Germany’s universal health care system on solid foundation

Based on a strict division between ambulatory and hospital care, the German system has found a good balance between public and private sector, a physician says.

H. Burkhard Dick

Germany has the oldest universal health care system in the world. Its foundation dates to 1883, when Otto von Bismarck, chancellor of the German Empire, promulgated and enforced the Health Insurance Act. Through a network of “sickness funds” to which all citizens were called to contribute in proportion to their income, health care coverage was provided to blue-collar workers first and then progressively to the entire population.

“Our system has remained basically the same. Contribution to sickness funds is mandatory, and the amount you pay is about 15% of your income. If you are an employed worker, this amount is equally divided between yourself and your employer,” H. Burkhard Dick, MD, OSN Europe Edition Chairman of the Editorial Board, said.

In 1990, the reunification of East and West Germany after the fall of the Berlin Wall in 1989 created an urgency to reorganize the system to include 17 million East German citizens, posing new and massive financial commitments.

“The western system of health insurances (both statutory and private) expanded into the eastern part. An immediate aid program of several billion Deutsche marks was supported by the federal government in order to upgrade the infrastructure. Many investments were going to hospitals and retirement facilities,” Dr. Dick said.

Not without struggle, but rapidly and efficiently, the goal was reached. By 1991, three-quarters of the East German population had complete coverage. Within 2 years, thanks to West German bank loans, a large number of physicians previously employed in state-run polyclinics set up private practices. East Germany underwent a huge renovation in health care infrastructures.

Organizational issues

The total number of ophthalmologists in Germany is currently 6,500. The largest percentage of ophthalmologists work in ambulatory settings, while a minority are employed by hospitals and clinics. In the German system, there is a sharp division between ambulatory and hospital care. Office-based practitioners are strictly separated from hospitals and provide a wide range of services. Hospitals provide mainly in-patient care and limited outpatient services. In both domains, there is full compatibility between public employment and private practice, and most ophthalmologists receive a good proportion of their income from private activity, mostly surgical. Outpatient surgery is a well-developed practice and relatively more common in ophthalmology than in other subspecialties.

According to Dr. Dick, the number and geographic distribution of eye specialists satisfies the needs of most of the population, and high-quality care is provided in all areas of the country in both ambulatory and hospital domains. More densely populated regions, such as North Rhine-Westphalia, Baden-Württemberg and Bavaria, have a high concentration of ophthalmologists, particularly in large cities.

A problem that is now becoming more evident is the increasing age of ophthalmologists and the lack of a young work force to replace retiring colleagues.

“While 10 to 15 years ago the number of newly graduated ophthalmologists exceeded by 2% to 3% the number of retiring colleagues, we are now facing the opposite situation. The number of medical students has remained relatively stable, but an increasing number of them, more than 10% in our specialty at present, don’t go into patient care in Germany. They choose scientific research, eye care companies or administration, or go into the German-speaking countries,” Dr. Dick said.

Patient care, he explained, has lost appeal because remuneration is low in relation to the amount of work and degree of responsibility entailed, particularly in the ambulatory care sector.

In addition, competition from opticians is becoming increasingly fierce for office-based practitioners. National societies such as the German Society of Ophthalmology, the German Professional Association of Ophthalmologists and the Association of German Ophthalmic Surgeons are addressing the specific concerns of ophthalmic surgeons regarding scope of optometric care and other issues.

“[German ophthalmic] societies are trying to raise recognition of the importance of eye care in the population. They are implementing national screening programs, for glaucoma, [age-related macular degeneration] and other age-related conditions. They are also putting pressure on the government for more adequate reimbursement of surgical procedures,” Dr. Dick said.

Role of private insurance

Purchasing a supplemental policy from a private insurance company is possible in Germany for citizens who meet certain income requirements.

“You can buy additional services, like coverage for procedures that are not provided under the state’s health system, or differentiate between being covered by the insurance for hospital care and by statutory social insurance for ambulatory care. You can also opt out of the statutory health insurance and have complete coverage from private insurance,” Dr. Dick said.

Private health insurance is used by 10% to 15% of German citizens, a high proportion of whom live in the western part of the country.

Procedures for which patients need to pay through private insurance or with their own money include refractive surgery, cataract surgery with premium IOLs and diagnostic tests such as applanation tonometry and optical coherence tomography.

“These are debated issues, of course, because tonometry and OCT need to be used routinely in the follow-up of glaucoma treatment and macular conditions. Also, there is no clear definition of what a premium IOL is. In my opinion, aspheric, aberration-free or blue-blocking IOLs should be considered standard, while multifocal, accommodative, light-adjustable and toric IOLs are premium options,” Dr. Dick said.

The reason examinations such as tonometry and OCT are not covered is purely financial, he explained. In ambulatory settings, where patients with chronic diseases are followed up, ophthalmologists are paid a fixed amount per patient per year, currently €10, to provide routine care. This small sum is not sufficient to cover the expenses of purchasing and using expensive instruments.

“Ambulatory-based specialists have to charge the patients for these exams, and this is how they top up their income, [which] would be otherwise disproportionally low,” Dr. Dick said.

Similarly, surgery for cataract is reimbursed as a package, with implantation of a standard monofocal IOL included. If a patient asks for a different lens, the entire procedure has to be performed as a private procedure in many states.

“This is subject to change in the next year with a new patient-centered care law modification, hopefully,” Dr. Dick said. “The two alternatives are paying nothing or paying it all, and there can be no compromise on this. The only way out is to purchase a private insurance plan, and quite a lot of patients do it on these occasions.” – by Michela Cimberle

References:

• Jakubowski E, Busse R; European Parliament. Health care systems in the EU: A comparative study. http://www.europarl.europa.eu/workingpapers/saco/pdf/101_en.pdf. Published May 1998.
• Naumann GO. Ophthalmology in Germany. Arch Ophthalmol.1998;116(10):1366-1368.

• H. Burkhard Dick, MD, can be reached at Institute for Vision Science, Ruhr University Eye Hospital, In der Schornau 23 - 25, DE-44892 Bochum, Germany; +49-234-2993101; fax: +49-234-2993109; email: burkhard.dick@kk-bochum.de.
• Disclosure: No products or companies are mentioned that would require financial disclosure.