Utilization of medical services in Germany—outline of statutory health insurance system (SHI)

Abstract

In Germany, the utilization of medical and health services is largely governed by structural and statutory provisions. These provisions are briefly described in the chapter to ensure a better understanding of relationships within utilization research and within the care sectors presented in this book, particularly for readers who are not familiar with the German system. The statutory health insurance (SHI) system with the general regulation principles and expenses as well as the structures of the outpatient and inpatient care and of long-term nursing care in Germany are presented. As regards the influence of system-related factors on utilization behavior, numerous health services are covered by health insurance, but SHI-financed services must be included in the catalog of services, which is fixed by law. Services are included in the catalog on the basis of criteria such as being evidence-based, necessary, and economical. The majority of health-care services are billed by the service provider directly to the insurance without involving the insured, who pay monthly contributions. A few services must be paid for by the insured or require co-payments. This may influence the utilization of necessary medical services, especially by patients of low socioeconomic status. In Germany, the range of available services and the frequency of actually provided services are strongly physician-dominated since many health-care services are restricted to physicians. In some cases, approval by the health insurance is required in addition to a physician prescription, a situation that may further affect utilization.