The hospital system in Germany
There are about 2000 acute care hospitals in Germany. They can be differentiated by sponsorship and by their service level:
Sponsorship responsibility rests with:
- Government, on the local level – i.e. towns and counties – or on the state level, where the federal states are responsible for university hospitals as part of their responsibility for education – overall 55% of all hospitals are government-carried.
- Free-non-profit institutions like the big churches with their federations, the Red Cross with it´s nurse societies and other non-profit organizations – 38%.
- Private for-profit companies and hospital chains - 7%.
As to medical service level, German state laws mostly provide four types of hospitals:
- Basic service or primary care hospitals - usually up to 200 beds and 2-3 medical disciplines
- Regular service or secondary care hospitals - up to 300 beds, 4-5 disciplines
- Central service or tertiary level hospitals - usually up to 500 beds with a wide spectrum of up to 8 different disciplines, often also teaching hospitals for medical universities
- Maximum care hospitals - big institutions, usually more than 1000 beds, mostly university hospitals with comprehensive spectrum, responsible for research and training as well as hospital treatment.
Medical departments or clinics are usually headed by one, sometimes more than one superintendent or chairman who are employed by the hospital. Alternatively, medical responsibility can also be in the hands of one or more practitioners or voucher physicians, who are self-employed, running their own private practice and treating patients in hospital on special contract basis.
For hospital services, i.e. medical, care and lodging with meals, the German government has introduced a general pricing system, called DRG, in 2004. Over the comng years, this will lead to uniform prices in all German hospitals. These "DRG costs" are case oriented lump sum prices, based on diagnosis and medical procedures, and they comprise all hospital costs, including physician care. If however, the patient decides to contract voluntarily for additional optional services, these costs are not included inthe DRG. Perhaps the most importan optional service is personal treatment by the medical superintendent or chairman of the clinic, which can lead to considerable additional costs, especially because all the chairmen whose clinics were involved will add their bills for personal services. On our website www.drg.german-hospital-service.com, we have itemized about 350 important DRGs as examples and supplemented also the possible additional optional physician costs. These sums, however, cannot be understood or accepted as fixed prices. Real costs may stay below, but may also be clearly higher, according to the hospital and the complexity of medical activity.
For the majority of German patients, the DRG-costs including the physician's costs are covered by general, compulsory social security health insurance. In many cases, it is also possible that a foreign health insurance covers the costs of treatment for foreigners, this however must be confirmed in advance unless the situation is an accident or medical emergency. For citizens of the countries of the European Union, this will generally be the case; EU jurisdiction has cleared that point a number of times now.
Any patients who are not covered by the general health insurance scheme, will have to pay for the costs of the medical treatment out of their own pocket, perhaps getting reimbursed if they have private coverage. International patients will normally also belong to this group, including emergency cases. This means, that for them also, the general DRG price scheme will be the basis of calculation, unless they opt for additional personal superintendent services. In most hospitals, the superintendent or chairmen will be entitled by the hospital to treat personal patients based on private arrangements, and bill the patients personally as a consequence. These costs will be on top of the hospital costs. Thus, in these cases, the patient receives two invoices: One from the hospital and one from the treating superintending doctor. If several superintendent doctors were involved, for example the surgeon, the radiologist and the laboratory physician, all these are entitled to bill their services separately.
Important to know: Even though they will be privately covered patients, international patients are not oblidged to opt for the additional superintendent treatment. It is illegal for the hospital to put any pressure on patients to opt for these additional services
Voucher physicians will also bill their medical services separately, both for the treatment in the practice and for their medical services in the hospital. In these cases, the hospital DRGs will be somewhat reduced.
Extra charges for special lodging
German hospitals usually have double bed rooms for two patients as standard. In these hospitals, an extra charge may only be applied for lodging in a single room. Hospitals that still have many 3-or more-bed-rooms, an optional surcharge is billed also for double bed room lodging. The surcharges are based on national regulations and amount to about 50.- to 70. -€ per day for the place in the double bed room and 80.- to 100€ per day for the single room. Accomodation for escorting family members is available in most hospitals, the general costs will be about 50.-€ per night.
In increasing numbers, smaller interventions are offered by hospitals also as outpatient surgery. This means: Patients arrive in the morning, get prepared and operated at first priority, have special restrooms where they can recover and get discharged at about 14.00 to 15.00, unless complications make a transfer to inpatient stay necessary. Foreign patients, who have interest in this treatment form should budget another couple of days in a suggested hotel after the medical intervention, so that any necessary follow-up examinations can be carried out without problems.
A specialty of the German health system is the well developed rehabilitation system: Special clinics receive the patient after the acute treatment and continue treatment with special rehabilitational procedures, for example physical therapy. This treatment contributes significantly to the success of the initial treatment but has to paid seperately. As a rule (e.g. for 21 days) the costs will be about 2500.- until 3000.-€.
Pay per use schemes apply for telephone costs during in-patient stay in the clinic, mostly with daily lump sums and a price per unit. Often the lump sum includes TV use. More and more clinics offer personal internet access at the bedside, this is also billed separately.
German medical students have to pass a primarily scientific basic study before they are admitted to the clinical part of their university courses. After the medical approbation examination, a phase of 5 to 7 years as assistant or resident physician ensues, before the young physician can pass the specialization examination as senior resident for one of the clinical fields. During this time, a clearly defined catalogue of diagnostic or operative procedures must be fulfilled (e. g. a certain number of the most important operations for a surgeon–to-be), and after passing this additional examination, the specialized consultant can either pursue his profession in a hospital, or as self-employed physician in private practice.
Training for the nursing profession has a duration of three years. It has to follow a government-prescribed curriculum, is offered by schools which stand under state supervision and provides theoretical education as well as on the job training. The examination is also state controlled. After a number of years in their job, nurses can acquire additional special certificates, e.g. as operation- nurse, anaesthetics-nurse or nurse-in-charge of a ward etc. These courses usually take another 2 years of in-service training.
Quality management is currently being introduced in all hospitals in Germany following pertinent legislation. In addition, for a number of years, compulsory quality surveillance programmes have been in force for certain frequent hospital procedures, and these data are being evaluated under government regulation. Increasing numbers of German hospitals are undergoing different quality management procedures, getting certified under the DIN-ISO, EFQM, KTQ, Procum-Cert or Joint Commission quality management schemes..