German Health System Overview
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Population Insurance Coverage For A Core Set Of Healthcare Services* (%) (2019):
Public Coverage: 89.5%; Primary Private Health Coverage: 10.5%; Total: 100%
*“Population coverage for health care is defined here as the share of the population eligible for a core set of health care services – whether through public programmes or primary private health insurance. The set of services is country-specific but usually includes consultations with doctors, tests and examinations, and hospital care. Public coverage includes both national health systems and social health insurance. On national health systems, most of the financing comes from general taxation, whereas in social health insurance systems, financing typically comes from a combination of payroll contributions and taxation. Financing is linked to ability-to-pay. Primary private health insurance refers to insurance coverage for a core set of services, and can be voluntary or mandatory by law (for some or all of the population.”
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
“Health insurance is compulsory in Germany, provided either under the SHI [Statutory Health Insurance] scheme or through substitutive PHI [Private Health Insurance]. Employees are usually insured in the SHI, but people whose income is above a fixed threshold or who belong to a certain professional group, e.g. the self-employed or civil servants, must or can opt to enroll in PHI for substitutive full coverage. Around 87% of the population is covered through SHI, while approximately 11% has substitutive PHI coverage. The other 2% (e.g. soldiers) are covered under special programmes. Around 61 000 people are uninsured.
“SHI covers a broad benefits basket, well beyond essential services, and benefits are the same for all those insured. Individuals covered by substitutive PHI usually enjoy benefits equal to or better than those covered by SHI. Benefits covered by SHI are legally defined in generic terms at the federal level, while details and decisions on including new technologies, pharmaceuticals or medical devices in the benefits basket are at the discretion of the Federal Joint Committee. These decisions are guided by structured Health Technology Assessments and are binding for all sickness funds, providers and patients.”
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.
“Patients in Germany generally have free choice of physicians (GPs and specialists). Individuals with private substitutive insurance (e.g. employees above an opt-out income threshold, the self-employed or civil servants) or who pay out of pocket have access to all licensed health care providers except when this is precluded by contractual limitations. Individuals covered by SHI may choose freely among ambulatory care physicians who have been accredited by the Regional Associations of SHI Physicians to treat SHI-covered patients (i.e. some 98% of all ambulatory care physicians in Germany). Patients may also choose freely among hospitals that have been contracted by the sickness funds; the beds in these hospitals represent 99% of all hospital beds in the country. Since 2009 all residents in Germany are required to have statutory health and long-term care insurance or substitutive coverage through a PHI plan. Patients who are eligible for coverage through the SHI system have virtually free choice of sickness funds and, in general, may switch sickness funds after an 18-month waiting period.
“Individuals covered by SHI are free to take out supplementary health insurance offered by private insurance companies. Individuals with substitutive PHI may also choose freely among private health insurers. For those insured under substitutive PHI switching from one private insurance company to another has been made easier since the possibility was introduced in 2007 to have active life reserves transferred from an old to a new insurer. Long-term care funds/insurers cannot be chosen freely as these are administratively connected to the sickness fund/health insurers (see Section 5.8 Long-term care).
“Recipients of long-term care benefits have free choice of their care provider based on the principle of self-determination. They can choose between in-kind benefits, cash benefits or a combination of the two. In general, patients can choose between different treatment options (if available) out of the given alternatives from a provider. Based on patient rights, other possibilities for patient choices relate to participating in (shared) treatment decisions and requesting second opinions from different providers (see Table 2.6).”
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 Germany, 88 percent of the population is covered by statutory health insurance, which is financed by financially and organizationally independent statutory health insurance funds, and 9 percent of the population is privately insured.15 The guiding principle of the German statutory health insurance system is solidarity regarding both income and provision of services: All insured people contribute a share of their income, irrespective of their health risk, and people are entitled to benefits according to their health needs, irrespective of their socioeconomic status, ability to pay, or location.16 All employed people earning less than the opt-out threshold, people receiving welfare benefits, and pensioners have mandatory statutory health insurance, and their nonearning dependents are insured free of charge. People with high income and self-employed people can purchase private health insurance or keep the statutory health insurance. Coverage of services is roughly the same in both systems, apart from certain newly launched drugs, which are paid for by private insurance. There is no restriction on patients’ choice of hospitals, and patient copays for hospital stays do not differ across hospitals.”
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
“Germany has the oldest social health insurance (SHI) system in the world. Health insurance is compulsory, but people with an income above a fixed threshold or belonging to a particular professional group (e.g. self-employed people or civil servants) can opt out of SHI coverage and enrol in (substitutive) private health insurance (PHI). About 11% of the population are covered by PHI; 89% by SHI. Although coverage is universal for all legal residents and only 0.1% of the population do not have health insurance, there are still gaps due to financial or administrative barriers (see Section 5.2). The multi-payer SHI system currently consists of 103 sickness funds and 41 PHI companies, and the three biggest sickness funds cover more than one third of the German population.”
Source: OECD/European Observatory on Health Systems and Policies (2021), Germany: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
“Since 2013 the Patient Rights Act (Gesetz zur Verbesserung der Rechte von Patientinnen und Patienten) has anchored patient rights in the German Civil Code §630a–h for all medical treatments by physicians and other health care professionals. Patients in Germany have the right to choose their physician and hospital freely; to seek a second opinion; to receive medical treatment according to recognized standards; to determine the treatment and its extent; to have the cost covered by their sickness funds for necessary communication aids to interact with physicians; to have medical procedures performed only with their legal consent; to receive a (patient) receipt (Patientenquittung) from their sickness fund, physicians, dentists or hospitals with a listing of costs and services obtained; to view their own medical records and have copies made at their own expense; to have their patient data treated with confidentiality; and to receive compensation in the event of medical error, lack of informed consent, or injury caused by pharmaceuticals or medical devices (see Table 2.7).
“Since 2006 there is also a Charter of Rights for People in Need of Longterm Care and Assistance containing eight articles on the following areas: self-determination and support for self-help; physical and mental integrity, freedom and security; privacy; care, support and treatment; information, counselling and informed consent; communication, esteem and participation in society; religion, culture and beliefs; and palliative support, dying and death (Bundesministerium für Familie, Senioren, Frauen und Jugend (BMFSFJ), 2019).”
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.
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Page last updated April 14, 2023 by Doug McVay, Editor.
