Zero Disease. Angelo Barbato

       The contribution paid to the Krankenkassen varies depending on the employee's income and corresponds to 15.5% of the monthly salary (53% of which is paid by the employee and 47% by the employer). Thus a financial equalization is applied to compensate for the different capacity of contribution of members: Each person pays proportionally to their income. The contribution of employees and businesses has grown over the past 15 years, going from 13.6% in 1998 to currently 15.5% of the monthly income.

      On top of the monthly contribution, supplements (Zuzahlungen) are added: you have to pay € 10 every three months to take advantage of medical consultations with all doctors recognized by the health insurance funds, and thereafter each time that you are using one visit to the doctor or dentist (including those covered by the policy) you have to pay a fee of 10 € (this "Praxisgebühr" has led to an observed reduction of 10% of the accesses). Even for the medicines you pay 10% of the price, and 10 € per day for hospitalization. Recently, an annual limit for additional expenses has been set (generally 2% of annual income, 1% for recipients of a continuing care because of a serious chronic disease), those who pass such percentage are reimbursed their insurance. Minors do not pay any additional charge.

       In Germany there is an obligation to be insured; those with a monthly income of more than € 4462.60 may choose to subscribe to private insurances (Private Krankenversicherung-PKV), rather than social ones.

      Private insurances, unlike the mutualistic funds in which the contribution depends on income, calculate the premium depending on the personal risk (in fact, it is provided thorough medical examination before enrolling). Private insurances often offer superior services of social insurance, pay better doctors, and also offer reimbursements for hospitalization in non-contracted private clinics. For young people with a high salary and no health problem, the contribution towards the private enterprises often costs much less; with age the insurance policy increases in price. However, even in case of serious diseases it may not exceed certain standard levels (for this reason it is custom for young people to appeal to insurances to create a capital backup with their savings). Nine million Germans, equal to 11% of the population are privately insured. The use of private insurance can also be a complementary purpose for those who are enrolled in the Krankenkassen (about 23 million). The main reason is to expand the financial protection in case of illness or hospitalization. The remaining 4% of the population is represented by people who get insurance coverage through special channels, such as the military or those with refugee status.

       The funding of the German health system is mainly based on the takings of the compulsory social insurance (57%) and on private insurances (9%). The central government is not involved in the health system neither as a financier nor as manager, or as the owner of sanitary manufacturing companies (except detailed cases, such as military hospitals). However, it governs the whole system, defining the rules by which the actors can move. Mutual aid societies and associations of physicians operate within administrative rules, only modifiable by the central government, just as they are regulated by laws and relations between the different actors of the system. Although the general health policies for the country are decided by the Central State, the management and the funding of the system takes place at regional level, where there are three institutions: the Land (through its Ministry of Health), mutual aid societies, associations of panel doctors and hospitals. It is the individual Länder who plan and finance investments and infrastructure (hospitals, departments, equipment, access to the conventions and specialized training), credit the volume of production, finance the hospital-area system integration and perform the review of legality. These can, for instance, control the activity of doctors and guide their prescription behavior towards less expensive drugs, as well as carry out surveillance on the quality of hospital care.

       The sickness insurance funds programming negotiate and acquire the services for their patients. The German system’s financing mechanism is therefore dualistic: the Land defines and funds investment, while the mutual aid society negotiates and finances the current healthcare costs by dealing with both hospitals and affiliated physicians.

      For hospital functions, the regional association for mutual aid signs a contract with each hospital, while for outpatient functions it negotiate a global agreement with the regional association of doctors.

      Mutual aid is called to protect the interests of its members, trying to influence the volume and the producer’s case mix, as well as to respect the insurance spending thresholds, implicitly set out by the Government through the maximum rate of contributions payable by the subscribers.

       With an excess of hospital beds (8.3 per 1,000 inhabitants compared to the OECD average of 4.8 and 2.6 in Sweden and 3.4 in Italy), the rate of hospitalization (25 admissions per 1,000 inhabitants compared to the OECD average of 15.5, 16.2 in Sweden and 12.8 in Italy) and the average duration of hospital stay (9.2 days compared to the OECD average of 7.4, 6.0 in Sweden and 7.7 in Italy); in terms of financial resources, Germany has the most important hospital network in Western Europe¹⁹ .

       The acute care hospitals were 2,017 in the year 2012, with 501,475 beds: 601 public, 719 private non-profit and 697 private for-profit, with a split percentage split of respectively 48%, 34% and 18% of beds. In addition to acute care hospitals, 1212 structures specializing in rehabilitation exist, holding 168,968 bed places. Among these institutions, only 19% are public, 26% are private non-profit and 55% private for-profit. 18% of hospital beds are in public facilities while the other structures respectively host 16% and 66%. Next to a progressive reduction of beds for acute illnesses, the number of beds in rehabilitation and psychiatric facilities has more than doubled.

       German citizens have full freedom of choice of care and professional place, with no distinction between general practitioners and medical specialists.

      This model - which does not include the role a of gatekeeper doctor, or a doctor who acts as a filter for access to specialist care - is typical of the Bismarck model, but is rapidly changing as a result of a reform approved in 2004.

      Such reform, since 2004, has introduced several innovations in order to strengthen local services (and to reduce the pressure on hospitals): among them is the need to encourage the enrollment of the clients to a general practitioner who in addition to playing the role of filter for access or "gatekeeper", also is responsible for the coordination of care. There is no obligation, but who does not comply is subject to reduced co-payments and waiting lists. The number of patients assisted by the "gatekeeper" or General Practitioner (GP) is growing (in 2012 to 4.6 million).

      Another innovation is the overcoming of the model of care based a single physician, with the development of medical centers of interdisciplinary care (increased from 70 to 1,814 from 2004 to 2012).