The report is available in English with a French summary - KCE

170 Musculoskeletal & Neurological Rehabilitation KCE reports 57
8.5 GERMANY
8.5.1 Health care organisation in general
A fundamental aspect of the German health care system is the sharing of decisionmaking
powers between the federal government, the individual states (Länder), and
designated self-governmental institutions. Responsibilities are delegated to membership
based, selfregulated institutions of payers and providers. These institutions adopt the
status of quasi-public corporations and guarantee the financing and delivery of benefits
outlined in the legal framework of the statutory health insurance. They are involved in
financing and delivering health care.
As is the case in many other countries, the role of private parties is penetrating the
organisational principles of the health care model.
8.5.1.1 Health insurance
In the Statutory Health Insurance (SHI), (covering 88% of the population), sickness
funds, their associations and associations of SHI-affiliated physicians and dentists
negotiate on the insured care. The most important body in the benefit negotiations
between sickness funds and physicians concerning the scope of benefits is the Federal
Joint Committee. Based on the legislative framework the Committee issues directives
relating to all sectors of care.
Citizens have a free choice of sickness funds. Employees with a gross monthly income
not exceeding a certain amount (€3.862 in 2004) are mandatory to have a membership
in a sickness fund. Higher income levels can opt out. Private insurance companies
provide health insurance policies that are substitutive or supplementary to the SHI.
The autonomous sickness funds are organized on a regional and/or federal basis. They
are obliged to raise contributions from their members and to determine the
contribution rate necessary to cover expenditures. Their responsibilities include
contracting, negotiating prices, quantity and quality assurance measures. Services
covered by such contracts are usually accessible to all fund members without any prior
approval by the fund, except for preventive spa treatments, rehabilitative services and
short-term home nursing care that require an indication setting.
A risk structure compensation scheme is in place which prevents the sickness funds to
refuse people at a higher risk for health care services. Members and their dependents
are entitled for the benefits: prevention of disease, screening for disease, emergency and
rescue care and treatment of disease. In the latter category ambulatory care, care by
allied health professionals and certain areas or rehabilitative care are included.
Ambulatory care is only described in generic terms whereas care by allied health
professionals is more elaborated. These services that are reimbursed by the SHI are
linked to indications and therapeutic targets and need to be prescribed by a physician.
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8.5.1.2 Health care policy making and organisation
The legislative authority regulates the procedures with which the contractual partners
determine the scope of SHI services. The “Federal Joint Committee” issues directives
about adequate and cost-effective medical interventions for the insured persons. In the
Länder as well as in the federal government, a department of health is installed, although
not always as a distinct ministry. The sickness funds have a central position in the health
insurance system.
The sickness funds are obliged to collect contributions from their members. In return
these funds negotiate prices, quantities and quality with providers on behalf of their
members.
Health care delivery in Germany is typified by a clear delineation between public health
services, ambulatory care and hospital care. The ‘strict’ legal and financial delineation