Le système de santé allemand : vers une plus grande responsabilisation de l'ensemble des acteurs (version anglaise)

Frédéric Rupprecht, Bruno Tissot, Frédéric Chatel

Description

Confrontée au dérapage de ses dépenses de santé, mais décidée à conserver l'héritage bismarckien d'une assurance-maladie au caractère fortement protecteur, l'Allemagne a entrepris de nombreuses réformes depuis dix ans. Dernière étape, la troisième réforme Seehofer a marqué un tournant en 1997. Après avoir, dans un premier temps, institué des mesures d'urgence afin de maîtriser les coûts, puis entrepris un certain nombre de réformes structurelles, les autorités ont, en effet, décidé de se désengager quelque peu du système de santé. Elles entendent promouvoir une plus grande responsabilité parmi ses acteurs, à savoir les caisses d'assurance, les prestataires de soins et les patients, moins par une régulation globale que par la mise en place d'incitations d'ordre microéconomique. Si le récent changement de gouvernement en octobre 1998 s'est traduit par la disparition de certaines mesures et un plus grand contrôle des dépenses, a priori à titre provisoire, ces évolutions de fond ne devraient pas être remises en cause.

Sujets

• INSEE
• Santé
• Europe
• Monde

Informations

• Publié par: insee
• Nombre de lectures: 46
• Langue: English

Extrait

German Healthcare System:
Promoting Greater
Responsibility Among
All System Players*
Frédéric Germany has been faced with escalating healthcare expenditures but is
Rupprecht, determined to preserve the Bismarckian legacy of a highly protective
Bruno Tissot, sickness-insurance system. To this end, it has undertaken many reforms in the
and Frédéric past decade. The latest wave—the third Seehofer reform in 1997—marked a
Chatel** turning-point.
After a first set of emergency measures to control costs, followed by a series of
structural reforms, the authorities have now decided on a partial disengagement
of the State from the healthcare system.
Their aim is to promote greater responsibility among its players—the insurance
funds, healthcare providers, and patients—less by an overall regulation than*Originally published as
“Le système de santé through new microeconomic incentives.
allemand: vers une plus
grande responsabilisation
de l’ensemble des While the October 1998 change of government has resulted in the abolition ofacteurs,” Économie et
Statistique, no. 318, 1998 some measures and in tighter spending controls (described as provisional), the
- 8, pp. 17-38.
basic scenario outlined above is unlikely to be called into question.
**At the time of writing,
Frédéric Rupprecht and
Bruno Tissot were on the
staff of the Forecasting
Directorate (DP) of the
French Ministry of
Economy, Finance, and
Industry; Frédéric Chatel ermany is one of the OECD countries with the A German patient spends 10%
was a student at the École
Nationale de Statistique Ghighest medical consumption. Moreover, it is more on health than a French patient
et de l’Administration experiencing a strong uptrend in healthcare expen-
Économique (ENSAE).
ditures—partly due to specific local factors such as
reunification and the existence of a dependency-in With 10.4% of its GDP going to pay for healthcare-
surance fund in the Social Security system. Yet the services, Germany is one of the countries that
Names and dates in
Germans do not seem to be in significantly better devote the biggest share of national wealth toparentheses refer to the
bibliography at the end of health than their neighbors. healthcare. In 1997, each German spent about
the article.
INSEE Studies no. 42, January 2000 1Table 1
A decade of reforms in the German healthcare system*
Year Name of reform Main features
1988-89 Blüm reform Reform of the pharmaceutical sector: Festbetrag
1993-95 Seehofer reform I Emergency measures to contain healthcare spending: macroeconomic controls
Introduction of flat-rate pricing for hospital procedures;
1995-96 Seehofer reform II
sickness-insurance funds opened to competition and restructured
1997 Sparpaket New emergency package: increase in co-payments
Sharp increase in co-payments; overall spending
1997-98 Seehofer reform III
caps replaced by individualized caps; greater competition between funds
*For more details on these reforms, see appendix.
USD2,300 on healthcare (in purchasing power The rise in German healthcare spending in recent years
parity terms): this is 10% more than, for example, is also due to specific local factors such as reunification
the French average. Among the industrialized and the creation of a dependency-insurance fund in the
nations, the United States is the only one to spend Social Security system.
more on healthcare per capita than Germany
(OECD Health data base).
Reunification offers
only a partial explanation of healthcareDespite a series of major reforms (table 1),
Germany is experiencing a rather steeper uptrend spending growth
in healthcare spending than its partners. The
weight of medical expenditures in GDP rose from Reunification has led to a substantial rise in
5% in 1970 to over 10% in 1997—a much bigger healthcare spending as a share of GDP. According
rise than in other predominantly public systems to the OECD, the percentage rose from 8.7% in
such as those of France and the U.K. (chart I). 1990 (former West Germany only) to 9.4% the
1Again, only the U.S.—where most healthcare following year (reunited Germany). Despite their
coverage is provided by the private economic lag, the new eastern Länder immediately
sector—registered sharper growth. The expansion benefited from the high level of medical coverage
of the healthcare-spending share of GDP appears to in the western part. In particular, the new Länder’s
be a common feature of developing countries, wages and hence social contributions lingered well
implying that health is a “superior” good (L’Horty, below those of western Germany. In 1993,
Quinet, and Rupprecht 1997). But it is not healthcare spending accounted for 14.5% of GDP
inevitable: starting from its high 1980 level, in the new Länder—a share close to that of the
Sweden has trimmed the percentage of healthcare U.S.—versus 8.4% in the old Länder, a rate lower
expenditures in GDP. than France’s (Schneider 1995). It would thus
seem logical to attribute part of the growth in
Chart I
Germany’s healthcare expenditures since 1990 to
National healthcare expenditures
reunification. Since 1993, however, the trends
have reversed. In the new Länder, medical
expenditures have leveled off or actually fallen as a
% of GDP 1970 share of GDP; in the old Länder, they have
198014.0 accelerated again after the dampening effects of the1990
12.0 1997 Blüm and Seehofer I reforms. Overall,
10.0 reunification largely explains the sharp rise in
spending in the early 1990s (especially in8.0
GDP-share terms), but fails to explain the6.0
persistence of the uptrend since approximately
4.0
21994 (table 2).
2.0
0.0
Germany United States FranceUnited Kingdom
1 In 1988, the ratio for then West Germany was 9.4%. The Blüm
reform substantially reduced the ratio in 1989 and 1990.
2 In the remainder of the article, we will not distinguish between old
Source: OECD Health data base, 1998 and new Länder: “Germany” will refer to reunified Germany.
2 INSEE Studies no. 42, January 2000The introduction of dependency insurance in 1995 habits—seems comparatively unhealthy: for
has increased the demand for benefits now better example, alcohol consumption was 14 liters per
reimbursed by the Social Security system, such as capita and per year in 1991, versus less than 9 liters
residential care in paramedical institutions and in Canada, the United Kingdom, and Japan.
specific care for people with disabilities. In some
cases, benefits previously granted in kind are now International comparisons published by the French
paid in cash, particularly to members of dependent Health Ministry’s Office of Statistics, Research,
persons’ families. and Information Systems (Service des Statistiques,
des Études et des Systèmes d’Information: SESI)
The rise in healthcare spending since the early confirm these results (SESI and DIRIS 1998).
1990s generated large deficits for the German Among the countries studied, Germany ranks last
sickness-insurance fund in 1991, 1992, 1995, and for the comparative rate of overall mortality, while
1996. These led to an increase in contributions to France ranks first. Cardiovascular diseases account
finance the additional benefits, and new insurance for almost half the deaths in Germany, compared
reforms in 1995 and 1997 (see appendix). In the with about one-third in France (table 3-B). The
medium term, the upward drift in German reasons for these disparities include the usual
healthcare spending may gain momentum because pathogenic behaviors: smoking, bad diet, and lack
of population aging. The increase in the number of of exercise (SESI and DIRIS 1998). Germany is,
elderly (and not just longer life expectancy) would with the United States, the country with the
cause healthcare spending to rise by 1.5 points of smallest drop in the mortality rate from
3GDP by 2030 (OECD 1997). cardiovascular diseases since 1980—in a period
when a large share of the decline in this rate in the
developed countries has been achieved through
Health conditions not significantly healthcare-system improvements such as better
better in Germany than elsewhere screening for diabetes and hypertension, and
surgical advances. In other words, Germany’s poor
Despite the rise in spending, the Germans do not performance in the cardiovascular statistics is
seem to enjoy significantly better health than other unquestionably due to individual behavior over
industrialized nations (table 3-A). The number of which the healthcare system has little influence,
years of potential life lost is rather high, and but also to the system itself, which is incapable of
Germany ranks last in Europe for life effectively curtailing the consequences of that
expectancy—both male and female. On balance, behavior. These findings are corroborated by other
these figures are far from satisfactory, especially summary indicators of the impact of the healthcare
given the volume of healthcare spending in system on health status. In sum, German
Germany: what is more, the figures are distinctly expenditures do not yield better health conditions
worse