German Health System Overview
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Germany’s COVID-19 Strategy
Hospital Beds Per 1,000 Population (2020): 7.82
Doctors Consultations (In All Settings) (Number Per Capita) (2020): 9.5
Hospital Average Length of Stay (All Causes) (2020): 8.7
Computed Tomography Scanners (Per Million Population) (2018): 35.33
Magnetic Imaging Resonance Units (Per Million Population) (2018): 34.47
Source: Organization for Economic Cooperation and Development. OECD.Stat. Last accessed Sept. 6, 2022.
“By international standards, the German inpatient care sector is large and varied. In 2017 Germany had 6.02 acute care beds per 1000 population, which is second highest in the EU after Bulgaria. Although acute hospital capacities have been reduced since 2000, the number of acute hospital beds is considerably higher than in neighbouring countries and almost 65% higher than the EU 28 average (Figure 4.1). This is partly due to a higher starting point in acute care bed capacities, and also due to a more pronounced decrease in other countries.
“Table 4.1 shows a substantial shift in the provision of inpatient care: the numbers of curative (or acute) hospital and rehabilitative care beds have decreased simultaneously (by more than 60,000 beds and 24,600 beds respectively between 2000 and 2017). At the same time, psychiatric care beds increased by almost 20% (or 17,400 beds) (see Section 5.11 Mental health care), while the number of beds in nursing and residential care has grown by 40% or 307,000 beds respectively (Statistisches Bundesamt, 2018b).”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
“In 2018 there were a total of 1925 hospitals providing 498,192 beds. Of these, 552 hospitals were publicly owned, 650 were private not-for-profit and 723 private for-profit hospitals, with bed shares of 48%, 33% and 19% respectively. Privately owned hospitals have, on average, 132 beds compared to an average of 433 beds in publicly owned hospitals. The number of publicly owned hospitals (general and “other”) almost halved between 1991 and 2018, whereas the number of private hospitals doubled over this period (Statistisches Bundesamt, 2020g). Moreover, there are vast regional differences regarding private for-profit ownership of hospitals: in Hamburg 41 out of 56 hospitals (73%) were under private ownership in 2018, while in Berlin and Mecklenburg-Western Pomerania more than half of the hospitals were privately owned. On the other hand, Saarland had only 0.6% privately owned hospitals in 2018. The 1585 acute care hospitals provide the overwhelming share of hospital beds (91%). The 279 psychiatric hospitals had a total of 46,610 beds in 2018 (9%) while the 61 day surgery hospitals have no beds.
“Using the categories of contractual status with sickness funds, acute hospitals fall into four groups: 1) 35 university hospitals, which account for approximatively 10% of all acute care hospital beds; 2) 1527 hospitals enlisted in state hospital requirement plans (87.7% of acute care hospital beds); 3) 138 acute hospitals additionally contracted by sickness funds according to §109 SGB V (1.7% of acute care beds); and 4) 160 acute hospitals without such contracts (0.5%). In the latter category, hospital services are not covered by SHI and are thus only accessible for privately insured and self-paying patients (the latter may also include patients with SHI).”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
“Germany has a very large hospital inpatient sector, with 7.9 hospital beds per 1,000 population – the highest in the EU and 50 % more than the EU average (5.3 beds). Bed capacity has been reduced by only 13 % since 2000, whereas countries like Finland and Denmark have reduced capacity by more than 40 % over the same period. This high capacity has long been criticised on efficiency grounds, and there are calls to reduce overcapacity. It is noteworthy, though, that during the COVID-19 crisis the high number of hospitals and acute and intensive care beds were available as a reserve to cope with the increase in patients (see Section 5.3).
“Germany also has high numbers of physicians and nurses, with per population ratios and growth rates well above the EU average (Figure 9). Growth in physician numbers has been particularly strong for hospital physicians. Since 2004, when the diagnosis-related group (DRG)-based hospital payment system was introduced, the number of doctors (by head count) in hospitals increased by 42 % (from 138,000 to 196,000 in 2017), while the number of doctors in ambulatory care increased by 25 %. Nevertheless, given the high number of hospital beds, the physician to bed ratio is comparatively low, and the nurse to bed ratio is one of the lowest in the EU.”
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
“In hospitals that are included in the hospital requirement plans, capital investment in high-cost medical equipment is financed by the states (see Section 4.1.1 Infrastructure, capital stock and investments). In 2018, 1095 out of the total of 1925 hospitals were equipped with 12,631 high-cost medical devices. Out of these, 1529 were computed tomography (CT) scanners, 5773 dialysis machines, 1174 angiography units, 478 gamma cameras, 123 positron emission tomography (PET) scanners, and 1007 magnetic resonance imaging (MRI) units (Statistisches Bundesamt, 2020g). For hospitals not eligible for state funding and for the ambulatory care sector, funding of high-cost medical technology must be amortized through reimbursements by the sickness funds or private capital.”
Source: Blümel M, Spranger A, Achstetter K, Maresso A, Busse R. Germany: Health system review. Health Systems in Transition, 2020; 22(6): pp.i–273.
“We investigated changes in hospital quality in Germany during the period 2012–19, considering a wide range of quality indicators. On average, significant shares of hospitals of low and high quality moved to the average quality category for all indicators we considered. However, in general, low-performing hospitals were more likely than high-performing hospitals to become average quality. This supports the hypothesis that low-quality hospitals are more likely to engage in quality benchmarking, whereas for high-quality hospitals, preserving reputation and altruistic motives are also important. Becoming understaffed as a result of an increase in patient demand did not explain the decline in the quality of high-performing hospitals.
“In the current setting, a hospital with acceptable quality that does not face fierce competition has no incentive to improve quality, other than its intrinsic motivation to do so. Evidence from a for-profit hospital chain in Germany supports the hypothesis that hospitals engage in quality benchmarking and that their intrinsic motivation is not enough to ensure quality improvement.23 However, if hospitals were only benchmarking, the best hospitals in oligopoly markets would not be more likely to remain in the high quality category than ordinary hospitals. Yet the best hospitals were more likely than ordinary hospitals to remain in the high quality category for half of the indicators that we examined. We found that even monopolist hospitals had the intrinsic motivation to provide high-quality care, but this became less pronounced in the presence of pressing financial concerns, such as for the obstetrics and neonatology indicators. In fact, Jonathan Kolstad has shown that the intrinsic response to quality reporting is about four times as large as the response resulting from profit incentives induced by changes in demand for quality.30 Furthermore, it is important to consider the unpredictable nature of demand for certain services, such as obstetrics, in addition to accounting costs when determining hospital reimbursements. Doing so can eliminate the financial pressure imposed by the randomness of the time at which patients require medical attention (pressure that can hinder quality improvement) and can avoid the underuse of resources to meet patients’ needs at the required time. Hence, quality incentives should be aligned with the intrinsic professional values of clinical care.9
“Quality indicators are mainly used in Germany to identify low performers,31 and enhancing the quality of the rest of the hospitals, as well as maintaining the quality of high performers, is left to market mechanisms, which are nonexistent in more markets than has been previously assumed by policy makers.32 In other words, policy makers should take action to speed up quality improvement by rewarding high-performing hospitals and reducing the financial pressures encountered in the provision of certain medical services that have high demand uncertainty.”
Source: Esra Eren Bayindir and Jonas Schreyögg. Public Reporting Of Hospital Quality Measures Has Not Led To Overall Quality Improvement: Evidence From Germany. Health Affairs 2023 42:4, 566-574
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Page last updated April 14, 2023 by Doug McVay, Editor.
