A Lesson from Berlin
By Patricia S. Simmons, M.D.
In September, I had the opportunity to be part of a delegation of Minnesota health care leaders who traveled to Berlin for seven days to study health care in Germany. The trip was part of a series of exchanges sponsored by the Center for German and European Studies at the University of Minnesota. The center was established in 1998 with a grant from the German government to promote interaction between the two countries. Since 2005, it has had a focus on health care, and its annual American and German Healthcare Forum has become a key venue for dialogue between Americans and Germans.
For several years, Germans have traveled to Minnesota to look at how our health care system works, and this fall, Minnesotans went to Germany to see theirs. Our time in Berlin was filled with lectures by and discussions with officials from the German Ministry of Health and a visit to a private hospital and clinic. What began as a look through a porthole at health care in Germany quickly became a look in the mirror.
The first thing I learned during my trip was that no country has a perfect system. Many nations in Europe are engaged in reforming and remodeling their health care systems. Germany is no exception, and leaders in its Ministry of Health are enthusiastic about exchanging ideas about approaches, outcomes, and best practices. In exploring the parallels and differences between the U.S. and German systems, I realized that we can learn from each other and apply those lessons to the reform efforts taking place in our state and country.
The first thing to realize is that Germany’s health care policy is guided by fundamental principles. Solidarity is one. In the context of health insurance, solidarity is the idea that those who have jobs help cover those who do not, the healthy help cover those who are sick, adults help cover children, the wealthy help cover the poor, and singles help cover families. The current government considers health care a right, and insurance coverage is guaranteed to all regardless of health status. Unlike the British model of nationalized health care or the Swiss market model, the Germans have what they call “social insurance.” The country has about 200 self-funded “sickness funds” that are financed by premiums paid by employers and individuals. Each insured contributes approximately 7 percent of his or her income, and employers contribute a match. People who are not employed or who have incomes below a certain level receive a government subsidy to help them afford their premiums.
The health insurance companies that run these funds are not-for-profit entities. Any money that is not spent on health services must be returned to the people they insure or used to provide added services. These companies are not allowed to deny coverage based on pre-existing conditions; to charge different premiums based on age, gender, or family status; or to rescind coverage and terminate a policy if the policyholder gets sick. All of these insurers offer a standard level of coverage determined by an independent board.
Only 10 percent of the population chooses to opt out of this public system for private health insurance. Private health insurance in Germany is similar to what we know in the United States. Premiums are differentiated based on age, gender, profession, marital status, and individual health status, and they increase as you age. People who purchase private insurance tend to be from the wealthier tier of society and do so to get coverage for more services. A quirk of the German health insurance system is that federal employees are required to purchase private insurance.
Choice is another principle that guides Germany’s health care policy. The majority of German hospitals and clinics are not privately owned, and people choose the physicians they want to see and the hospitals where they want to receive care. Like here, these choices are often made based on the recommendations of others and proximity. Hard data on performance is not yet readily available, although there are efforts underway to make it so.
Although the principles of solidarity and choice have guided Germany’s policy through the years, they are subject to change. Health care is as prominent a political issue in Germany as it is here, and our German hosts were anxiously awaiting the results of the national elections that were taking place the last day of our visit (September 27). As in the United States, German political parties have different philosophies and positions on health care and health insurance.
The German health care system does face a number of challenges. One is lack of integration. Clinic physicians do not have hospital privileges, and hospital physicians cannot provide follow-up care after their patients are discharged. In addition, providers often work alone. In the United States, and particularly in Minnesota, health care is often delivered using a team approach. Germany has fewer bachelor’s-level nurses and virtually no advanced practice nurses or mid-level providers—all of whom are integral to the U.S. system. I can’t imagine delivering care without having my colleagues in nursing beside me. In studying the German system, I again realized the value of having professional diversity in our health care teams: It leads to creative ideas that help determine how we care for our patients.
A colleague on the trip commented that the reason health care costs in Germany are lower than in the United States is that we pay our doctors too much. The pediatrician in me rose to the bait! Yes, we do pay physicians more in the United States, even pediatricians, who are among the lowest on the pay scale here. But the comparison is woefully incomplete if we do not consider the different work that physicians do in each country. Because Germany has an oversupply of physicians and no advanced practice providers, physicians do many tasks that in the United States would be performed by others. For example, in Germany it is the physicians rather than the nurses who give most of the immunizations. Thus, the discrepancy in physician salaries makes some sense. That is not to say we have it right in this country: Indeed we don’t, as we preferentially pay for procedures and underpay for cognitive work, particularly primary care.
German health policy leaders have been particularly interested in Minnesota’s approach to integrated care delivery and the creativity we bring to making care better and more efficient. They are aware of U.S. data that show that integrated systems deliver higher-quality care at a lower cost. And they are well-aware that Minnesota stands out with respect to delivering care in an integrated fashion and offering patients value for their health care dollar. Hearing the Germans’ admiration for our system was like having someone tell you how great your little brother is when you think he is just OK most of the time. It makes you take a closer look. Although I am not satisfied with our health care system, it was reassuring to hear its strengths lauded in Berlin. As we work to expand access to health care through better insurance coverage and offer higher-value care in our state and nation, we need to recognize that we have critical components that must be preserved.
Viewing a nation’s health care system through a porthole carries the risks of oversimplification and of misunderstanding. Clearly, there is much that I did not see in Germany and do not understand. I think having universal insurance coverage goes a long way toward improving health and ultimately reducing costs; but there must be more to it. How a nation prepares people to take care of their own health, how it helps them make informed decisions, whether it provides them with access to primary care as well as specialty services, and whether it gives them the opportunity to live in healthy, nourishing environments ultimately defines the health of the people of a state and nation.
Maybe the most valuable lesson learned on my trip to Berlin is how it made me feel about us. Seeing the Germans’ commitment to universal access to quality health care was inspiring and hearing their leaders acknowledge the good in our system left me feeling genuinely optimistic. With the higher education institutions in Minnesota tailoring the education of physicians, nurses, and other health care providers to meet our state’s changing needs; with the strength of our integrated health care delivery systems; with state leaders striving to make policy that increases coverage and improves access to high-value care; with national attention focused on health care reform; with a public rightfully demanding greater value for their health care dollar; and with opportunities to learn from the successes and limitations of other nations; I can’t help but be optimistic about what lies ahead.
Patricia Simmons is a professor of pediatrics and chair of pediatric and adolescent gynecology at Mayo Clinic.