Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition

Abstract

Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their health-care providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer-provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany's neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.

Health sciences libraries in Germany: new directions

“…The total number of health personnel is 5.6 million including 400,000 physicians (365,000 practicing, 150,000 in private practice) and 91,000 dentists (71,000 practicing; Busse, Bl€ umel et al, 2017;Federal Statistical Office Germany, 2019). Clinical education is provided by 39 medical schools and 30 dental schools (German Rectors' Conference).…”

Limiar de eficiência em avaliações de tecnologias em saúde

“…Tido como modelo e adotado há 135 anos por Otto von Bismarck, o sistema de saúde público alemão (sigla SHI para statutory health insurance) tem como princípio a solidariedade entre os segurados (Busse et al, 2017). Este abrange aproximadamente 90% da população alemã, cerca de 70 milhões de pessoas.…”

“…A contribuição para o SHI gira em torno de 15,5% do salário do segurado e é dividida igualmente entre empregado e empregador (Holtorf et al, 2009). Neste modelo de sistema de saúde, pessoas com salários maiores dão suporte as que recebem menos, os mais jovens compensam os mais velhos, saudáveis os doentes e pessoas sem filhos as que possuem (Busse et al, 2017).…”

Strengthening public health in Germany: overcoming the Nazi legacy and Bismarck’s aftermaths

“…''Germany and health'' is the title of a recent Lancet series examining the country's health-care system (Busse et al 2017) and its growing engagement in global health (Kickbusch et al 2017). Interestingly, public health in Germany receives short shrift in this series.…”

“…We propose that this is also due to the way in which its health system is organized. Germany maintains a model of social security in health (SSH), introduced by Bismarck in 1883, in which statutory health insurance companies provide health-care coverage for their members (Busse et al 2017). One advantage of the SSH is the high degree of consumer satisfaction it achieves through its pronounced disease orientation and focus on individual patients.…”