In this slideshow, Dr Caroline Wagner, Research Fellow, Scientific Institute of Techniker Krankenkasse (TK) for the Benefit and Efficiency in Health Care (WINEG), Germany, draws on case studies in Germany of large and small hospitals to discuss whether either is better. Dr Wagner spoke at the Nuffield Trust European Summit 2014, which was supported by KPMG.

1. Big Hospitals versus Small Hospitals
- is Either Better?
European Health Care Summit:
Future organization of hospital services
21 January 2014 | Nuffield Trust, Brussels
Dr. Caroline Wagner

2. Statutory Health Insurer: Techniker Krankenkasse
• Founded 1884 in Leipzig for technicians
• 8,68 million insured - currently largest SHI
• Annual growth (2013): + 284,000 insurants
• 12,857 employees and 247 branches
• Total Budget: 21,3 billion EUR
• 27% for hospital care (5,7 bil. EUR )
Increase of 9.3 % (2013 to 2014)
• Compulsory uniform contribution rate for
all statutory health insurers:
15.5% of tax income up to 4.050 Euro
 7.3 % borne by employer
 8.2 % borne by employee

3. Statutory Health Insurers in Germany are
public bodies - but self-administered
Private Company
Public Body with
Governmental Body
Self-Administration
For-Profit Health
Insurer
Statutory Health
Insurer
Ministry of Health
1994: 1,162
2004: 280
2014: 132
Reduction of statutory health insurers:
89% in the last twenty years

4. Mix of Public and Private Health Insurance
Private Supplementary
Health Insurance
Statutory Health Insurance
70.2 Million SHI Insurants = 89%
Possibility to opt out for employees with
an annual income more than 48,600 €
Statutory Long Term Care
Insurance
Private
Health
Insurance
8.5 Million Insurants
= 11 %
Private Long
Term Care
Insurance

5. Players: Statutory Health Insurance - Health Care
• Service guarantee
• Mix of collective and
selective provider
contracts
Health Care
Provider Market
• Free choice of insurer
• Open enrolment
• Income related contribution shared
between employer and employee
• Free co-insurance for family
members
• Risk adjustment
• Comprehensive benefit package
• Benefits in kind
Insurers
Health Insurance Market
Care
providers
Regulatory framework
• Federal government
• State governments
• Joint self-government of
insurers and providers
Insured
• Free choice of provider
• No enrolment with GPs
• Small Co-payments: e.g.
hospital care 10 EUR per
day up to 28 days

6. Statutory Health Insurance Expenditures in Germany
Largest Share: Hospitals
Dentist,
7%
1. Hospitals
2. Pharma
3. Physicians
4. Dentist
60 bil. EUR
30 bil. EUR
28 bil. EUR
12 bil. EUR
Physicians,
16%
Hospitals,
36%
Pharma,
17%
Others,
24%
Source: Ministry of Health

7. Dual Funding of Hospitals
1. Statutory health insurance funds and
Statutory health insurance funds bear the running costs
i.e. via renumeration of the provided health services
2. Federal states "Bundesländer"
Federal states finance capital investments based on state hospital plan
State subventions for new building possible via investment programmes
Subventions vary by state
Dual funding sources for hospitals =
separation of decisions about capacities
and responsibilities for costs
7

8. Basic Types of hospitals in Germany
1. Acute hospitals (including university hospitals)
2. Prevention and Rehabilitation hospitals
Follow-up care and after surgery care
Rehabilitation and prevention
No contracts with statutory sickness health insurers
1.233 facilities (2011)
3. Psychiatric hospitals
Traditionally specialised in psychiatric treatments
Psychosomatic medicine
Now also often covered by acute hospitals
8

9. Interlocking of inpatient and outpatient sector
• 1993 Gesundheitsstrukturgesetz i.e. Health Care Structure Act)
Opening up of the hospitals for outpatient surgery
Improvement of collaboration primary care and hospital physicians
Currently 1,247 hospitals with ambulatory operations
• 2003 GKV Modernisierungsgesetz i.e. Health Care Modernisation Act
New contracts options: outpatient treatments in hospitals,
particularly disease management programmes, chronic diseases
• 2007 GKV Wettbewerbsstärkungsgesetz i.e. Competition Fortification Act
Simplification of access to outpatient treatments concerning highly
specialised care and complex as well rare diseases
• 2012 GKV Versorgungsstrukturgesetz i.e. Structure Provision of Care Act
If co-operation exists, statutory oupatient doctors are entitled to
undertake ambulatory treatments and operations in hospitals
9

10. Number of Hospitals in Germany 1992 - 2012
2,250
2,200
2,150
2,100
2,050
2,221
2,197
2,166
2,139
2,104 2,087 2,083
2,084
2,064
2,045
2,000
2.017
1,950
1,900
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Source: Federal Statistics Agency

11. Beds, Utilisation, Cases and Length of Stay
Years
Beds
(million)
Utilisation
(%)
Cases
(million)
Length of
Stay (days)
2002
547.3
80
17.4
9.2
2003
541.9
78
17.3
8.9
2004
531.3
75
16.8
8.7
2005
523.8
75
16.5
8.7
2006
510.8
76
16.8
8.5
2007
507.0
77
17.2
8.3
2008
503.4
77
17.5
8.1
2009
503.3
77
17.8
8.0
2010
502.7
77
18.0
7.9
2011
502.0
77
18.3
7.7
2012
501.5
77
18.6
7.6

12. Hospitals in Germany by Ownership
Public
2012
24% (601)
2002
33% (817)
1992
Charity based
28% (719)
44% (697)
34% (877)
43% (1062)
0%
Private
37% (950)
33% (527)
23% (369)
50%
100%
Source: Federal Statistics Agency

13. Hospital Market in Germany - Size
Number of
Employees
Number of
Hospitals
Turnover
(m EUR)
Fresenius/Helios
70.000
117
5.500
Asklepios
34.000
150
2.980
Sana
26.000
48
1.790
Rhön
15.000
10
1.000
Schön
8.500
17
591
Paracelsus
4.800
29
345
Municipal Leader:
Vivantes (Berlin)
14.391
100
900
Charitable Leader:
St. Franziskus-Stiftung
(Münster)
11.212
13
645
Private Leaders:
13

14. Thank you for your attention
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