The German healthcare system

Health care in Germany is based on four basic principles:

• Compulsory insurance: Everyone who lives in Germany is legally required to have health insurance. Most people have to get public health insurance (gesetzliche Krankenversicherung, or GKV), also known as "statutory" health insurance. But employees with a gross income above a certain amount (known as the Versicherungspflichtgrenze) can choose between public health insurance and private health insurance. Other groups of people have this option, too, including many self-employed people and freelancers, public officials, judges and soldiers.
• Funding through insurance premiums: Health care in Germany is mostly financed through the regular payments (premiums) of health insurance members and their employers. It is also subsidized through taxpayers' money. To give you an idea of what this means: State-funded healthcare systems like those in Great Britain or Sweden are almost completely financed through taxes. In the United States, most people have to get private health insurance or carry the costs of treatments and loss of earnings due to illness themselves.
• Solidarity: In the German healthcare system, all public health insurance members and employers carry the costs together through monthly premium payments. Your premium is calculated based on a percentage of your income: The more you earn, the more you pay. But people who earn more than a certain amount (known as the Beitragsbemessungsgrenze) all pay the same maximum premium. Some family members can be insured for free – for example, if they have no income themselves, or don't earn enough. Anyone who gets ill has an equal right to the same medical care, regardless of their premium level. This means that the rich help the poor, and the healthy help the ill.
• Self-governance: The German healthcare system is not run by the government. The government sets the legal framework for medical care. But the further organization, development and financing of individual medical services is mostly regulated within the healthcare system itself. This task is carried out by supporting organizations and care providers, including public health insurers, doctors and hospitals. In the case of health insurers, for example, representatives of the insured members and employers make decisions about things like budget issues, extra services (freiwillige Leistungen) and additional fees (Zusatzbeiträge). Doctors and psychotherapists organize the nationwide provision of health care in associations of statutory health insurance physicians and dentists (kassenärztliche Vereinigungen). The Federal Joint Committee (Gemeinsamer Bundesausschuss or G-BA) is the highest decision-making body within the self-governing system. You can read more about this below, in the section “Structure and institutions of the healthcare system.”

The beginnings of the German healthcare system can be traced back to the Middle Ages, when craftsmen were members of guilds. The guilds provided an early form of health insurance based on the principle of solidarity: All guild members paid into a joint fund which was then used to help individual members if they had financial difficulties, for instance because of an illness. There were also insurance funds organized for factory workers as early as the beginning of the industrial revolution. These different forms of social insurance were then standardized through Otto von Bismarck’s social policies in the late nineteenth century. Health insurance was the first to be introduced, in 1883. Its primary goal was to provide insurance in the event of illness, mainly for workers involved in both industrial and non-industrial production.

Anyone who was insured was granted the right to free medical treatment and medication, as well as sickness benefits and a funeral allowance. At that time, about 10 percent of the population had health insurance – compared to nearly 100 percent in Germany now.

The introduction of health insurance in 1883 was closely followed by the introduction of statutory accident insurance (Unfallversicherung) in 1884 and pension funds (Rentenversicherung) in 1889. Unemployment insurance (Arbeitslosenversicherung) was introduced in 1927.

Accident insurance covers things like medical services needed for work-related accidents or illnesses, and includes payments in the event of work-related disability or death. Accident insurance is also compulsory for employees, but it is funded solely by employers.

Statutory pension funds are funded in equal parts by employees and employers. These funds are used to pay retirement pensions, disability pensions and rehabilitation costs for employees.

Long-term nursing care insurance (Pflegeversicherung) – the fifth branch of the social insurance system – was not introduced until 1995. It covers part of the costs of nursing care and assistance (outpatient, inpatient or at home) if they're needed. Like health insurance, long-term nursing care insurance is compulsory in Germany. People who have public health insurance automatically have statutory nursing care insurance, too. Those with private health insurance have to get private nursing care insurance themselves.

The legal basis of the five social welfare branches is described in the German Social Code (Sozialgesetzbücher).

The Federal Ministry of Health (Bundesministerium für Gesundheit, or BMG for short) is responsible for policy-making at the federal level. Its tasks include developing laws and drawing up administrative guidelines for the self-governing activities within the healthcare system. The Ministry of Health directs a number of institutions and agencies responsible for dealing with higher-level issues of public health. Examples include the Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte – BfArM) and the Paul Ehrlich Institute (PEI). BfArM makes decisions concerning the approval of pharmaceuticals. The Robert Koch Institute (RKI) monitors and protects the health of the population by, for instance, monitoring the development of infectious diseases and taking measures to fight them. The Paul Ehrlich Institute is responsible for approving vaccines, for example.

When it comes to matters concerning public health insurance, the Federal Joint Committee (G-BA) is the highest decision-making body within the self-governing healthcare system. It decides things like which medical services will be covered by the public health insurers and what form that coverage will take. It is also responsible for quality assurance in health care, so it regulates things like the qualifications needed for certain treatments. The G-BA is made up of representatives of doctors, dentists, psychotherapists, hospitals, public health insurers and patients.

It is supported in its role by – among others – two independent scientific institutes: the Institute for Quality and Efficiency in Health Care (IQWiG) and the Institute for Quality Assurance and Transparency in Health Care (IQTIG). IQWiG assesses the benefits and harms of medical treatments, for example. IQTIG mainly looks into the quality of health care in German doctors' practices and hospitals. Both institutes do research to produce scientific reports and make recommendations. These are taken into consideration when the G-BA makes decisions about health care. IQWiG also runs our website InformedHealth.org (and the German version gesundheitsinformation.de) to fulfill its goal of providing people who live in Germany with reliable health information.

The main healthcare providers, institutions and associations include:

• Health insurers: The public health insurers are required to provide people in Germany with health insurance and make sure that they receive medical care. This is done through contracts with many different institutions and organizations, including the associations of statutory health insurance physicians and dentists, as well as hospital and pharmacy associations. The National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) is the federal-level association of all public health insurers. Its activities are governed by law and it represents the interests of the different insurers. Private health insurers offer their members full, partial or add-on coverage. They are represented by the Association of Private Health Insurers (PKV-Verband).
• Associations of statutory health insurance physicians and dentists: Doctors (physicians) and psychological psychotherapists who work in practices where the treatment costs are covered by public health insurers all belong to associations known as kassenärztliche Vereinigungen (KV) at the state level. Dentists are organized in associations of statutory health insurance dentists (Kassenzahnärztliche Vereinigungen – KZV). The corresponding federal-level bodies are the Federal Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung – KBV) and the Federal Association of Statutory Health Insurance Dentists (Kassenzahnärztliche Bundesvereinigung – KZBV). The scope of these associations’ tasks is defined by law: The tasks include ensuring that there are enough doctors' practices everywhere, negotiating the doctors' fees with public health insurers, and checking the financial records and accounts of doctors' practices.
• Hospital federation: The German Hospital Federation (Deutsche Krankenhausgesellschaft – DKG) represents the state and national associations of hospital owners, which include district, city and local governments, churches, non-profit associations and private organizations.
• Pharmacy associations: Pharmacies are responsible for supplying medication, as well as providing information and advice about it. To make sure enough medication is available, pharmacy associations sign agreements with the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) and public health insurers. Then pharmacies can offer medication and bill the health insurers for it.
• Other healthcare professions: These include physical therapists, speech therapists, nurses and midwives. If they are self-employed and offer outpatient care for people with public health insurance, their respective associations also sign agreements with the GKV-Spitzenverband and the insurers. The agreements cover things like which treatments can be offered and how much they can cost.
• Physician, dentist, psychotherapist and pharmacist chambers: At the individual federal state (Bundesland) level, everyone qualified in these professions must be members of their respective state chamber. These chambers are responsible for things like supervising the professional obligations of the members and ensuring compliance with the Radiation Protection Ordinance. They also oversee the professional certification and the medical board examinations, and assess and resolve malpractice claims. The state chambers have corresponding chambers at the federal level.
• Public Health Service (Öffentlicher Gesundheitsdienst – ÖGD): The main task of the Public Health Service is to protect people from health risks. Regional health departments regulate things like hygiene in communal buildings, protection against infections, and the general promotion of good health. They also offer advice and help – for instance, for people with mental health problems or addiction issues.
• Patient organizations and support groups: Many people have come together to form patient organizations and support groups that provide patients with advice and help. In addition, various patient organizations represent the interests of patients when it comes to issues related to healthcare policy. They are also represented in the Federal Joint Committee (G-BA), where they can put forward proposals and have a say in discussions.

A treatment is considered to be outpatient care (ambulante Versorgung) if you can go straight home afterwards and don't have to stay overnight in a hospital. In Germany, it is mainly provided in the practices of doctors, dentists, psychotherapists and other healthcare professionals. Most doctors and dentists have a “Kassenzulassung” (public health insurance accreditation). This means they treat people who have public health insurance and the treatment costs are covered by public health insurers.

When people are ill or need medical advice, they usually go to see their family doctor (Hausarzt) first. In Germany, general practitioners, internists and pediatricians are considered to be family doctors. These doctors can refer you to the right kind of specialist – like a skin specialist (dermatologist) or women's health specialist (gynecologist) – for particular medical problems. It is usually also possible to go straight to a specialist without a referral. But referrals are needed for certain types of doctors, like radiologists.

Besides the individual practices, there are many group practices (Gemeinschaftspraxis) and medical care centers (Versorgungszentrum – MVZ) in Germany, with two or more doctors or other healthcare professionals working together. Larger group practices can often offer services that are usually only available in hospitals, like special diagnostic examinations or day surgery. These practices are sometimes referred to as "Praxiskliniken" ("practice clinics").

Outpatient care also includes (in rarer cases) treatment received in the hospital or at a psychiatric institution which does not involve an overnight stay.

If you have to spend one or more nights in a hospital for treatment, it is referred to as “inpatient treatment” (stationäre Behandlung). Most hospitals treat all patients, regardless of whether they have public or private health insurance. But some private hospitals will only treat privately insured patients.

In Germany, different hospitals are financed by different bodies and organizations:

• Public hospitals (financed by the federal state, district, city or local government)
• Charity-run or church-run hospitals (operated by organizations like the Red Cross or churches)
• Private hospitals (run by private companies or people)

People who have public health insurance also have to pay 10 euros per day towards their accommodation and meals if they stay in the hospital. Known as a Zuzahlung, these fees are documented in a contract between the patient and the hospital before the treatment is carried out.

The aim of rehabilitation treatment (Reha) is to prevent or reduce disability and the need for nursing care. For instance, it can help people to become stronger and more independent after getting over a serious illness and recovering from intensive treatment. This is often done immediately after a hospital stay, for instance following surgery. There are also rehabilitation centers for people with mental health problems or addiction issues.

Depending on the illness, rehabilitation will include different treatments and activities, like physical and occupational therapy, psychological care or dietary advice. It may also involve learning about how to manage the illness or how to use medical aids properly.

There are different types of rehabilitation treatment:

• Inpatient rehabilitation, where you stay at a rehabilitation hospital (Rehaklinik).
• Outpatient rehabilitation, where you only go to the rehabilitation center during the daytime and then sleep at home.

You apply for rehabilitation treatment yourself. A doctor has to confirm that it is medically necessary. Depending on the cause of your illness and your work situation, the costs of rehabilitation treatment will be covered by your public health insurance, pension fund (Rentenversicherung), accident insurance (Unfallversicherung) or long-term nursing care insurance (Pflegeversicherung). The hospital or doctor's practice can tell you which insurance is the right one in your case. Adults have to pay a fixed amount (Zuzahlung) of 10 euros per day themselves. This may be different for outpatient rehabilitation treatment, depending on the insurance provider. If you have private health insurance, the costs of rehabilitation treatment may not be covered. That will depend on your insurance policy.