare in liaison with the GP practice.
Almost all state health interactions are carried out using a smart card (carte vitale). This contains details of you and your family's rights to medical treatment and, like the UK driving licence, comes with a paper form - an attestation - that is used to augment the card in identifying citizens to state-run healthcare professionals.
GP visits cost EUR23 and, after your card is swiped, the money is paid back into your bank account by the state, usually within a few days. Currently one euro is 'voluntarily' withheld to fund a number of worthy healthcare activities.
Outpatient and pharmacy interactions are similarly smart card enabled, but the carte vitale system reimbursement rate is between 70% and 100%, depending on the type and point of treatment.
Most French citizens belong to a mutual society (mutuelle) that tops up the reimbursement to 100%. The mutual also liaises with the state healthcare operation - the CPAM (Caisse Primaire d'Assurance Maladie) - on reimbursements.
Some citizens are also privately insured, as in the UK, but there are few patients treated privately in the state system, as happens in the NHS when a consultant refers a private patient into the NHS system.
Inpatient treatment is more complex, as the carte vitale is augmented by forms and the paper attestation for treatment in the private sector.
Germany's state healthcare system is the oldest in Europe, dating back to the 1880s. Around 15% of people opt out of the state scheme for private health insurance, usually when they are younger, as premiums are lower.
Citizens pay into one of the 300 statutory state sickness funds through their payroll or bank. Payments are around 13% of gross earnings, although citizens can elect to switch funds to save on premiums with government blessing - people can even compare fund rates online.
Some funds operate on a pay-for-treatment-and reimburse basis, but some treatment centres - notably GPs and hospitals - have arrangements with local sickness funds to save patients paying.
Inpatient stay reimbursements are complex and are not based on treatments, a situation that has caused many experts to suggest health reforms (Gesundheitsreform). The German health care reform law (January 2004) simplified a previously highly complex administration, seeking to reduce paper trails and sickness fund premiums as a result.
Comparing healthcare contribution rate is made more complex because accident (Arbeitsunfallversicherung) and long-term care insurance (Pflegeversicherung) is usually bundled with health insurance by many funds.
The Federal Ministry of Health controls all aspects of state healthcare, organised in a similar structure to the pre-1974 NHS in the UK, with the ministry working directly with hospitals and GPs and with local council delegations in many city areas.
German hospitals operate under diverse ownership, with a mixture of state, private, mutual and friendly societies. Germans can visit any GP or specialist they wish - they can even walk into a specialist clinic off the street.
The unemployed are funded separately though the social fund or the AOKs (Allgemeine Ortskrankenkasse), the local funds of last resort, which cover about one-third of the population.
Sweden has radically different healthcare model to much of Europe: fully government funded and highly de-centralised. It is 70% funded by local taxes, with the Ministry of Health and Social Affairs establishing principles and guidelines for care at a national level.
But regionally, it is the countries' 21 councils that effectively control the healthcare system, again showing similarities to the pre-1974 NHS. The councils, known as municipalities are responsible for healthcare provision, particularly where community care and psychiatric services are involved. They are powerful organisations, also running water supplies and social welfare in their areas.
Not all treatment is free at the point of care, though 97% is government-funded. Patients pay a nominal fee at the point of care and, as in the UK, the service is GP-centric. Drug treatments are nominally charged - as in the UK - subject to a capped rate of around £150 per year.
GP visits are also charged at around £12 per visit, although citizens can also visit private doctors at the same rate. A similar fee is levied on hospital outpatient visits. If patients register, they can also qualify for a capped rate of around £70 a year for GP and hospital healthcare. As in Belgium, dentistry is private, and is only partially funded by the state.
This article first appeared in The Guardian