Big Hospitals versus Small Hospitals - is Either Better?

European Health Care Summit: Future organization of hospital services 21 January 2014 | Nuffield Trust, Brussels Dr. Caroline Wagner

Statutory Health Insurer: Techniker Krankenkasse

• Founded 1884 in Leipzig for technicians

• 8,68 million insured - currently largest SHI

• Annual growth (2013): + 284,000 insurants

• 12,857 employees and 247 branches

• Total Budget: 21,3 billion EUR

• 27% for hospital care (5,7 bil. EUR )

Increase of 9.3 % (2013 to 2014)

• Compulsory uniform contribution rate for

all statutory health insurers:

15.5% of tax income up to 4.050 Euro

7.3 % borne by employer

8.2 % borne by employee

Statutory Health Insurers in Germany are public bodies - but self-administered

Private Company Public Body with

Self-Administration Governmental Body

For-Profit Health

Insurer

Statutory Health

Insurer

Ministry of Health

1994: 1,162

2004: 280

2014: 132

Reduction of statutory health insurers: 89% in the last twenty years

Mix of Public and Private Health Insurance

Statutory Long Term Care

Insurance

Statutory Health Insurance Private

Health

Insurance

Private Supplementary

Health Insurance

Private Long

Term Care

Insurance

70.2 Million SHI Insurants = 89%

Possibility to opt out for employees with

an annual income more than 48,600 €

8.5 Million Insurants

= 11 %

Players: Statutory Health Insurance - Health Care

Insurers

Health Care

Provider Market

Insured Care

providers

Health Insurance Market

Regulatory framework

• Free choice of insurer

• Open enrolment

• Income related contribution shared

between employer and employee

• Free co-insurance for family

members

• Risk adjustment

• Comprehensive benefit package

• Benefits in kind

• Free choice of provider

• No enrolment with GPs

• Small Co-payments: e.g.

hospital care 10 EUR per

day up to 28 days

• Service guarantee

• Mix of collective and

selective provider

contracts

• Federal government

• State governments

• Joint self-government of

insurers and providers

Statutory Health Insurance Expenditures in Germany Largest Share: Hospitals

Hospitals, 36%

Others, 24%

Pharma, 17%

Physicians, 16%

Dentist, 7%

1. Hospitals 60 bil. EUR

2. Pharma 30 bil. EUR

3. Physicians 28 bil. EUR

4. Dentist 12 bil. EUR

Source: Ministry of Health

7

Dual Funding of Hospitals

1. Statutory health insurance funds and

Statutory health insurance funds bear the running costs

i.e. via renumeration of the provided health services

2. Federal states "Bundesländer"

Federal states finance capital investments based on state hospital plan

State subventions for new building possible via investment programmes

Subventions vary by state

Dual funding sources for hospitals =

separation of decisions about capacities

and responsibilities for costs

8

Basic Types of hospitals in Germany

1. Acute hospitals (including university hospitals)

2. Prevention and Rehabilitation hospitals

Follow-up care and after surgery care

Rehabilitation and prevention

No contracts with statutory sickness health insurers

1.233 facilities (2011)

3. Psychiatric hospitals

Traditionally specialised in psychiatric treatments

Psychosomatic medicine

Now also often covered by acute hospitals

9

Interlocking of inpatient and outpatient sector

• 1993 Gesundheitsstrukturgesetz i.e. Health Care Structure Act)

Opening up of the hospitals for outpatient surgery

Improvement of collaboration primary care and hospital physicians

Currently 1,247 hospitals with ambulatory operations

• 2003 GKV Modernisierungsgesetz i.e. Health Care Modernisation Act

New contracts options: outpatient treatments in hospitals,

particularly disease management programmes, chronic diseases

• 2007 GKV Wettbewerbsstärkungsgesetz i.e. Competition Fortification Act

Simplification of access to outpatient treatments concerning highly specialised care and complex as well rare diseases

• 2012 GKV Versorgungsstrukturgesetz i.e. Structure Provision of Care Act

If co-operation exists, statutory oupatient doctors are entitled to undertake ambulatory treatments and operations in hospitals

Number of Hospitals in Germany 1992 - 2012

2,221 2,197

2,166

2,139

2,104 2,087 2,083 2,084

2,064 2,045

2.017

1,900

1,950

2,000

2,050

2,100

2,150

2,200

2,250

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Source: Federal Statistics Agency

Beds, Utilisation, Cases and Length of Stay

Years

Beds

(million)

Utilisation

(%)

Cases

(million)

Length of

Stay (days)

2002 547.3 80 17.4 9.2

2003 541.9 78 17.3 8.9

2004 531.3 75 16.8 8.7

2005 523.8 75 16.5 8.7

2006 510.8 76 16.8 8.5

2007 507.0 77 17.2 8.3

2008 503.4 77 17.5 8.1

2009 503.3 77 17.8 8.0

2010 502.7 77 18.0 7.9

2011 502.0 77 18.3 7.7

2012 501.5 77 18.6 7.6

Hospitals in Germany by Ownership

43% (1062)

33% (817)

24% (601)

37% (950)

34% (877)

28% (719)

23% (369)

33% (527)

44% (697)

0% 50% 100%

1992

2002

2012

Public Charity based Private

Source: Federal Statistics Agency

13

Hospital Market in Germany - Size

Number of Employees

Number of Hospitals

Turnover (m EUR)

Private Leaders:

Fresenius/Helios 70.000 117 5.500

Asklepios 34.000 150 2.980

Sana 26.000 48 1.790

Rhön 15.000 10 1.000

Schön 8.500 17 591

Paracelsus 4.800 29 345

Municipal Leader: Vivantes (Berlin)

14.391 100 900

Charitable Leader: St. Franziskus-Stiftung (Münster)

11.212 13 645

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