German Health System Overview
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Outcomes
Health System Coverage
Costs for Consumers
Health System Expenditures
Germany’s COVID-19 Strategy
Population, Mid-Year 2019: 83,517,000
Projected Population Mid-Year 2030: 83,136,000
Percentage of Population Under Age 25 Years, Mid-Year 2019: 24%
Percentage of Population 65 Years Or Over, Mid-Year 2019: 22%
Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019: Data Booklet (ST/ESA/SER.A/424).
Percent of Adults Aged 65 Years and Over Their Own Health as Fair, Poor or Very Poor (2019): 57.7%
People With Dementia Per 1,000 Population (2021): 21.8
Projected Number of People With Dementia Per 1,000 Population in 2050: 35.9
Long-Term Care Workers Per 100 People Aged 65 And Over (2019): 5
Long-Term Care Beds In Institutions and Hospitals Per 1,000 Population Aged 65 And Over (2019): 54.2
Long-Term Care Spending as a Share of GDP (%) (2019): 2.2%
Source: OECD (2021), Health at a Glance 2021: OECD Indicators, OECD Publishing, Paris, https://doi.org/10.1787/ae3016b9-en.
Formal Long-Term Care Workers At Home (FTE) (2019): 260,422
Formal Long-Term Care Workers In Institutions (FTE) (2019): 438,852
Long-Term Care Recipients In Institutions Other Than Hospitals (Aged 65 Years and Older) (2020): 721,668
Long-Term Care Recipients At Home (Aged 65 Years and Older) (2017): 2,817,557
Source: Organization for Economic Cooperation and Development. OECD.Stat. Last accessed Sept. 7, 2022.
“On a per capita basis, all categories of health spending are above the respective EU averages (Figure 8), with spending on pharmaceuticals and medical devices almost 60 % higher than average. Over recent years, long-term care (LTC) spending has grown more strongly than all other expenditure categories.
“The recent LTC reform is likely to further increase expenditures because the benefit basket and eligibility criteria have been expanded and demand for services has increased (Section 5.3). Furthermore, spending on prevention has increased since 2015 due to the legal obligation for sickness funds and long-term care funds to invest more in health promotion and prevention.”
Source: OECD/European Observatory on Health Systems and Policies (2019), Germany: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.
“In order to care at home for close relatives requiring care, employees can, in addition, be released completely or partly from their work obligations for up to six months (longterm care leave). Since 1 January 2015, employees can make use of a release from work corresponding to the long-term care leave in order also to provide care outside the home for close relatives in need of care who are minors. They have a right to complete or partial release from work for up to three months to support close relatives in the last phase of life. The right to a release from work under the Act on Long-Term Care Leave does not apply for employers with 15 or fewer employees as a rule.
“Since 1 January, 2015, employees have had a legal right to family care leave, i.e. partial release from work obligations for up to 24 months if they work for at least 15 hours a week, from employers unless these generally have 25 or fewer employees. Employees can also be released from work under the Act on Long-Term Family Care Leave for the provision of care outside the home for close relatives in need of care who are minors. The minimum working time of 15 hours a week helps to ensure that employees do not give up their employment activity completely to provide long-term care. Long-term care leave and long-term family care leave combined may not exceed a total period of 24 months per close relative in need of care.”
UN Economic Commission for Europe (2017). Country Report – Federal Republic of Germany. UNECE, Geneva, Switzerland.
“Long-term care (LTC) has been managed by the statutory long-term care insurance (LTCI) since it was introduced in 1994 as Book XI of the Social Code. The statutory LTCI consists of the mandatory social LTCI (i.e. the public scheme) and mandatory private LTCI. Starting in 1995, all members of statutory sickness funds (including pensioners and the unemployed), as well as all people with full-cover private health insurance, were declared mandatory members of LTCI. This was the first time that mandatory membership was introduced for those with private health insurance – making it the first statutory insurance with nearly population-wide membership. In 2018, 72.8 million (87.7%) were covered by mandatory social LTCI and about 9.2 million (11.1%) by mandatory private LTCI (Bundesministerium für Gesundheit (BMG), 2020n).
“Similar to the SHI [Statutory Health Insurance] principles, members and their employers jointly contribute 3.05% of monthly gross income, that is, 1.525% each. Pensioners have to contribute the entire 3.05% from their pension. As a result of the Child Bonus Act (2005), childless SHI members who are 23 years and over pay a 0.25%-points increased contribution rate (a total contribution of 3.3%).”
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 contrast to SHI, benefits are available upon application only in the statutory LTCI. The Medical Review Boards evaluate if the applicants are “in need of care” and place them into one of five grades (or deny care). Most of the private health insurers purchase this evaluation service from the Medical Review Boards. Entitlement to insurance benefits is given when care is expected to be necessary for at least six months (hence “long-term” care), while short-term nursing care continues to be funded by the sickness funds and private insurers if included in the benefits basket. Beneficiaries with a care dependency then have a choice of receiving cash-benefits or professional nursing care (or a combination of both) while staying at home or of receiving professional nursing services in nursing homes. The amount of benefits provided depends on the care grade needed.
“Between 2015 and 2017 the three Strengthening Long-Term Care Acts (Pflegestärkungsgesetze I–III) (see Section 6.1 Analysis of recent reforms) came into force which fundamentally changed the eligibility criteria and assessment procedure in the LTCI system. Prior to the PSG II, “in need of care” legally referred to those individuals who have a physical, psychological or mental disease, and/or a handicap that requires a significant amount of help to carry out daily activities of everyday life. The Medical Review Boards assessed the care needs according to a standardized and complex assessment procedure and categorized the applicant into one of three care levels (1 – 3, and in practice, applicants suffering from dementia were classified as level 0). As a result of PSG II, these three care levels have been transformed into five care grades and the assessment procedure has fundamentally changed. The most significant change within the care grades is for persons suffering from dementia (the new care grade I replaces the former care level 0 for this group).
“Furthermore, several measures expand LTC benefits or improve flexibility to combine individual benefits. PSG I introduced new benefits for family caregivers, e.g. the right to an additional vacation for caregivers (see Section 5.9 Services for informal carers), additional means for renovating homes to adapt them to older people’s needs, an expansion of existing cash-benefits, and the requirement for more capacities and medical personnel in nursing homes.”
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.
“Cash-benefits are intended to cover home care delivered by relatives at the following monthly rates: € 316 in grade II, € 545 in grade III, € 728 in grade IV and € 901 in grade V. Within care grade I impairments are limited, and people are initially only entitled to part of the benefits from LTCI. Cash-benefits, professional home care and inpatient nursing services are not covered in grade I, but people in need of care (irrespective of the care grade) are eligible for a relief amount of up to € 125 per month for caring relatives.
“In addition, relatives serving as carers at home can attend training courses free of charge, and short-term replacement care is provided when usual carers take holidays. Carers are also covered by statutory accident insurance and statutory retirement insurance, financed by the sickness fund administering the long-term care insurance of the person in need (see Section 5.9 Services for informal carers). The limits for professional ambulatory services delivered on an in-kind basis are € 689, € 1298, € 1612 and € 1995 respectively. Professional ambulatory care can be supplemented by care in day or night clinics as well as in old age or special nursing care homes. For people choosing fully residential nursing care, monthly benefit limits are € 770, € 1262, € 1775 and € 2005 respectively (Bundesministerium für Gesundheit (BMG), 2019g).”
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 Jan. 25, 2023 by Doug McVay, Editor.
