German M.D.s Largely Praise Country's Insurance System

In the late 19th century, Prussian Prime Minister Otto von Bismarck did the German people a great favor. After he united their numerous principalities into one country, he established a universal public-health-insurance system for them. It was the world's first, in fact.

True, the system, established in 1883, originally applied only to low-income workers and certain government employees, but it was gradually expanded to cover most of the German population. And as it became available to most Germans, its coverage also continued to balloon.

During the late 1960s and early 1970s, for example, when West Germany was flush with money, physicians sometimes prescribed automobiles for physically handicapped patients, and public health insurance picked up the tab. Even today, when prescribed cars are no longer a reimbursable expense, German public health insurance still provides a cornucopia of benefits—for example, a spa cure for certain conditions. (See Original article: Most Germans Choose Public Insurance for more information on how Germany's public health-insurance system works.)

Praise From German Psychiatrists

Not surprisingly, German psychiatrists have some good things to say about their system.

For example, when Psychiatric News asked Hannelore Ehrenreich, M.D., a psychiatrist affiliated with the Max Planck Institute of Experimental Medicine in Goettingen, what she liked about Germany's public health-insurance system, she frankly replied: “That we have insurance! There are still countries where there is none, and if I remember correctly, there are quite a few people in the United States who are not health insured. Here, most people are. It is an obligation. I mean, there are some people who might fall through the net, but normally all Germans are obliged to be health insured.”

“Not only do nearly all Germans have health insurance, but health insurance that pays for a broad range of diagnoses and treatments with high standards,” Andreas Stroehle, M.D., director of the psychiatry and psychotherapy clinic at Charite-Universitaetsmedizin Berlin, stated. (Charite-Universitaetsmedizin is one of the largest university medical centers in Europe.)

“Some strengths of the German public health-insurance system are that it makes health care practically free at the point of entry and leaves people without worries that their health care may not be covered,” Stefan Priebe commented. Priebe, a German psychiatrist, currently works in London as a professor of social and community psychiatry at Queen Mary University.

Still other advantages of the system, he said, are that “it provides a balance between richer and poorer states [in Germany] ... and enables a provision of services that are relatively independent from state politics and politicians, but clearly regulated by rules set on national and regional levels.”

Moreover, except in emergencies, one is free to visit the doctors, clinics, and hospitals of one's choosing, Frank Schneider, M.D., attested. Besides being director of the psychiatry and psychotherapy clinic at the University of Aachen, Schneider is president-elect of the German Society for Psychiatry, Psychotherapy, and Neurology.

Finally, Kai Treichel, M.D.—a Berlin psychiatrist who worked as a consultant in London and who studied various European health care systems while obtaining an M.B.A. from Oxford University—likes the fact that physicians in Germany still have the autonomy, under the public health-insurance system, to provide outpatient care as private practitioners. This is not so in the United Kingdom and the Scandinavian countries, he noted. There, most physicians are government employees.

Psychiatric Coverage Generous

German psychiatrists also have some good words for the German public health-insurance system regarding its treatment of psychiatric patients specifically.

“One advantage of the system is that psychiatric patients get the same care that nonpsychiatric patients do and are not discriminated against by the health-insurance laws,” Anne Berghoefer, M.D., a psychiatrist and health economist at Charite-Universitaetsmedizin Berlin, pointed out.

Indeed, the system provides generous mental health benefits, Torsten Fuerstenberg, M.D., of the Institute for Health and Social Research in Berlin, concurred. So did Schneider: “Every psychiatric patient, whether inpatient or outpatient, can afford care.”

For instance, psychotropic medications and psychotherapy are essentially free—only small and income-dependent co-payments have to be paid for them, Schneider explained. Furthermore, the types of psychotherapy covered include not only cognitive-behavioral therapy, but psychodynamic psychotherapy, and even psychoanalysis in some instances, Treichel said.

System Not Free From Criticism

Yet German psychiatrists have some criticism of their system as well.

Since the richest Germans do not have to participate in the public health-insurance system—that is, they can opt out and buy private health insurance instead—their money is not available to help subsidize the health care of the vast majority of Germans, Berghoefer observed.

The government—not the physicians—decides which medical procedures are to be reimbursed under the public health-insurance system, Kathrin Meyer zur Capellen, M.D., reported. She is a psychiatric trainee in a community hospital in Augsburg.

German physicians are not reimbursed all that well by the public health-insurance system, Peter Zwanzger, M.D., director of the psychiatry and psychotherapy clinic at the University of Muenster, opined. (Indeed, an article in the April 24 Healthcare Economist reported that the purchasing power of German physicians' wages is lower than that of American physicians. However, this lower purchasing power is due not just to the amount of money German physicians get from the public health-insurance system, but to the hefty amount of taxes that are withheld from their wages to help finance Germany's numerous social programs, including the public health-insurance one.)

The German public health-insurance system includes “perverse incentives to over-provide diagnoses and therapies, making the system unnecessarily expensive,” Priebe said. It is also less focused on evidence-based care and rational planning than the British public health-insurance system is, he added. And it “requires complex negotiations between insurance companies, service providers, and regional authorities to negotiate budgets,” he pointed out.

And not only are the negotiations complex, but they pit various medical specialists against each other for the money available, Thomas Schulze, M.D., asserted. Schulze, a German psychiatrist, currently works in the United States at the National Institute of Mental Health. “So what it means is, psychiatrists are fighting neurologists, neurologists are fighting surgeons, and so on for the money ... ” he explained. “As a result, many German doctors say that they will only take private patients because they don't want to deal with this hassle anymore. But there aren't so many people with private insurance.”

Yet in Ehrenreich's opinion, one of the biggest weaknesses of the German public health-insurance system is its lack of flexibility. “When you ask for an evaluation of a new therapy, a new program, or whatever [in hopes that the system might reimburse it], you are confronted with a state of knowledge of 20 or 30 years ago,” she said. “For instance, if a new medication is very expensive, but promising for a particular psychiatric condition, but not to the degree that it is a standard treatment, it used to be possible to file an individual-case application. This means that we could ask whether a particular patient could receive it. Nowadays, that is much more difficult.”

Criticism of Psychiatric Coverage

Yes, German psychiatrists also have some negative things to say about how the German public health-insurance system treats psychiatric patients.

For instance, limits on health-care reimbursement in the outpatient sector sometimes keep psychiatrists from prescribing, on an outpatient basis, those psychotropic medications they believe would be most effective for their patients, Joerg Nikitopoulos, M.D., remarked. He is a psychiatrist and health economist at the Central Institute of Mental Health in Mannheim.

Schizophrenia patients are usually not able to earn enough money to meet the level required by law to opt out of public health insurance and to buy private health insurance instead, Schneider observed. Yet private insurance tends to offer better benefits than public insurance does, he said.

Suggestions for the United States

All told, German psychiatrists believe that their experiences with the German public health-insurance system, both pro and con, might help Americans decide where they want to take their own health-insurance system, especially now that health-insurance reform is a hot Presidential-election issue.

“My major critique of the American system is that there are people who can get away without having any health insurance,” said Ehrenreich, who has also worked in the United States. “This ultimately costs the government a lot. My major recommendation is that the United States makes it an obligation for everybody to have health insurance, at least to some degree.”

Although both Germany and the United States are free-market societies, Germans are a lot more “socialistic” than Americans, Schulze observed—that is, they view it as the government's responsibility to provide a panoply of services to people who are less well off, less healthy, or less well educated. As a result, he reasoned, it would be very difficult for Americans, at least for those strongly opposed to government-funded health coverage, to adopt Germany's public health-insurance system in its entirety.

Nonetheless, he ventured, Americans might be willing to adopt at least some aspects of the German system. For example, he proposed, why not start by requiring all employers to pay at least part of their employees' health insurance?

Note to readers: German psychiatrist Kai Treichel, M.D., quoted in this article, is a nephew of the writer. ▪