Healthcare in Germany

The University Medical Center Freiburg

Germany has a universal[1] multi-payer health care system paid for by a combination of statutory health insurance (Gesetzliche Krankenversicherung) officially called "sickness funds" (Krankenkassen) and private health insurance (Private Krankenversicherung), colloquially also called "(private) sickness funds".[2][3][4][5][6]

The turnover of the health sector was about US$368.78 billion (€287.3 billion) in 2010, equivalent to 11.6 percent of gross domestic product (GDP) and about US$4,505 (€3,510) per capita.[7] According to the World Health Organization, Germany's health care system was 77% government-funded and 23% privately funded as of 2004.[8] In 2004 Germany ranked thirtieth in the world in life expectancy (78 years for men). It had a very low infant mortality rate (4.7 per 1,000 live births), and it was tied for eighth place in the number of practicing physicians, at 3.3 per 1,000 persons. In 2001 total spending on health amounted to 10.8 percent of gross domestic product.[9]

According to the Euro health consumer index, which placed it in 7th position in its 2015 survey, Germany has long had the most restriction-free and consumer-oriented healthcare system in Europe. Patients are allowed to seek almost any type of care they wish whenever they want it.[10]

History

Germany has the world's oldest national social health insurance system,[1] with origins dating back to Otto von Bismarck's social legislation, which included the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889. Bismarck stressed the importance of three key principles; solidarity, the government is responsible for ensuring access by those who need it, subsidiarity, policies are implemented with smallest no political and administrative influence, and corporatism, the government representative bodies in health care professions set out procedures they deem feasible.[11] Mandatory health insurance originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population.[12] The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population are covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1,100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.[13] Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physicians' associations and sickness funds.

1970–Present

Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[14] The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[15]

Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[16][17] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[18]

Regulation

The healthcare system is regulated by the Federal Joint Committee (Gemeinsamer Bundesausschuss), a public health organization authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine decisions regarding healthcare in Germany.[19]

Health insurance

German health care spending (red) as a percentage of GDP for 1970 to 2015 compared with other nations

Health insurance is compulsory for the whole population in Germany. Salaried workers and employees below the relatively high income threshold of almost 60,000 Euros per year are automatically enrolled into one of currently around 130 public non-profit "sickness funds" at common rates for all members, and is paid for with joint employer-employee contributions. Provider payment is negotiated in complex corporatist social bargaining among specified self-governed bodies (e.g. physicians' associations) at the level of federal states (Länder). The sickness funds are mandated to provide a unique and broad benefit package and cannot refuse membership or otherwise discriminate on an actuarial basis. Social welfare beneficiaries are also enrolled in statutory health insurance, and municipalities pay contributions on behalf of them.

Besides the "Statutory Health Insurance" (Gesetzliche Krankenversicherung) covering the vast majority of residents, the better off with a yearly income above 59,400 Euros (2018) (US$66,967), students and civil servants for complementary coverage can opt for private health insurance (about 11% of the population). Most civil servants benefit from a tax-funded government employee benefit scheme covering a percentage of the costs, and cover the rest of the costs with a private insurance contract. Recently, private insurers provide various types of supplementary coverage as an add upon of the SHI benefit package (e.g. for glasses, coverage abroad and additional dental care or more sophisticated dentures). Health insurance in Germany is split in several parts. The largest part of 89% of the population is covered by a comprehensive health insurance plan provided by statutory public health insurance funds regulated under specific the legislation set with the Sozialgesetzbuch V (SGB V), which defines the general criteria of coverage, which are translated into benefit packages by the Federal Joint Committee. The remaining 11% opt for private health insurance, including government employees.[20]

All wage workers pay a health-insurance contribution based on their salary if they are enrolled in the public subsystem whereas private insurers charge risk-related contributions. This may result in substantial savings for younger individuals in good health. With age, private contributions tend to rise and a number of insurees formerly cancelled their private insurance plan in order to return to statutory health insurance; this option is now only possible for beneficiaries under 55 years.[13][21]

Reimbursement for outpatient care was on a fee-for-service basis but has changed into basic capitation according to the number of patients seen during one quarter, with a capped overall spending for outpatient treatments and region. Moreover, regional panel physician associations regulate number of physicians allowed to accept Statutory Health Insurance in a given area. Co-payments, which exist for medicines and other items are relatively low compared to other countries.

Insurance systems

Total health spending per capita, in US$ PPP-adjusted, of Germany compared amongst various other developed countries

Germany has a universal multi-payer system with two main types of health insurance. Germans are offered three mandatory health benefits, which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.

Accident insurance for working accidents (Arbeitsunfallversicherung) is covered by the employer and basically covers all risks for commuting to work and at the workplace.

Long-term care (Pflegeversicherung) is covered half and half by employer and employee and covers cases in which a person is not able to manage his or her daily routine (provision of food, cleaning of apartment, personal hygiene, etc.). It is about 2% of a yearly salaried income or pension, with employers matching the contribution of the employee.

There are two separate types of health insurance: public health insurance (Gesetzliche Krankenversicherung) and private insurance (Private Krankenversicherung). Both systems struggle with the increasing cost of medical treatment and the changing demography. About 87.5% of the persons with health insurance are members of the public system, while 12.5% are covered by private insurance (as of 2006).[22]

Public insurance

Emergency vehicle in Hannover

Regular salaried employees must have public health insurance. Only public officers, self-employed people and employees with a large income, above c. €50,000.00 per year (adjusted yearly), may join the private system.

In the Public system the premium

  • is set by the Federal Ministry of Health based on a fixed set of covered services as described in the German Social Law (Sozialgesetzbuch – SGB), which limits those services to "economically viable, sufficient, necessary and meaningful services"
  • is not dependent on an individual's health condition, but a percentage (currently 15.5%, 7.3% of which is covered by the employer) of salaried income under €52,200.01 per year.
  • includes family members of any family members, or "registered member" ( Familienversicherung – i.e., husband/wife and children are free)
  • is a "pay as you go" system – there is no saving for an individual's higher health costs with rising age or existing conditions.

Private insurance

In the Private system the premium

  • is based on an individual agreement between the insurance company and the insured person defining the set of covered services and the percentage of coverage
  • depends on the amount of services chosen and the person's risk and age of entry into the private system
  • is used to build up savings for the rising health costs at higher age (required by law)

For persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. Since private health insurance is usually more expensive than public health insurance, the higher premiums must then be paid out of a lower income. During the last twenty years private health insurance became more and more expensive and less efficient compared with the public insurance.

In Germany, all privately financed products and services for health are assigned as part of the 'second health market'.[23] Unlike the 'first health market' they are usually not paid by a public or private health insurance. Patients with public health insurance paid privately about 1.5 Billion Euro in this market segment in 2011, while already 82% of physicians offered their patients in their practices individual services being not covered by the patient's insurances; the benefits of these services are controversial discussed.[24] Private investments in fitness, for wellness, assisted living, and health tourism are not included in this amount. The 'second health market' in Germany is compared to the United States still relatively small, but is growing continuously.

Economics

Health economics in Germany can be considered as a collective term for all activities that have anything to do with health in this country.[25] This interpretation done by Andreas Goldschmidt in 2002 seems, however, very generous due to several overlaps with other economic sectors.[26] A simple outline of the health sector in three areas provides an "onion model of health care economics" by Elke Dahlbeck and Josef Hilbert[27] from "Institut Arbeit und Technik (IAT)" at the University of applied sciences Gelsenkirchen:[28] Core area is the ambulatory and inpatient acute care and geriatric care, and health administration. Around it is located wholesale and supplier sector with pharmaceutical industry, medical technology, healthcare, and wholesale trade of medical products. Health-related margins are the fitness and spa facilities, assisted living, and health tourism.

According to this basic idea, an almost totally regulated health care market like in the UK were not very productive, but also a largely deregulated market in the United States would not be optimal. Both systems would suffer concerning sustainable and comprehensive patient care. Only a hybrid of social well-balanced and competitive market conditions created a relevant optimum.[29] Nevertheless, forces of the healthcare market in Germany are often regulated by a variety of amendments and health care reforms at the legislative level, especially by the "Social Security Code" (Sozialgesetzbuch- SGB) in the past 30 years.

Health care in Germany, including its industry and all services, is one of the largest sectors of the German economy. Direct inpatient and outpatient care equivalent to just about a quarter of the entire 'market' - depending on the perspective.[7] A total of 4.4 million people working in this, that means about one in ten employees in 2007 and 2008.[30] The total expenditure in health economics was about 287.3 billion Euro in Germany in 2010, equivalent to 11.6 percent of gross domestic product (GDP) this year and about 3.510 Euro per capita.[31]

Drugs costs

The pharmaceutical industry plays within and beyond direct health care a major role in Germany. Expenditure on pharmaceutical drugs is almost half as high as those for the entire hospital sector. Pharmaceutical drug expenditure grew by an annual average of 4.1% between 2004 and 2010. Such developments caused since the 1980s numerous health care reforms. An actual example of 2010 and 2011: First time since 2004 the drug expenditure fell from 30.2 billion Euro in 2010 to 29.1 billion Euro in 2011, i. e. minus 1.1 billion Euro or minus 3.6%. That was caused by restructuring the Social Security Code: manufacturer discount 16% instead of 6%, price moratorium, increasing discount contracts, increasing discount by wholesale trade and pharmacies.[32]

Statistics

The reduction in infant mortality between 1960 and 2008 for Germany (green) in comparison with Australia, France, the Netherlands, the United Kingdom, and the United States.

In a sample of 13 developed countries Germany was seventh in its population weighted usage of medication in 14 classes in 2009 and tenth in 2013. The drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. The study noted considerable difficulties in cross border comparison of medication use.[33] It has the highest number of dentists in Europe - 64,287 in 2015.[34]

Major diagnosis

In 2002 the top diagnosis for male patients released from the hospital was heart disease, followed by alcohol-related disorders and hernias. For women, the top diagnoses related to pregnancies, breast cancer, and heart disease.

Hospitals

The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the United States (5 to 6 days).[35][36] Part of the difference is that the chief consideration for hospital reimbursement is the number of hospital days as opposed to procedures or diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[37]

The Charité university hospital in Berlin

An incomplete list of university hospitals in Germany is :

In 2017 the BBC reported that compared with the United Kingdom the Caesarean rate, the use of MRI for diagnosis and the length of hospital stay are all higher in Germany.[38]

Waiting Times

According to several sources from the past decade, waiting times in Germany remain low for appointments and surgery, although a minority of elective surgery patients face longer waits. In 1992, a study by Fleming et al. (cited in Siciliani & Hurst, 2003, p. 8),[39] 19.4% of German respondents said they'd waited more than 12 weeks for their surgery.

In the Commonwealth Fund 2010 Health Policy Survey in 11 Countries, Germany reported some of the lowest waiting times. Germans had the highest percentage of patients reporting their last specialist appointment took less than 4 weeks (83%, v. 80% for the U. S.), and the second-lowest reporting it took 2 months or more (7%, vs. 5% for Switzerland and 9% for the U. S.). 70% of Germans reported that they waited less than 1 month for elective surgery, the highest percentage, and the lowest percentage (0%) reporting it took 4 months or more (The Commonwealth Fund, 2010, pp. 19–20).[40]

Both Social Health Insurance (SHI) and privately insured patient experienced low waits, but privately insured patients' waits were even lower.[41] According to the Kassenärztliche Bundesvereinigung (KBV), the body representing contract physicians and contract psychotherapists at federal level, 56% of Social Health Insurance patients waited 1 week or less, while only 13% waited longer than 3 weeks for a doctor's appointment. 67% of privately insured patients waited 1 week or less, while 7% waited longer than 3 weeks (Kassenärztliche Bundesvereinigung, 2016).[42]

In a 2009 study to measure waiting time differences between SHI and private insurance, interviewers posed as patients and requested appointments. They told hospitals they could not get a normal referral, which is generally required from an outpatient doctor. Care requested was not immediately urgent, but was care urgent enough to get treated in a couple of weeks. (This may limit generalization to other waits). Mean waiting time was 8.9667 days. Those posing as SHI patients waited longer at some but not all hospitals, and longer on average. Not all hospitals asked their insurance status. However, among those that did, mean waits for SHI patients was 10.5533 days, while privately insured patients' mean waiting time was 8.9667 days. Hospitals asking insurance type had a longer overall mean wait than those not asking for it (Kuchinke, Sauerland & Wübker, 2009).[43]

Waits also varied somewhat by region. Waits were longer in eastern Germany according to the KBV (KBV, 2010), as cited in Health at a Glance 2011: OECD Indicators.[44]

Germany has a large hospital sector capacity measured in beds. High capacity on top of significant day surgery outside of hospitals (especially for ophthalmology and othopaedic surgery) with doctors paid fee-for-service for activity performed were cited by Siciliani and Hurst as likely factors preventing long waits, despite hospital budget limitations. Activity-based payment for hospitals also is linked to low waiting times (Siciliani & Hurst, 2003, 33-34, 70). Germany introduced Diagnosis-Related Group activity-based payment for hospitals (with a soft cap budget limit) (Busse & Blümel, 2014, pp. 142–148).[45]

See also

References

  1. 1 2 Bump, Jesse B. (October 19, 2010). "The long road to universal health coverage. A century of lessons for development strategy" (PDF). Seattle: PATH. Retrieved March 10, 2013. Carrin and James have identified 1988—105 years after Bismarck’s first sickness fund laws—as the date Germany achieved universal health coverage through this series of extensions to growing benefit packages and expansions of the enrolled population. Bärnighausen and Sauerborn have quantified this long-term progressive increase in the proportion of the German population covered mainly by public and to a smaller extent by private insurance. Their graph is reproduced below as Figure 1: German Population Enrolled in Health Insurance (%) 1885–1995.
    Carrin, Guy; James, Chris (January 2005). "Social health insurance: Key factors affecting the transition towards universal coverage" (PDF). International Social Security Review. 58 (1): 45–64. doi:10.1111/j.1468-246X.2005.00209.x. Retrieved March 10, 2013. Initially the health insurance law of 1883 covered blue-collar workers in selected industries, craftspeople and other selected professionals.6 It is estimated that this law brought health insurance coverage up from 5 to 10 per cent of the total population.
    Bärnighausen, Till; Sauerborn, Rainer (May 2002). "One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low income countries?" (PDF). Social Science & Medicine. 54 (10): 1559–1587. doi:10.1016/S0277-9536(01)00137-X. PMID 12061488. Retrieved March 10, 2013. As Germany has the world’s oldest SHI [social health insurance] system, it naturally lends itself to historical analyses
  2. ↑ "Duden - Krankenkasse - Rechtschreibung, Bedeutung, Definition, Synonyme". www.duden.de.
  3. ↑ The use of the term "Krankenkasse" for both public and private health insurances is so widespread that Duden doesn't even label this usage as colloquial.
  4. ↑ "The Case for Universal Health Care in the United States". Cthealth.server101.com. Retrieved 2011-08-06.
  5. ↑ "German Health Care System – an Overview - Germany Health Insurance System". www.germanyhis.com.
  6. ↑ DiPiero, Albert (2004). "Universal Problems & Universal Healthcare: 6 COUNTRIES — 6 SYSTEMS" (PDF). Archived from the original (PDF) on 21 February 2006.
  7. 1 2 A. J. W. Goldschmidt: Der 'Markt' Gesundheitswesen. In: M. Beck, A. J. W. Goldschmidt, A. Greulich, M. Kalbitzer, R. Schmidt, G. Thiele (Hrsg.): Management Handbuch DRGs, Hüthig / Economica, Heidelberg, 1. Auflage 2003 ( ISBN 3-87081-300-8): S. C3720/1-24, with 3 revisions / additional deliveries until 2012
  8. ↑ World Health Organization Statistical Information System: Core Health Indicators
  9. ↑ Germany country profile. Library of Congress Federal Research Division (December 2005). This article incorporates text from this source, which is in the public domain.
  10. ↑ "Outcomes in EHCI 2015" (PDF). Health Consumer Powerhouse. 26 January 2016. Archived from the original (PDF) on 2017-06-06. Retrieved 27 January 2016.
  11. ↑ Clarke, Emily. "Health Care Systems: Germany" (PDF). Civitas. Archived from the original (PDF) on 2013-10-05. Retrieved 25 September 2013.
  12. ↑ "History of German Health Care System". Photius.com. Retrieved November 14, 2011.
  13. 1 2 "Gesetzliche Krankenversicherungen im Vergleich". Archived from the original on 2014-06-01. Retrieved 2009-01-25.
  14. ↑ Kirkman-Liff BL (1990). "Physician Payment and Cost-Containment Strategies in West Germany: Suggestions for Medicare Reform". Journal of Health Care Politics, Policy and Law (Duke University). 15 (1): 69–99. doi:10.1215/03616878-15-1-69. PMID 2108202.
  15. ↑ Henke KD (May 2007). "[External and internal financing in health care]". Med. Klin. (Munich) (in German). 102 (5): 366–72. doi:10.1007/s00063-007-1045-0. PMID 17497087.
  16. ↑ "Germany: Health reform triggers sharp drop in number of hospitals". Allianz. 25 July 2005. Retrieved November 14, 2011.
  17. ↑ "Average Length of Hospital Stay, by Diagnostic Category --- United States, 2003". Centers for Disease Control and Prevention. Retrieved November 14, 2011.
  18. ↑ Borger C, Smith S, Truffer C, et al. (2006). "Health spending projections through 2015: changes on the horizon". Health Aff (Millwood). 25 (2): w61–73. doi:10.1377/hlthaff.25.w61. PMID 16495287.
  19. ↑ E. REINHARDT, UWE. "A German Import That Could Help U.S. Health Reform". The New York Times. Retrieved 25 May 2013. Germany’s joint committee was established in 2004 and authorized to make binding regulations growing out of health reform bills passed by lawmakers, along with routine coverage decisions. The ministry of health reserves the right to review the regulations for final approval or modification. The joint committee has a permanent staff and an independent chairman.
  20. ↑ David Squires; Robin Osborn; Sarah Thomson; Miraya Jun (November 14, 2013). International Profiles of Health Care Systems, 2013 (PDF) (Report).
  21. ↑ Schmitt, Thomas (21 May 2012). "Wie Privatpatienten in die Krankenkasse schlüpfen" (in German). Handelsblatt.
  22. ↑ SOEP – Sozio-oekonomische Panel 2006: Art der Krankenversicherung
  23. ↑ J. Kartte, K. Neumann: Der zweite Gesundheitsmarkt. Die Kunden verstehen, Geschäftschancen nutzen, o.O.: Roland Berger Strategy Consultants, München, 2007
  24. ↑ Pfeiffer D, Spitzenverband der Gesetzlichen Krankenkassen GKV →Mitteilung im Nachrichtendienst dapd vom 4. February 2012
  25. ↑ A. J. W. Goldschmidt: Leading the Global Game - M&A between Competitiveness and Conflicts. Speech as „guest speaker“ with round table-discussion „health economy and logistics“, 9th Symposium of Organisationsforum Wirtschaftskongress e.V. in the University of Applied Science Cologne on March, 8th 2002
  26. ↑ A. J. W. Goldschmidt: Paragraph „Unternehmensbedeutung“ in: Krankenhausmanagement mit Zukunft?. In: A. J. W. Goldschmidt, J. Hilbert (Hrsg.): Krankenhausmanagement mit Zukunft - Orientierungswissen und Anregungen von Experten. kma Medien in Georg Thieme Verlag KG, Stuttgart, 2011, (ISBN 978-3-13- 161231-1): p. 4.
  27. ↑ Josef Hilbert
  28. ↑ E. Dahlbeck, J. Hilbert: Beschäftigungstrends in der Gesundheitswirtschaft im regionalen Vergleich. Internet-Dokument. Gelsenkirchen: Inst. Arbeit und Technik. Forschung Aktuell, Nr. 06/2008 → http://www.iat.eu/forschung-aktuell/2008/fa2008-06.pdf
  29. ↑ A. J. W. Goldschmidt, J. Hilbert: Von der Last zur Chance – Der Paradigmenwechsel vom Gesundheitswesen zur Gesundheitswirtschaft. In: A. J. W. Goldschmidt, J. Hilbert (Hrsg.): Gesundheitswirtschaft in Deutschland. Die Zukunftsbranche. Band 1 der Schriftenreihe: Gesundheitswirtschaft und Management. kma-Reader - Die Bibliothek für Manager. Wikom-Verlag (Thieme), Wegscheid, 2009 ( ISBN 978-3-9812646-0-9): p. 20-40
  30. ↑ Statistisches Bundesamt: Beschäftigung in der Gesundheitswirtschaft steigt weiter an. Pressemitteilung Nr. 490, Berlin, 17.12.2008
  31. ↑ Statistisches Bundesamt Deutschland, Wiesbaden, 2012
  32. ↑ B. Häusler, A. Höer, E. Hempel: Arzneimittel-Atlas 2012. Springer, Berlin u. a. 2012 ( ISBN 978-3-642-32586-1) Archived 2013-01-01 at the Wayback Machine.
  33. ↑ Office of health Economics. "International Comparison of Medicines Usage: Quantitative Analysis" (PDF). Association of the British Pharmaceutical Industry. Archived from the original (PDF) on 2015-11-11. Retrieved 2 July 2015.
  34. ↑ Ballas, Dimitris; Dorling, Danny; Hennig, Benjamin (2017). The Human Atlas of Europe. Bristol: Policy Press. p. 79. ISBN 9781447313540.
  35. ↑ Length of hospital stay, Germany group-economics.allianz.com, undated
  36. ↑ Length of hospital stay, U.S. MMWR, CDC
  37. ↑ Borger C, Smith S, Truffer C, et al. (2006). "Health spending projections through 2015: changes on the horizon". Health Aff (Millwood). 25 (2): w61–73. doi:10.1377/hlthaff.25.w61. PMID 16495287.
  38. ↑ "NHS Health Check: How Germany's healthcare system works". BBC News. 9 February 2017. Retrieved 10 February 2017.
  39. ↑ Siciliani, S., & Hurst, J. (2003). Explaining Waiting Times Variations for Elective Surgery across OECD Countries. OECD Health Working Papers, 7, 8, 33-34, 70. https://dx.doi.org/10.1787/40674618616
  40. ↑ The Commonwealth Fund. (2010). Commonwealth Fund 2010 Health Policy Survey in 11 Countries (pp. 19-20). New York, NY: Author. Accessed from http://www.commonwealthfund.org/~/media/files/publications/chartbook/2010/pdf_2010_ihp_survey_chartpack_full_12022010.pdf
  41. ↑ "Welche private Krankenversicherung PKV soll ich auswählen - Tipps und Angebote | 123 Versicherung" (in German). 20 July 2017. Retrieved 7 October 2018.
  42. ↑ Kassenärztliche Bundesvereinigung. (2016). Health data: Die Wartezeit ist für die meisten kurz The wait is short for most. Retrieved from Google Translate
  43. ↑ Kuchinke, B. A., Sauerland, D., & Wübke, A. (2009). The influence of insurance status on waiting times in German acute care hospitals: an empirical analysis of new data. International Journal for Equity in Health, 8, 44. doi: 10.1186/1475-9276-8-4
  44. ↑ "Organization for Economic Cooperation and Development - Health at a Glance 2011: OECD Indicators". 2011.
  45. ↑ Busse R., & Blümel, M. (2014). Germany: health system review. Health Systems in Transition, 16(2), 142-148. Available from http://www.euro.who.int/__data/assets/pdf_file/0008/255932/HiT-Germany.pdf?ua=
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