German Health Insurance: The Evolution and Current Problems of the Pioneer System

The German system of social health insurance is one of the oldest in the world, but it has proven to be astonishingly flexible. Presently about 90 per cent of the population living in the Federal Republic of Germany (FRG) is cared for by social health insurance. The patient does not have a direct economic relationship with the doctor, and the doctor does not deal directly with the sick fund on financial matters. The association of insurance doctors is the intermediate organization between sick funds and the doctor. It is a self–governed organization of insurance doctors supervised by governmental authority. But beyond legislation the government cannot exert direct influence on doctors or sick funds, particularly since the contributions (except for retired people) are paid not by the government but by the insured and their employers. There are deficiencies in the mode of paying the doctor, leading the doctor to perform many unwarranted services. Moreover, there are apparent disadvantages of inadequate integration of preventive, curative, and rehabilitative services, and of hospital, outpatient, and office practice services. The strictly followed regulation on economical prescribing diminishes the quality of the physician's services. Presently, neither the political parties in parliament, nor the federal government, nor the doctors show tendencies to change the system basically. However, there is strong inclination for selective changes. But there is a lack of planning and of good data which might be drawn on for planning and for the evaluation of the quality, effectiveness, and efficiency of the system.