The German Health Care System in International Comparison
A Patient Perspective
Background: International health care systems of industrial countries show great differences in organization and financing. During 2008 the Commonwealth Fund interviewed sicker adult patients from eight countries to compare aspects of quality of health care.
Methods: In total, 9633 randomly selected patients from Australia, Canada, France, Germany, The Netherlands, New Zealand, United Kingdom, and the USA were recruited for structured interviews. All participants were adults who reported being in poor health, having a serious illness or disability, having been hospitalized, or having had major surgery in the past two years.
Results: In total, only 34% of participants in Germany rated the quality of their health care as „excellent“ or „very good“. This fraction was larger in the other countries (up to 66%). Sicker adults in Germany consulted more physicians. Problems with coordination were reported by all countries, in particular concerning the communication between specialist/general practitioner, hospital/general practitioner and the flow of information to the patients.
Conclusion: Although sicker adults report similar experiences and problems with coordination their satisfaction with health care differs internationally. Compared to a similar survey in 2005 the general satisfaction of sicker adults with health care in Germany has improved.
In 1999 the Commonwealth Fund began collecting data on health care in five countries, using a uniform methodology, in order to compare the quality of the health care systems (1–9). Up until 2004, data were collected in Australia (AUS), Canada (CAN), New Zealand (NZ), the USA, and the United Kingdom (UK); in 2005 Germany (D) took part in the study for the first time (10, 11). In 2006 the Netherlands (NL) joined in, and in 2008 France (F). The Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG) contributed to the design and financed the German surveys.
The target groups and main focus changed from year to year. In 2008, as in 2005, the study related to the experiences of sicker adults who were particularly dependent on health care provision (11).
Respondents were asked about the following:
- A general assessment of the health care system and health care provision
- Ease of access to health care, including waiting times and delays
- Relationship with family doctor/primary care physician and specialists, including coordination of care and medical drugs
- Experiences in hospital and in emergency departments
- Consumption of prescription drugs, including coordination of treatment with several drugs and considerations of cost
- Patient safety, including medical errors in drug administration, the communicating of false diagnostic results, or delays in information about results
- Experiences with preventive measures, including follow-up care and the management of chronic diseases
- Access to information technology, including the possibility of email correspondence with family/primary care physician and access to personal medical files
- Extent of health insurance, any additional financial burdens due to illness.
A summary description of the experience of respondents with chronic diseases has been published separately (6). The present article describes selected results for Germany and compares them, where meaningful, with the findings for 2005 (11).
The study is based on structured telephone interviews with randomly selected respondents. Coordinated by Harris Interactive Inc. on behalf of the Commonwealth Fund, the interviews were carried out between 3 March and 30 May 2008 simultaneously in Australia, Germany, France, Canada, New Zealand, the Netherlands, the USA, and the United Kingdom. Respondents were adults over 18 years of age who reported their health as fair or poor and reported having a chronic disease or disability, and/or having been hospitalized or having undergone major surgery within the past 2 years. Hospital stays relating to uncomplicated childbirth were not included.
In Germany, households were randomly selected using random digit dialing and contacted by telephone. The target person was defined as the adult in the household who had most recently had a birthday. In the first part of the interview, all interviewees were asked for basic demographic data. In the second part, the questions were about their state of health, in order to identify suitable participants.
The third, extensive part of the interview was then carried out with suitable (sicker) participants.
In all countries the interviewers used computers to work their way through the questions and record the answers (CATI, computer-assisted telephone interview). Interviews lasted for an average of 17 minutes; the range in all countries was 14 to 22 minutes.
Profile of the patient sample
In Germany a total of 3192 persons were successfully interviewed, corresponding to a participation rate of 31%. The figures by which the participation rate was arrived at are given in the supplementary material accompanying this article.
Out of 3192 persons who underwent the screening interview, 1320 (41%) fulfilled the inclusion criteria as “sicker” patients. Of these 1320 persons, 1201 took part in the complete survey. Deviations of the sample from the average in all the countries in respect of age, sex, (German) federal state, and level of education were adjusted by weighting according to data from the Federal Statistical Office for 2007; in Germany this gave a weighted population of 1077 men and women (eTable 1 gif ppt). All analyses in the present study relate to this weighted “base” population, unless otherwise stated. Both absolute and relative rates are given. Relative rates are presented as percentages. Table 1 (gif ppt) shows the characteristics of the German respondents alongside those of other nations. Further information will be found in the supplementary material.
Health problems among respondents
Between 13% (CAN) and 23% (UK) of respondents assessed their health as fair or poor; in Germany the rate was 16%. Table 2 (gif ppt) and eTable 2 (gif ppt) list data on the other criteria that led to inclusion in the survey. Overall, between 33% (CAN) and 45% (AUS) of the respondents in the original screening interviews fulfilled the criteria for further questioning; in Germany the figure was 34%.
General assessment of the health care system and
health care provision
There was no unanimity among German respondents in their assessment of the health care system: 25% thought that it was so bad that it needed changing from the ground up. Only the USA had a higher disapproval rate (30%). On the other hand, almost as many respondents (24%) thought that the Germany system did not function badly, taken all round, and only small changes were needed. Most respondents saw some good things, but also a need for fundamental change (Table 3 gif ppt).
Assessment of the quality of medical care
The answers to questions about the quality of medical care provision during the past year varied greatly (Table 4 gif ppt). Between 34% (D) and 66% of respondents (NZ) answered “excellent” or “very good.”
Germany had the lowest rate of assessment as “excellent” or “very good”; there was no change on this between 2005 and 2008. On the other hand, the number of those who thought the quality of provision in Germany was “fair” or “poor” was also relatively low at 12%. The range in the other countries was between 9% (F) and 19% (USA). In Germany, 53% of respondents described the quality of care as “good.”
Extent of health insurance and extra costs
In all of the countries included in this study it is possible to have private (extra or top-up) health insurance in addition to the statutory/public health cover (Table 1). Between 16% (NL) and 83% (UK) had only the basic cover; 16% (UK) to 81% (NL) had private health cover exclusively or as an extra. In Germany, 11% of sicker patients were privately insured, and another 10% had top-up private insurance in addition to statutory health insurance. The USA stands out on this point, because 21% of respondents had no health insurance at all and were treated in special medical centers.
Despite these insurances and other kinds of health cover, extra payments from private means (“out-of-pocket”) were usual in all countries (eTable 3 gif ppt). The proportion of those who had had to pay the equivalent of more than 640 euros (1000 US$) in the previous 12 months was between 5% (F, UK) and 39% (USA); in Germany it was 12%.
In Germany, 28% of respondents said they had gone without medicines, a visit to the doctor, or an examination or treatment at least once during the previous 2 years on grounds of cost. In 2005 the figure was also 28% (11) (eTable 3). Respondents on an annual income of less than 29 000 euros had done this slightly more often (30%) than those with an income above the average (25%).
Relationship with primary care physician and specialists
In all countries apart from the USA, at least 95% of respondents always went to the same place (“medical home”) when they were ill. In most cases this is a family doctor (primary care physician), but in England 8% and in the USA 10% went to a medical facility with a rotating staff of physicians (Table 5 gif ppt). In Germany, 43% of patients questioned were given an appointment to see a family doctor on the same day if they had an acute medical problem, but longer waiting times were also frequent. In the Netherlands and New Zealand, only 3% and 5% respectively had to wait more than 6 days for an appointment; in the other countries the rates ranged from 13% (UK) to 32% (CAN). In Germany, 24% had to wait 6 days or more.
Waiting times of over 4 weeks to see specialists are not rare either: in Germany, 21% of respondents had to wait at least a month for an appointment, and 11% even had to wait for over 2 months. However, this is still lower than in other countries, in which the rates went up to 30% (CAN) (Table 5).
The health systems also differ in terms of the significance of emergency admissions to hospital. Twenty-seven percent of sicker patients in the Netherlands and 34% in Germany said they had been admitted to an emergency department in the past 2 years; in Canada and the USA, the figures were almost twice as high.
Communications between physicians and patients seem to be in need of improvement in all countries. Thirty-six percent of German respondents said that the aims and priorities of treatment had not been mentioned to them, 69% had not received a written treatment plan, and only 21% had been contacted by the doctor after the visit to see whether they were getting on all right (eTable 4 gif ppt). Only one respondent in 10 in Germany reported having a doctor who scored positively on all these points; in other countries the rate was higher. On the whole, though, patients said that doctors who made an effort to include them in decisions were the rule rather than the exception.
Coordination and continuity of care
Given the criteria for inclusion of respondents, it was to be expected that more than one physician was involved in patient care. Germany stands out in these results in that 47% of respondents were under treatment by at least four doctors (Table 6 gif ppt). Even in the two countries ranking next, Australia and the USA, the rates were notably lower, at 37% and 35%. In the other countries, the highest rate was 28%.
This finding draws the gaze to aspects of coordination of care. In Germany, 33% of respondents reported that the specialist had no information on their existing medical history; in other countries the highest rate was 22% (USA). Thirty-three percent of German respondents had had the impression during the past 2 years that time was sometimes or often wasted because of poorly organized medical care. This was more frequent than in the other countries, with the exception of the USA (35%). Table 6 also contains data on aspects of treatment in hospital.
Medications and patient safety
In Germany, 12% of respondents said that there had been errors in their treatment; in France (9%), the Netherlands (8%), and the United Kingdom (10%) the rates were slightly lower. Supplementary eTable 5 also gives data on errors in the use of medications and diagnostic examinations.
This survey of sicker patients confirms that in 2008, too, there were large differences internationally between patients’ experiences and satisfaction with their health care systems. In every country there are elements that appear in need of improvement. In addition, in all the countries there is a significant proportion of patients who are dissatisfied; the numbers are smallest in the Netherlands and in the United Kingdom.
In comparison to the 2005 survey (11), general satisfaction with the health system in Germany has improved slightly in terms of numbers. It cannot, however, be ascertained whether this change is due to a difference in the make-up of the patient sample or whether it represents a genuine trend to greater satisfaction.
Despite this, as in 2005, it was apparent that, in their subjective assessment both of the German health care system as a whole and of the quality of their own individual medical care, German patients were less satisfied than the respondents of most of the other nations. Although 87% of respondents in Germany said the quality was at least good, most of them nevertheless wanted some fundamental changes. This discrepancy was also seen in 2005. However, it cannot be inferred from these data that the treatment results in Germany were actually worse.
It is possible that patients in Germany are more critical or have higher expectations than patients in the other countries. It is a known sociological phenomenon that objectively good conditions of life can be subjectively perceived as poor (16). This shows that levels of satisfaction are determined not just by the reality of health care provision, but by the levels of expectation against which reality is being measured.
It is possible that Germans tend to give more negative assessments. Jürges (17) compared self-reported health in various European countries with rates of reported health impairments. This study showed that in comparison to the European average, the German respondents tended to rate their own health as poorer for the same frequency and severity of disease. International comparisons that fail to account for such national differences in reporting styles can therefore lead to erroneous conclusions.
One single aspect in which Germany stands out internationally is that almost half the respondents reported being under the care of more than four doctors. This means that their treatment is in many hands and coordination is thus more difficult. One finding of this survey is that patients in Germany more frequently report particular problems of coordination.
A strength of this survey is that the same set of questions was administered in all the countries at the same time. The authors therefore assume that the survey reliably shows up existing differences in perception in the various participating countries. The rates of diseases varied between countries, for reasons that are unclear. These differences in disease rates may also mean that differences in experience between countries are partly due to differences of care in medical specialties.
One limitation of surveys of this sort is that internationally they are increasingly having problems in achieving high response rates. With a response rate of 31%, participation in Germany was at a level that is usual for such surveys. The consequences for findings of a low response rate is a subject that is widely debated (12–15, 18). A low response rate does not necessarily mean that the findings of a survey are grossly biased.
Another limitation of this survey is that the respondents’ subjective assessments cannot be objectively verified.
It is not really possible to draw conclusions about causal relationships from surveys of this kind. However, the authors are of the opinion that the data do reflect the views of patients about the German health care system with adequate reliability. Against this background, the authors believe this survey is a valuable contribution to the current German discussion, because it places the assessment of the strengths and weaknesses of the Germany health care system against an international yardstick. The patients’ actual experiences show that some things can be improved, but they do not call the German health care system as a whole into question.
Conflict of interest statement
The authors declare that no conflict on interest exists according to the guidelines of the International Committee of Medical Journal Editors.
Manuscript received on 29 June 2009, revised version accepted on
5 November 2009.
Translated from the original German by Kersti Wagstaff, MA.
Dr. rer. medic. Klaus Koch
Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG)
Dillenburger Str. 27
51105 Köln, Germany
@eSupplement and eTables available at:
care systems: experiences of patients with health problems in six countries. Health Aff (Millwood) 2005; Suppl Web Exclusives: W5–509–525. MEDLINE
Dr. rer. medic. Koch, Dr. rer. nat. Schürmann, Prof. Dr. med. Sawicki
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