“Finally, although LTCI [Long-Term Care Insurance] benefit amounts are uniform across Germany, provider charges are not. Beneficiaries who choose higher cost providers or live in areas where providers charge more will need to pay extra to get the same level of service. Additional costs may also arise if beneficiaries choose nursing home care when the LTCI fund deems it unnecessary; in these cases, benefits are limited to the cost of home care. Consequently, families must either pay out of pocket or apply for means-tested social assistance for eligible expenses. Indeed, German law requires family members “in the direct line of descent” to cover the cost of care (Moskowitz, 2001). Many elderly who do not move into nursing homes supplement their LTCI benefits with uncompensated help from family, friends, and neighbors, or hire cheaper, “gray market” labor (sometimes, by using the cash benefit to do so) (Theobald, 2012b). About 4% of Germans have chosen to purchase additional private LTCI to supplement their mandatory public or private coverage if they go into claim (Nadash & Cuellar, 2017).”

Source: Pamela Nadash, BPhil, PhD, Pamela Doty, PhD, Matthias von Schwanenflügel, LLM Eur, The German Long-Term Care Insurance Program: Evolution and Recent Developments, The Gerontologist, Volume 58, Issue 3, June 2018, Pages 588–597.

“The challenge of the German LTCI [Long-Term Care Insurance] model is that a self-funding mandate can be difficult to sustain in the face of an aging population: revenues vary based on who is in and out of the labor force, as well as the demographic profile of the working population. One of the most remarkable achievements of the German program has been its ability from 1994 through the present day to accurately forecast demand and associated expenditures. Other countries with universal financing for LTSS (most notably, Japan) have not been as successful: although attributed to higher than anticipated demand, reasons for this are poorly understood. An important constraint to such programs is on the revenue-generating side: it can be politically difficult to increase revenue by raising premiums set by legislatures—which is why Germany’s most recent reforms, which increase premiums and index-link benefits, are so significant.

“Its other notable feature is the program’s explicit tradeoff regarding affordability and benefits: the program does not aim to cover the full cost of care. Thus Germans trade low benefits—a program that is inexpensive because it is mandatory but also acceptable as mandatory because it is so inexpensive—for comprehensive, high dollar policies affordable only to affluent low-risk individuals—policies that are affordable only because they exclude lower-income, higher risk individuals (as does the U.S. private insurance market).”

Source: Pamela Nadash, BPhil, PhD, Pamela Doty, PhD, Matthias von Schwanenflügel, LLM Eur, The German Long-Term Care Insurance Program: Evolution and Recent Developments, The Gerontologist, Volume 58, Issue 3, June 2018, Pages 588–597.

“The German health system exhibits a comparatively low degree of digitalization, both in terms of overall infrastructure and in the uptake of online health services. For instance, internet coverage with very high capacity networks stood at 33%, which is below the EU average, and overall good coverage of fast broadband is worse in rural areas (European Commission, 2020a). Communication between citizens and public authorities is overwhelmingly paper-based and Germany ranked 26th in the use of electronic government services out of 28 EU Member States in mid-2019 (European Commission, 2020a). Moreover, with specific regard to health services, the use of online health care services and medical data exchange remains well below the EU average (European Commission, 2020c, 2020d).”

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.

“The Hospital Future Law and prolonged financial support for hospitals and nursing homes

“On September 2, the Federal Cabinet adopted the draft for the “Hospital Future Law” that intends to to support the digital infrastructure of hospitals in the coming years (see also Section 2.1: Stimulus package’s investments in infrastructure and equipment). Hospitals are to receive an investment package of around four billion euros. The Federal Government will provide EUR 3 billion, the Länder are to invest another EUR 1.3 billion. During the corona pandemic it became clear that there were deficits or slow progress in the digitalisation and networking of hospitals which is partly a result of the lack of financing of capital investment through the Länder. Funding will  be provided for investments in emergency capacities and digital infrastructure to promote internal, intra-sectoral and cross-sectoral care, in particular to digitalise process organisation, documentation and communication, and to introduce or improve telemedicine, robotics and high-tech medicine.  Financial support will also be provided for improved information security and the targeted development and strengthening of regional service structures in order to harmonise supply structures both in normal operation and in times of crisis. Necessary personnel measures and cross-border projects can also be financed by the Hospital Future Fund. In 2021 and 2023 the state of digitalisation will be evaluated. Accordingly, the fund will be established at the Federal Office for Social Security and will be funded by the Federal Government, the Länder and the funding agencies from January 2021. The Länder can submit applications for funding  as of now and until the end of 2021.

“In addition the financial support for hospitals, the existing hospital structural fund, which was established in 2016 to improve regional inpatient care structures, will be extended by two years until 2024. In case of revenue shortfalls related to COVID-19 hospitals may agree on compensation with the SHI funds on an individual basis. Similarly, to cover additional expenditure related to COVID-19 to-up payments can be agreed. Moreover, financial support for residential care facilities to cover additional expenditure related to COVID-19 and revenue shortfalls will be extended until 31 March 2021. The benefits were initially limited until 30 September. Also the support for informal carers providing care to relatives. They can still take 20 working days off at short notice until the end of December 2020 in case of an acute nursing case due to Covid-19. The care support allowance can still be claimed for 20 working days instead of the previous ten. The Act is expected to be adopted by the Federal Parliament beginning October 2020.”

Source: COVID-19 Health System Response Monitor. A project of the European Observatory on Health Systems and Policies, the European Commission, and the World Health Organization Regional Office for Europe. Last accessed Oct. 2, 2020.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated Jan. 25, 2023 by Doug McVay, Editor.