Access and choice – competition under the roof of solidarity in ...

Health Economics, Policy and Law (2010), 5, 31–52 

& Cambridge University Press 2009 doi:10.1017/S1744133109990144 

Access and choice -- competition under the 

roof of solidarity in German health care: an 

analysis of health policy reforms since 2004 

MELANIE LISAC 

Project Manager, International Network Health Policy & Reform, Bertelsmann Stiftung, Gütersloh, Germany 

LUTZ REIMERS 

Department of Public Finance and Health Economics, Technische Universität Berlin, Germany 

KLAUS-DIRK HENKE* 

Professor of Public Finance and Health Economics, Technische Universität Berlin, Germany 

SOPHIA SCHLETTE* 

Senior Expert Health Policy, Bertelsmann Stiflung, Gütersloh, Germany, currently on a sabbatical as Senior 

International Adviser, Kaiser Permanente Institute for Health Policy, Oakland, CA, USA 

Abstract: This paper analyses the influence of recent German health care 

reforms, the Statutory Health Insurance Modernization Act 2004 and the 

Statutory Health Insurance Competition Strengthening Act 2007, on different 

dimensions of access and choice. More specifically, we look at and discuss the 

effects of these policies on the availability, reachability and affordability of 

health care as well as on their impact on consumers’ choice of insurers and 

providers. Generally, patients in Germany enjoy a high degree of free access 

and a lot of freedom to choose, partly leading to over- and misuse of health 

services. Concerning choice of insurers, one result of our analysis is that in the 

statutory health insurance system, the introduction of a greater variety of 

benefit packages will develop into an additional parameter of choice. In 

contrast to that, insurees more and more accept certain restrictions of choice 

and direct access to providers by enrolling into new forms of care (such as 

gatekeeping-, disease management- and integrated care programmes). 

However, they might benefit from better quality of care and more options for 

products and services that best fit their needs. 

1. Introduction 

Germans enjoy a high degree of free access to health care and of choice of both 

providers and health care insurance. Compared to other industrialised countries, 

the health care infrastructure is well developed and within easy reach; numbers 

*Correspondence to: Sophia Schlette, Bertelsmann Stiftung, Gütersloh, Germany. Email: sophia.schlette@ 

bertelsmann-stiftung.de, and *Klaus-Dirk Henke, TU Berlin, at KHenke@finance.ww.tu-berlin.de 

31

32 M E L A N I E L I S A C E T A L . 

of physicians and nurses per population lie above OECD (Organisation for 

Economic Co-operation and Development) average. Rather than underuse, the 

German system is characterised by over- and misuse of health care services 

(Advisory Council on the Assessment of Developments in the Health Care 

System, 2001). Therefore, policy makers have recently introduced measures to 

induce more rational utilisation of services and to limit free choice of providers 

for patients, which stands in contrast to developments in the USA, the UK and 

some other countries, where patient choice has been increased. 

The Statutory Health Insurance Modernization Act of 2004 (2004 reform) and 

the Statutory Health Insurance Competition Strengthening Act of 2007 (SHI- 

CSA) constitute turning points in this regard (Federal Ministry of Health, 2003, 

2007a). The 2004 reform introduced a quarterly co-payment for first visits to an 

outpatient provider and for visits to any other physician during the same quarter 

without referral. 1 Both acts promote care coordination by introducing voluntary 

restrictions on patients’ choice of provider and elements of managed care. 

At the same time, the 2004 and 2007 reforms aim to increase competition 

among health care providers and health insurers by giving patients more choice 

between health insurers and benefit packages. The objective of these measures is 

to improve efficiency, quality and patient responsiveness. 

While the focus of this paper is on the aforementioned reform measures, we 

also look into other measures of the 2004 and 2007 reforms that have an impact 

on access and choice, for example, measures that aim to mitigate negative effects 

of the looming shortage of health care providers in some German regions, and 

the extension of the benefit basket to include additional preventive, rehabilitative 

and palliative care services. 

The paper is organised as follows. In Section 2, we outline the method and our 

analytical framework. In Section 3, we describe the measures relevant to access 

and choice introduced with the 2004 and 2007 reforms, and we assess their 

impact on the different dimensions of access and choice. In the final section, we 

discuss the implications of our findings for policy makers and researchers. 

2. Method and analytical framework 

2.1 Method 

We review the content and objectives of two major health care reforms in 

Germany: the Statutory Health Insurance Modernization Act of 2004 and the 

Statutory Health Insurance Competition Strengthening Act of 2007. Within the 

analytical framework outlined below, we assess the impact of these reforms on 

different dimensions of access (affordability, availability, reachability) and 

choice (patients’ choice of health insurance system, health insurers, benefit 

1 Cost-sharing in the form of co-payments for pharmaceuticals, medical aids, transport costs and so 

on, already existed before 2004.

packages, providers). To do so, we use a variety of literature sources, including 

academic literature, policy documents and results from population surveys, such as 

the German Socio-Economic Panel Study (see Grabka et al., 2006; Schreyögg and 

Grabka, 2008) and representative surveys of statutory health insurance (SHI) 

and private health insurance (PHI) insurees carried out by the research institutes 

of local sickness funds, Wissenschaftliches Institut der Ortskrankenkassen, WIdO 

(see Zok, 2004, 2005), the Central Research Institute for Ambulatory Health Care 

in Germany (see Koch and Brenner, 2005) and the Healthcare Monitor of the 

Bertelsmann Stiftung, a German non-profit foundation (see Gebhardt, 2005). 

2.2 Analytical framework 

Access and choice – competition in German health care 33 

Definitions of access in the health economic literature emphasise different aspects 

of access. A common definition sees access as a minimum set of benefits that 

ensures that no citizen falls beneath a particular level of care. Another common 

definition sees access guaranteed when the same level or quality of health care is 

equally accessible to all, regardless of social status, residence and income (Wörz 

et al., 2006). Roberts et al. (2004) distinguish between physical availability 

measured by inputs (such as capital investments, human resources, knowledge) in 

relation to the population and the effective availability of care (what services are 

offered at what locations and at what prices?). Cost, travel time, poor services 

and so forth are possible barriers to access. Wagstaff and van Doorslaer (2000) 

circumscribe the term by saying that access is what is usually meant by ‘receipt of 

treatment’. An early definition by Le Grand (1982) thinks of access in terms of the 

money and time cost that people incur in obtaining health care, thus neglecting 

the role of income. Olson and Rodgers (1991) define access as the maximum 

attainable level of consumption of medical care, given the individual’s income, 

and the time and money prices associated with consumption. 

For the purpose of this paper, we combine some of the above and refer to 

three different dimensions of access. First, availability of care (including capacity 

of the system such as number of providers), second, reachability (geographical 

distribution of providers) and third, affordability (including financing 

and insurance arrangements and the reimbursability of services). In general, 

there are few infrastructural or geographic barriers to access health care in 

Germany and most of the debate on access in Germany focuses on affordability 

as the paramount dimension of access. This focus on affordability can partly be 

derived from the outstanding role that the notion of solidarity plays in German 

social policy at large: solidarity, that is, support among individuals of a group 

and collective action in order to achieve a specified aim (for example, good 

health) is explicitly stipulated as one of the leading principles in the Social Code 

Book V, the legal framework for the German SHI system. 

Choices in health care arise in many situations and are usually held to be 

desirable. Their benefits can be seen in their intrinsic worth and individual


liberty (Dowding, 1992), which increases sovereignty on the consumer’s side 

(Rice, 2001). In microeconomic theory, choice is a prerequisite for decentralised 

decision-making, resulting in efficient allocation of resources. Applied to health 

care, choice would then lead to lower prices and better quality, provider 

responsiveness, innovation and so on (Thomson and Dixon, 2006). However, 

choices in health care bear costs as well. An overload of choices increases 

information costs and might even lead to confusion in consumers. Especially 

in health care, issues such as rationality and bounded-rationality, merit goods 

and the way choices are presented are relevant. In addition to that, (change in) 

health status significantly influences what choices are made: for example, 

insurance is bought by healthy people but used by sick people (Aaron, 2008). 

When analysing dimensions of choice in health care, it is helpful to distinguish 

between choice on the demand side (e.g. what insurance, which physician, 

which hospital and so on) and choice on the supply side (e.g. medical career 

choices, treatment choices, investment choices by pharmaceutical manufacturers) 

(Sloan and Kasper, 2008). Throughout this paper we focus on choice 

on the demand side. According to Thomson and Dixon (2006), consumer choice 

in health care can refer to at least four different decisions: choice between public 

and private insurance, choice of public insurance fund, choice of first contact 

care provider and choice of hospital. 

In the German health care system, choice is a longstanding feature tied to its 

social health insurance system tradition. The dimensions of choice analysed in this 

paper are based on Thomson and Dixon’s taxonomy but take into account the 

particularities of the German health care system. First, we look at choice between 

the SHI and the PHI system. Second, German patients can choose among different 

insurers within either the statutory or the private insurance system. We consider 

choice among different benefit packages within one sickness fund or insurance 

company to be our third dimension of choice. And finally we analyse choice of 

(in- and outpatient) providers. Table 1 summarises the different dimensions of 

access and choice serving as a framework for our analysis. 

3. Elements of 2004 and 2007 reforms and their impact on access 

and consumer choice 

3.1 Availability and reachability of care 

3.1.1 Financial incentives for physicians to settle in underserved areas 

As mentioned earlier, there are (so far) few infrastructural or geographical 

barriers to health care in Germany. Looking at the ratio of health professionals 

to the population, Germany lies above the OECD average: in 2005, there were 

3.4 practicing physicians per 1000 inhabitants in Germany, whereas the OECD 

average is 3.1 per 1000 (Organisation for Economic Co-operation and Development, 

2007).

Table 1. Dimensions and indicators of access and choice 

Access to health care Consumer choices in health care 

Dimensions Possible indicators Dimensions Possible indicators 

Availability 

of care 

Reachability 


Affordability 


Physical capacity (e.g. 

number of providers) 

Geographical distribution 

(distance 

to providers) 

Financing and insurance 

arrangements, 

reimbursability of services 

However, demographic change is expected to lead to a reduction of this rather 

comfortable ratio. Due to uneven distribution of physicians across and within 

regions, and with many doctors approaching retirement, some regions in the 

Eastern part of Germany may in fact be facing a shortage of physicians within 

the next five years. Whereas, on average, 17.4% of all general practitioners 

(GPs) in the West are 60 years or older, this percentage amounts to about 30% 

in the five Eastern German states (Klose et al., 2007). In just one year, between 

December 2005 and December 2006, the number of GPs in the East decreased 

by 3.1% (Federal Association of SHI Physicians and Federal Physicians 

Chamber, 2003; Federal Association of SHI Physicians, 2007). These developments 

may reduce access to primary health care, particularly for elderly people 

with reduced mobility. 

To mitigate this development, from 2010 on the SHI-CSA envisages additional 

financial incentives, that is, even higher reimbursement rates, for physicians who 

settle in underserved areas. To offset the looming shortfall of physicians, another 

strategy is the employment of community nurses, the equivalent of nurse practitioners 

in other countries, who visit patients in their homes and assume tasks 

previously performed in physician practices (Blum, 2006). 

3.2 Affordability of care 


Choice between statutory 

and private insurance 

system 

Choice among different 

sickness funds or insurers 

Choice among benefit 

packages 

3.2.1 New co-payment for outpatient physician visits 

Legal barriers (e.g. level of 

income threshold or type of 

occupation) 

Number of sickness funds and 

insurers, price vs quality 

competition, old-age provisions 

Freedom to offer differentiated 

benefit packages for sickness 

funds 

Choice of providers Freedom to choose among 

in- and outpatient providers, 

managed-care-elements 

Reforms during the last 20 years have steadily increased both the level of copayments 

and the number of drugs, inpatient health care services and medical 

aids on which co-payments were imposed with the aim to contain overall public 

health care expenditures. The share of private expenditure in total health care


expenditure has consequently gone up over years: from 18.4% in 1995 to 

23.1% in 2004 (OECD, 2007). 2 In order to ensure equal access to care based on 

need, financial hardship regulations and exemptions based on age, income and 

health status were introduced. Children up to 18 years of age are exempt from 

co-payments. For low-income individuals and the chronically ill, yearly limits 

for co-payments exist (2% and 1% of gross annual household income, respectively, 

since 2004). 

As a novelty in the German health care system, the 2004 reform introduced a 

flat fee for visits to outpatient physician offices. Patients have to pay h10 per 

calendar quarter for the first appointment at a doctor’s office (or hospital outpatient 

wing) and for each physician visit without a referral from the physician 

seen first. The aim of this measure is to reduce unnecessary physician visits, 

increase cost awareness and encourage self-medication of petty diseases (Gebhardt, 

2005). Physicians transfer the payments to sickness funds, so the h10 fee is no 

incentive for providers to attract patients to generate a higher income. 

Empirical studies show mixed results regarding the impact of the h10 fee on 

access to and utilisation of ambulatory health care services. Data from the 

Bertelsmann Stiftung’s Healthcare Monitor 3 indicate that the number of physician 

visits initially declined (by about 8% between spring 2003 and spring 

2005) but remained relatively stable subsequently (Gebhardt, 2005). Grabka 

et al. (2006) showed decreased unnecessary consultations for 2004, the year of 

the introduction of the h10 fee, but the user fee appears to have no major impact 

on demand for physician visits overall (Schreyögg and Grabka, 2008). 

Zok initially showed that low-income earners tended to avoid physician visits 

shortly after the introduction of the h10 practice fee, but could not replicate 

these results in a later study (Zok, 2004, 2005). Another study showed that 

patients in bad health were more likely to reduce visits than patients in good 

health. Physicians argued that the number of medically needed physician visits 

went down as well, and that patients made less use of preventive health checkups 

and that utilisation of outpatient services among children and adolescents 

decreased (Gebhardt, 2005). Both prevention check-ups and physician visits 

for children remain exempt from the user fee though. It should be noted 

that these are very early observations, just one year into practice fee experiences, 

and that patients may be more familiar with the regulations now. In a more 

recent study, Schreyögg and Grabka (2008), for example, could not find evidence 

that the h10 fee acted as a deterrent for low-income people or the 

chronically ill. 

2 For an international comparison of out-of-pocket and voluntary health insurance payments, see 

Thomson et al. (2003). 

3 The Bertelsmann Stiftung’s Healthcare Monitor is a survey instrument that from 002 to 2008 

interviewed 1500 SHI insured twice a year, and about 500 office-based physicians once a year about 

health care. See http://www.bertelsmann-stiftung.de/cps/rde/xchg/SID-0A000F0A-A3AC0FA5/bst_en/ 

hs.xsl/prj_7097_7113.htm.

3.2.2 Introduction of universal mandatory health insurance 

The number of uninsured individuals in Germany is very small compared to 

other countries; however, it has been rising over the last years. Prior to 2007, it 

amounted to about 200,000 individuals (0.2% of the population) (Laschet, 

2005). The SHI-CSA, in force since April 2007, made universal health insurance 

mandatory. Today every resident is required to take out health insurance, either 

through social health insurance or privately. Whilst public insurers have always 

been obliged to enrol applicants, private insurers had freedom to contract or 

not. Under the new law, individuals have the right to get covered at least under a 

basic benefit package where they had last been insured, public or private (the 

dual German health insurance system is described in more detail in Section 3.3). 

Prior to the reform, a basic benefit package in the private insurance system 

was only open to existing customers or to people older than 65 years and for 

people over 65 years. Since January 2009, private health insurers are required to 

extend access to their basic benefit package. Existing customers could opt for 

this new plan within six months of its introduction, i.e. prior to July 1st, 2009. 

Furthermore, clients older than 55 years, former clients who can no longer 

afford the risk-related premiums, and new clients can always access the basic 

package. 4 New insurees can choose this benefit package without medical 

underwriting. The basic benefit package includes benefits similar to those 

offered in the SHI; insurance plans cannot exclude any services. The premium is 

not to exceed the maximum SHI contribution rate and can be lowered if the 

premium surpasses a certain percentage of the insured’s income. To the extent 

that the additional risk cannot be actuarially reflected because of the premium 

cap at the maximum SHI contribution rate, PHI companies expect a marked 

increase for regular risk-rated premiums, claiming that the obligation to offer 

the basic benefit package without medical underwriting might increase moral 

hazard behaviour of the insured, resulting in inefficiencies. 

3.2.3 Extension of the benefit basket 


Under the SHI-CSA, the statutory benefit basket has been extended to include 

new or additional services, especially in the area of prevention and rehabilitation. 

Since April 2007, sickness funds are required to pay for rehabilitative care 

services for the elderly. This is designed to improve health status of elderly 

persons after accidents or illnesses and to assist them to lead an active and 

autonomous life in their own home. Moreover, sickness funds now have to 

reimburse vaccinations recommended by disease control and prevention experts 

from the Robert Koch Institute. Financial support for families with children at 

rehabilitative facilities was also added to the SHI catalogue. Additionally, the 

4 Access of clients older than 55 years and of people who can no longer afford the premiums 

anymore, is restricted to the basic benefit package offered by their current insurer.


SHI-CSA will improve access to care for the terminally ill by including palliative 

care into the benefit basket of sickness funds. 

It should be noted that prior to the 2007 reform, there was a trend to exclude 

medically unnecessary services from the SHI benefit basket due to rapidly 

increasing health expenditures. Consecutive governments felt pressure to apply 

stricter cost containment measures. Among others things, they excluded from 

the benefit basket non-prescription drugs for petty diseases and introduced 

tighter rules for health technology assessment (Busse and Riesberg, 2005). 

However, given that still the Social Code Book V stipulates that the SHI has to 

provide ‘‘medically necessary services according to the principles of solidarity 

and appropriateness in a sufficient and efficient way’’, the benefit basket of the 

German SHI remains quite comprehensive; exclusions from the benefit catalogue 

have so far not caused access shortages. Insurees always had rather good 

access to a wide range of high-quality services. Benefit packages of the different 

sickness funds are framed by the Social Code. 5 In general, approximately 95% 

of the SHI benefits are identical in all statutory funds (von Maydell et al., 2006). 

3.3 Choice between the statutory and the private system 

Germany is unique in the sense that it is the only country in the Northern 

hemisphere that has two separate health insurance systems – the public SHI 

system and a private system, both providing full-coverage health insurance. 

The SHI system today insures 85.5% of the German population (Federal 

Statistical Office, 2007; Federal Ministry of Health, 2007b; Statutory Health 

Insurances, 2008). Members are enrolled in one of 196 sickness funds. The 

number of sickness funds has gone down rapidly since 1993 (1221 sickness 

funds) due to the merging of sickness funds that resulted from the opening of 

funds that used to ensure members from a specific company, guild or profession 

only (Federal Ministry of Health, 2005; Statutory Health Insurances, 2008). The 

SHI system is a pay-as-you-go system and it is compulsory for those earning less 

than h4,050 (in 2009) a month, for pensioners, students, the unemployed and 

disabled individuals, and it is a family insurance, that is, non-income earning 

family members comprising offspring up to age of 25 years are co-insured for 

free. Individuals with an income above the threshold or the self-employed can 

voluntarily remain in the social system in which, up to the contribution ceiling, 

contributions are related to ability to pay, or they can opt out and purchase PHI. 

Sickness funds have to contract with all applicants. Generally, contributions are 

equally shared among employers and employees in the SHI system. The 2004 

reform, however, introduced an extra contribution for employees of 0.9% to 

5 Since 2004, reimbursable services are determined jointly by sickness funds and health care providers 

in the Federal Joint Committee, the unified decision-making body of payer and provider corporatist 

constituencies also known as ‘self-administration’ of the German health care system (Busse et al., 2005).


cover dentures and sick pay moved away from the traditionally equal sharing of 

contributions between employees and employers. 

In contrast to the SHI system, the 47 private health insurers charge individually 

risk-rated premiums according to the state of health, age, sex, coverage 

and so on (benefit principle). Premiums are partly paid for by the employer (the 

highest average employer’s contribution in the SHI serves as a maximum). The 

nature of benefit packages varies considerably from plan to plan, depending on 

individual contracts, and private plans do not have to contract with all applicants. 

Currently, about 10.2% of the population takes out private health insurance 

(Federal Statistical Office, 2007; Association of Private Health Insurers, 2008). 

In order to guarantee moderate premium increases at a higher age, private 

plans use part of their revenue from premiums to build old-age provisions. In 

2007, these provisions added up to h123.6 billion invested in capital or stock 

markets (Association of Private Health Insurers, 2008). Until the 2007 reform, 

old-age provisions were tied to a specific private insurance company (the new 

regulations are described in Section 3.4); thus, the longer an individual stayed in 

a particular insurance company, the less attractive it became to switch to another 

insurance company because leaving your former insurance meant losing your 

old-age provisions. It also meant undergoing a new health exam for risk rating 

under a new plan, making choice for a PHI company a once-in-a-lifetime choice. 

Table 2 summarises the main differences between the SHI and the PHI system. 

3.3.1 SHI-CSA introduces restrictions for taking out PHI 

The SHI-CSA raises restrictions for taking out PHI, thereby decreasing choice 

for some, that is, high-income earners. Whilst prior to the 2007 reform insurees 

could opt out of SHI if their income exceeded the threshold in one year, it now 

has to exceed this level for three consecutive years. This provision is meant to 

increase financial fairness in health insurance: high-income earners can no 

longer leave social health insurance as easily, and their contributions will remain 

within the SHI system. 

Generally, the introduction of the basic benefit package (see Section 3.1) is 

expected to move private insurances closer to the SHI system. Hence, the SHI- 

CSA would constitute a first step towards a uniform health insurance market. 

3.4 Choice of insurer within public and private system 

3.4.1 Choice within SHI system moves from price to quality and differentiated 

benefit packages 

Since 1996, the vast majority of SHI insurees can freely choose their sickness 

fund (Wörz and Busse, 2005). Insurees are entitled to switch funds every 18 months 

or whenever contribution rates are increased. Since 1996, about one in four 

individuals have changed their sickness fund at least once (Braun et al., 2006).


Table 2. Comparison of statutory health insurances (sickness funds) and private health insurances in 

Germany 

Statutory health insurance Private health insurance 

Type of Compulsory insurance by law 

insurance (pay-as-you-go-system) 

Insured > Compulsorily insured 

> Voluntarily insured 

Private contract (funded system) 

> Employees with a monthly income 

.h4,050 (2009) 

> Public servants, self-employed, etc. 

Obligation to 

contract 

Yes No (except in the basic benefit package) 

Financing > Social security contributions > Risk-oriented premiums (benefits principle) 

(ability to pay) 

(state of health, age, sex, coverage, etc.) 

> Employer’s 

contribution 

and employee’s > Partially paid by employer 

> Risk-adjustment scheme 

Redistribution > From healthy to sick 

individuals 

> From young to old 


> From singles to families 

> From high to low income (up 

to the contribution ceiling) 

> From men to women 

Co-insurance Dependents are co-insured 

of dependents without extra costs 

Benefits > Principle of benefits in kind 

Refund of 

contributions 

> Identical benefit package 

> New choices of benefit 

packages (y 53 of the Social 

Code V) 

> For voluntarily insured 


> For individuals who chose 

a new benefit package 

> From healthy to sick individuals 

> No other redistributional effects (saving 

accounts) 

Dependents have their own individual contract 

with respective premiums 

> Cost reimbursement principle 

> Benefits according to private contracts 

> Basic benefit package with benefits similar 

to the statutory health insurance system 

Generally possible 

Studies show that the main reason for changing was the contribution rate. 6 

Individuals that changed funds were in better health than those who did not 

change (Wörz and Busse, 2005), and younger persons were more willing to 

change than the elderly (Braun et al., 2006). 

6 Prior to 2009, contribution rates ranged from about 12–15.5% of earned income, up to the contribution 

ceiling of h3600 (2008). Therefore, individuals could save h62 per month at the most, if they 

changed their sickness fund.


Choice of insurer within the SHI system will change substantially with the 

introduction of the so-called Health Fund, enacted in 2007. 7 In force since 1 

January 2009, the Health Fund constitutes the major structural change in the 

SHI financing system since its inception. It collects money from three different 

sources: contributions from employers, employees and from general tax revenue. 

While salary-related SHI contributions make up for the biggest part of 

Health Fund resources, funding from the federal government was introduced 

only recently: in 2006, h4.2 billion were transferred into the SHI system from 

tobacco tax revenue increases. In 2007 and 2008, this amount was again 

reduced to h1.5 billion per year. With the SHI-CSA, the tax pillar of the Health 

Fund will be again increased to h3 billion in 2009 and rise over time. 8 

Figure 1 summarises the basic functioning of the Health Fund. Sickness funds 

will receive Health Fund transfers made up of a lump sum payment and a riskadjusted 

payment. This latter payment reflects age, sex and a list of 80 costintensive 

diseases. Thus, the new system attempts to take into consideration the 

clinical characteristics and progression of disease in addition to demographic 

factors used in the previous risk-adjustment scheme. 9 

If a particular sickness fund cannot cover its expenditures with the Health 

Fund transfers received, it can charge an additional premium from its insured. 

Conversely, sickness funds that are run efficiently can pay out surpluses to their 

insured. 

What are the Health Fund’s implications for choice in the SHI system? On 

the financing side, the fact that contribution rates will be set by the government 

will move choice away from choice among different contribution rates towards 

choice among different additional premiums or refunds, alongside with 

increasingly differentiated benefit packages, quality and service aspects. Competition 

over extra premiums (or refunds, respectively) is likely to intensify as 

these will have to be paid for (or gained) by the insured alone (whereas increases 

or decreases in contribution rates were shared evenly among insurees/employees 

and their employers). However, two restrictions do limit the competitive role 

of the additional premium: first, it cannot exceed 1% of a household’s income; 10 

and second, the Health Fund has to cover at least 95% of all expenses of 

7 For an assessment of the Health Fund see Henke (2007) (also available in English: ‘The Health 

Fund: Political and Economic Aspects and its Role as a Competitive Instrument’). 

8 Increasing public funds does not have a direct impact on access to care. From a distributive point of 

view, taxes may be more progressive than the (proportional) contribution rate, have a broader base than 

payroll taxes and have to be paid by all citizens (including civil servants and the self-employed). 

9 Introduced in 1994, the previous risk equalisation scheme aimed to mitigate factors with an impact 

on contribution revenues of the sickness funds. These factors were age, sex, number of non-contributing 

dependents, number of insured pensioners with reduced earning capacity, type of sick benefits rights and 

income differences of sickness fund members. In 2007, the risk adjustment scheme resulted in a financial 

transfer of h18.5 billion (Federal Social Insurance Authority, 2008). 

10 Up to an additional premium of h8 per month, the one-per cent-clause does not apply. An 

additional pay out will also be limited.

Employer’s 

Contribution 

(set by government) 

Employee’s 

Contribution 

(set by government) 

Health Fund 

(from January 1st 2009) 

Transferrals 

(lump sum payment and risk 

adjusted payment) 

Federal Government 

Funds (taxes) 

196 Statutory Health Insurances (SHI) (2009) 

Figure 1. Functioning of the ‘Health Fund Model’ in the Statutory Health Insurance from 1 January 2009 

Source: Based on Henke (2007) and Lisac (2007) 

Additional Premium / 

Refund for Insured 

(nominal / income- 

related) 

Additional premium or 

refund according to the 

efficiency of the respective 

sickness fund 

42 M E L A N I E L I S A C E T A L .


the SHI system (at the beginning, the Fund’s revenues cover all of the SHI 

expenditures). 

3.4.2 New portability clause in PHI system 

The 2007 reform introduced a portability clause in the PHI system, which 

allows insurees to take along old-age provisions, limited in magnitude, to the 

basic benefit package in case they want to change their private insurance 

company. 11 In the past, the fact that old-age provisions were tied to a specific 

insurer and were thus lost when switching to another PHI company had constituted 

a major obstacle to the choice of private insurers (see Section 3.3). 

Competition among private health insurers and choice for the privately insured 

could have been improved even more had the portability clause not been limited 

to the amount determined by the basic benefit package (German Council of 

Economic Experts, 2006). However, critics feared that full portability of old-age 

provisions might have led to risk selection on the insurer’s side in order to win 

healthier customers and that it could cause difficulties because of differences in 

coverage between sending and receiving companies. Such an approach would 

have required actuarial models that allow for old-age provisions differentiated 

according to morbidity risks. The new portability regulation therefore represents 

an intermediate step. Moreover, the privately insured can now change 

insurers without renewed underwriting if they choose the basic benefit package. 

For all these reasons we come to the conclusion that the SHI-CSA has increased 

choice for PHI customers. 

3.5 Choice among different benefit packages 

Choice for insurees and patients has been widened, in that sickness funds in the 

SHI can now offer different benefit packages and insurance products, such as 

GP-centred care, deductible health plans, disease management programmes 

(DMPs) and so on. Individuals voluntarily accept minor restrictions in choice of, 

and access to, providers in return for better services under some of these new 

benefit packages. Thus, it can be argued that the 2007 reform increases choice 

and responsiveness to individuals, as patients can now choose benefit packages 

that might be better suited to their individual preferences. 

According to the revised y 53 of the Social Security Code V, sickness funds 

have new options in four areas: 

1. Deductibles 

The option of signing up for a deductible, that is, a maximum amount that 

the insured has to pay out-of-pocket per year in exchange for a refund will be 

opened to the compulsorily insured. Previously this option was available only for 

those voluntarily insured in the SHI system. 

11 People that have been insured prior to 1 January 2009 can only take along their provisions 

between January and June 2009.


2. Refund of contributions 

The option of contribution refunds, limited to a monthly contribution, will also 

be extended to the compulsorily SHI insured. 

3. New forms of medical provision 

Refunds can be tied to the condition that the insured joins one of the new 

forms of care, such as GP-centred schemes (gatekeeper model), DMPs or 

integrated care. 

4. Cost-reimbursement principle 

Insurees can now choose between the classic SHI benefits-in-kind scheme and the 

newly offered cost-reimbursement option. Also, fee-for-service for paying 

ambulatory care providers can be traded in exchange for a higher additional 

premium [e.g. the insured can choose the (higher) rate of the PHI system]. 

Currently, a large number of sickness funds are developing new benefit packages 

in these areas. However, the new benefit packages require the insured to sign up 

for at least three years, 12 have to be self-supporting and are not allowed to be 

cross-subsidised by other packages. 

From an economic point of view, the new benefit packages will enable sickness 

funds to focus more on the preferences of the insured; thus, in theory, 

raising choice among sickness funds and efficiency. On the other hand, redistribution 

effects will be reduced, for example, if young, higher-income earners 

choose contracts with higher deductibles, there will be less cross-subsidisation 

for the elderly or low-income individuals than today. Also, more benefit options 

carry a risk of reducing transparency, thus raising the transaction costs of 

choice. It will be more difficult to compare the various insurance benefit 

packages. Moreover, sickness funds will have to start building actuarial 

departments in order to calculate refunds or additional premiums, which will 

increase their administrative (overhead) costs. 

3.6 Choice of provider 

The Advisory Council on the Assessment of Developments in the Health Care 

System 13 has repeatedly shown that the German system suffers at the same time 

from over-, under- and misuse of health care services. Amongst other things, 

inefficiencies have been attributed to the lack of coordination across and 

between health care providers (Advisory Council, 2001, 2003). Also, there has 

always been a strict divide between ambulatory and hospital care in Germany. 14 

12 Except for benefit packages with new forms of medical provision where insured only have to 

commit for one year. 

13 The Advisory Council on the Assessment of Developments in the Health Care System (formerly 

the Advisory Council for the Concerted Action in Health Care) is required to submit a report to the 

Ministry of Health and the legislative branches of the national government every two years. The reports 

aim to identify areas in which health care services are excessive, inadequate or inappropriate, and to 

specify and analyse measures for solving these problems. 

14 The fragmentation extends to rehabilitation, long-term care and prevention.


The separation largely results from different payment schemes within the two 

sectors and from the way the negotiating process between health care providers 

and SHI plans is currently organised. 15 

Providers of ambulatory care (GPs and specialists) belong to one of 17 

Regional Associations of Statutory Health Insurance Physicians, which contract 

with the regional head associations of SHI sickness funds. The traditional bargaining 

process within the self-administration system 16 is based on corporatist 

contracting: SHI physicians in the ambulatory sector are reimbursed according 

to a fee-for-service schedule with a fixed budget and floating (point) values. 

In return for being reimbursed by the sickness funds, the regional physician 

associations have to secure the provision of ambulatory care. 17 Besides payments 

from the SHI system, ambulatory providers usually generate a second 

flow of income that varies in volume by specialty when treating privately insured 

patients. Here, reimbursements are based on a different fee-for-service schedule, 

that is, not tied to a fixed budget and generally allows for higher payment rates. 

The hospital sector has two funding sources: operating costs are reimbursed by 

sickness funds based on the G-DRG system introduced in 2004, 18 and capital 

investments (buildings and large medical devices) are covered by state funds. State 

governments also engage in the planning and securing of hospital infrastructure. 

Prior to 2004, departures from standard care were very rare and existed only 

on a regional level in experimental settings. New forms of care with a focus on 

gatekeeping and better coordination remained unpopular even after integrated 

care contracts had been eased with the 2000 reform. This can be partly 

attributed to lack of appropriate financial incentives and experience. Moreover, 

legal, tax and organisational obstacles had to be overcome. For instance, until 

2004, SHI physician associations (Kassenärztliche Vereinigungen, KVs) were 

compulsory partners in integrated care contracts. But with more selective contracting 

opportunities after 2004, KVs could be by-passed and would therefore 

lose influence. This caused conflicts of interest and impeded the advancement of 

integrated care at the time (Hesse, 2005). Aside from early integrated care 

experiences some sickness funds started voluntary GP-centred care schemes. 

15 Germany has a parallel structure for specialist care: as elsewhere, specialists provide inpatient care 

in hospitals as employees, and specialty doctors can also provide secondary care as self-employed solo 

practitioners outside the hospitals – a situation that leads to overuse. 

16 In Germany, decision-making powers are decentralised to the members of the self-administration 

(or self-governance), that is, to payers (sickness funds) and providers (physicians and hospitals). These 

self-administration bodies decide, for example, which benefits get reimbursed by social health insurance 

and the remuneration level for services. The federal government has only supervisory powers and sets the 

regulatory framework within which the self-administration bodies are free to take decisions. 

17 According to the Social Code, the KV has to guarantee adequate medical services in terms of 

quality, geographical reachability, time, needs and economic efficiency. 

18 The German Diagnosis Related Groups (G-DRG) system is based on the Australian Refined 

Diagnosis Related Groups (AR-DRG) (Version 4.1) which in turn partly derives from the US system of All 

Patient Refined DRGs (APR-DRG).


Bonus payments and lower co-payments worked as incentives for the insured to 

enrol in those plans. 

The idea of managed care has gained further momentum since the SHI-CSA of 

2007 in Germany. Managed care elements (e.g. gatekeeping, utilisation reviews, 

quality measurements and so on) are expected to improve quality of care and 

to control costs via better coordination and a more efficient use of health care 

resources. Since the 2004 reform, the number of GP-centred schemes, DMPs, 

medical care centres and integrated care projects has steadily increased. 

3.6.1 GP-centred care 

Since 2004, sickness funds are required to offer GP-centred approaches to their 

members. Enrolment is voluntary. The purpose is to increase quality and efficiency 

of care by assigning the GP a stronger coordinating and guiding role. 

As of December 2007, of those eligible to enrol in a GP programme, roughly 

19% participated – half of the sickness funds had not yet begun to offer GP 

programmes (Federal Ministry of Health, 2008). 

Data from the Bertelsmann Stiftung’s Healthcare Monitor show that GP 

programme enrolees are usually older, have more severe diseases, and suffer more 

often from chronic diseases than non-participants. The number of specialist visits 

without referral is lower in the group of GP scheme participants than among nonparticipants, 

indicating that GPs have assumed a stronger guiding and coordinating 

role. Most GP programme participants are satisfied with the coordinating role of 

their family doctor: 92% think that referrals were made at the right time and that 

the GP explained the referral in an understandable way. Regarding the willingness 

to enrol in GP models, for most (potential) participants it is important that they can 

keep their previous GP. Moreover, participants want to freely choose a specialist 

if access to specialists is tied to a referral from their GP. If the choice of specialists 

(or of hospitals and pharmacies) is left to the GP, willingness to enrol decreases 

drastically. Financial advantages are a major incentive for insurees to enrol in GP 

models (Böcken, 2006). 

3.6.2 Disease Management Programmes 

Disease management programmes were first introduced in 2003. Physicians and 

patients can enrol in these programmes, which provide coordinated care along 

centrally defined, evidence-based standards, on a voluntary basis. Sickness funds 

currently offer DMPs for six chronic conditions: diabetes types 1 and 2, coronary 

heart disease, breast cancer, asthma and chronic obstructive pulmonary 

disease. In December 2008, more than 5 million individuals participated in 

DMPs (AOK Kompakt, 2008; Federal Social Insurance Office, personal communication). 

In addition to their potential in improving care for the chronically 

ill, there is a strong economic incentive for sickness funds to increase participation 

in DMPs: the number of chronically ill registered in DMPs is taken into


consideration within the risk-adjustment scheme. In accordance with evaluation 

requirements set out in the law, many DMPs have been self-evaluated by 

the sickness funds that run them; results from patient and physician surveys 

carried out by the funds indicate that satisfaction with quality and coordination 

of care has considerably increased. Individuals participating in DMPs showed 

better health outcomes, for example improved blood sugar levels and blood 

pressure values (Van Lente and Willenborg, 2006; Elkeles et al., 2008; Graf 

et al., 2008). 

3.6.3 Integrated care and medical care centres 

The 2004 reform introduced the possibility to establish medical care centres 

(polyclinics), and the right for sickness funds and providers to enter into integrated 

care contracts. To incentivise integrated care, especially intersectoral 

cooperation between medical and non-medical providers (such as speech 

therapists, occupational therapists and so on) and long-term care providers, 1% 

of the total SHI budget is redirected to these new cooperative arrangements. 

However, start-up financing ended in late 2008. 

The number of integrated care contracts rose continuously: from 613 contracts 

at the end of the first year (2005) with a financial volume of h237.4 million and 

2.07 million insured, to almost 6000 with a financial volume of h820 million and 

4 million insured at the end of September 2008 (Federal Office for Quality 

Assurance, 2008). Contrary to policy intentions, most integrated care contracts still 

cover specific diseases or indications (e.g. artificial hips, knee prosthesis), rather 

than offering population-oriented integrated care as encouraged by legislation. 

Medical care centres or polyclinics have been the predominant form of 

ambulatory care in the former German Democratic Republic (Henke, 1991). 

After reunification, most of the polyclinics had been dismantled and outpatient 

care in the Eastern states was modelled after West Germany’s ambulatory 

system, with solo practitioners and few group practices. Today, only about 

30 former polyclinics still exist and operate as medical care centres. With the 

2004 reform, medical care centres resurfaced throughout the country. Since 

2005, their number increased from 270 to more than 1000 at the end of 

June 2008 (Federal Association of SHI Physicians, 2008). They integrate 

different specialties as well as health and non-health professionals. On average, 

four physicians work together and most of these centres are managed out of 

hospitals, by physicians (Preusker, 2007). 

All in all, the 2004 reform and the SHI-CSA of 2007 set out the legal and 

organisational framework for better coordination and cooperation in Germany’s 

health care. Increasing numbers of DMPs, integrated care arrangements and 

medical care centres show that providers and payers slowly but surely are engaging 

in new forms of care. The majority of patients enrolled are satisfied with the quality 

of care these programmes provide. However, one key challenge for the successful


implementation of new forms of care will be to convince patients that more patient 

navigation and somewhat less choice will work to their advantage. Moreover, it 

remains to be seen whether integrated care arrangements will continue to flourish 

now that start-up financing has come to an end. 

4. Discussion and conclusions 

4.1 Financial incentives for providers to mitigate problems in 

availability and reachability 

There are relatively few infrastructural or geographic barriers to access in health 

care in Germany. Moreover, problems in reachability of services due to demographic 

developments and shortage of providers in some regions are addressed 

one by one through the promotion of new forms of care and additional financial 

incentives for providers to start practice in underserved areas, as stipulated in 

the SHI-CSA. However, the take-up rate of financial incentives, like guaranteed 

incomes for providers in underserved areas, remained low in the past. Thus, it 

remains to be seen if these measures achieve their intended objectives. 

4.2 Do new co-payments decrease affordability of care? 

The increase and implementation of new co-payments deliberately established 

barriers to access in Germany in order to reduce unnecessary provider visits. 

Research results showed that these measures seem to have achieved their objectives, 

at least temporarily. However, some studies also indicated unintended 

negative social and health effects. More research is needed to probe these developments, 

and policy makers should carefully watch the impact of co-payments on 

affordability of care. While it is true that increases in patient cost-sharing are 

cushioned by exemption rules and cost-sharing ceilings to ensure affordability 

of health services, especially for low-income earners and individuals with severe 

and/or chronic conditions, it needs to be ensured that people are aware of certain 

rules and limitations. As Eller et al. (2002) showed in their study, this was, for 

example, not the case with hardship regulations that were in place prior to the now 

existing co-payment ceilings. Ignoring newer regulations, people seemed to forgo 

necessary or recommended care (e.g. preventive services). 

4.3 Mandatory health insurance increases affordability of care 

Making universal health insurance mandatory in 2007, insurance coverage was 

expanded to the whole population and hence the solidarity principle was 

strengthened. Every citizen now is obliged, but also entitled to be covered under a 

comprehensive basic benefit package. Also, the SHI benefit basket was expanded, 

taking into account the demographic developments and new needs by making more 

preventive, rehabilitative and palliative services available to the insured population.


4.4 More choice and competition to increase quality and efficiency 

While ensuring a high level of access and solidarity, Germany is experimenting 

with more choice and competition, primarily in the health insurance market. 

With the development of new benefit packages by sickness funds, choice within 

health insurance has been further expanded since 2007. The introduction of 

portability of old-age provisions increases choice for privately insured individuals 

to some degree, but it will not substantially increase competition, as it will be 

limited to the basic benefit package. 

The new risk-adjustment scheme will ensure a level playing field for all sickness 

funds. Further, the introduction of the Health Fund is likely to move the existing 

choice among different contribution rates towards choice among additional premiums 

or refunds. However, given premium ceilings, competition on the financing 

side remains limited. A greater variety of benefit packages may well develop into an 

additional parameter for competition. Furthermore, PHI plans converge towards 

the SHI system. Comparing the German reforms internationally, the new elements 

influencing choice of health insurance (refinement of the risk-adjustment scheme, 

the Health Fund, and the beginning convergence of statutory and private health 

insurers) show similarities to recent developments in the Dutch health care system. 

Overall, it remains to be seen if increased choice among different benefit 

packages will have negative effects. For example, when many young and healthy 

individuals choose the new low-premium tariffs (e.g. tariffs with refunds or 

deductibles), this might threaten solidarity due to lower redistribution effects 

between young and old, healthy and sick, and so forth. 

4.5 Trying to find the balance between free choice of provider and 

stronger patient guidance 

Finally, we identified the introduction of managed care elements as a further 

strand in current health policy reforms in Germany that also aim at higher 

quality and increased efficiency. Gatekeeping, DMPs and integrated care have 

been promoted by the government since 2004, and slowly but surely find their 

way into the system. The impact of these new models of care on access and 

choice is two-fold. When enrolling in these programmes, insurees accept certain 

restrictions in choice and direct access to providers, but they gain benefits in the 

form of better quality care. Therefore, reduction of choice of providers should 

not be overemphasised – GP schemes, DMPs, etc., remain for patients. Rather, 

new insurance products should be seen as increasing choice for insurees to opt 

for customised products. Still, patients have not yet fully embraced these new 

forms of care. Barriers to better uptake – including values and individual preferences 

of insurees – as well as conditions under which insurees are willing to 

participate in such programmes need to be researched more in-depth. 

Besides the benefits that these new forms of care bring to insurees, they also 

open a window of opportunity for sickness funds enabling payers to contract


selectively with providers and to become players responsible for quality and 

efficiency of services. 

Acknowledgements 

We thank the members of the European Health Policy Group for their helpful 

feedback on an earlier version of this paper and two anonymous referees. 

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