As a participant in a seminar hosted by the Minnesota Urological Society last weekend, I read some curious things about the German health system in a recent commentary  (“Single-payer health care: What it is, what it isn’t,” March 17).

I am surgeon in chief of a department of urology in a German public hospital. I am involved in daily discussion about the German medical system.

It is definitely not a single-payer system.

The German health system is more complex than it seems, and is a multi-payer system.

Every working person has to pay about 15 percent of his or her salary for health insurance. There are more than 130 health insurance companies. About 10 percent of the population is, as we call it, privately insured. You’d have to earn more than 46,000 euros (about $60,000) to have the right to be a “private patient.” The unemployed and homeless are taken care of by the state, i.e., taxpayers.

The market does not dictate prices at all — it is the DRG system. Hospitals are reimbursed according to “diagnosis related groups” — a system that classifies all diseases into about 365 groups.

How much the hospitals get paid for a patient’s stay depends on the complications and comorbidity index. There is a bit of competition to attract as many private patients as possible, and the highest DRGs, to beef up the budget of a hospital. But a government regulation will cut any surplus that exceeds 15 percent for the whole hospital.

The DRG system has led to a totally ­economics-oriented medical system, with all its pitfalls. Private patients risk overdiagnosis and overtreatment because they are the system’s secret money source. Hospitals can charge them up to two or three times more than for a regular patient. The nonprivate patient has longer waiting times and does not always see the best specialists.

Between 60 and 70 percent of the public hospitals in Germany are predicted to go bankrupt within three or four years. The health insurance companies gathered more than 15 billion euros on their side. The hospitals have to finance their own buildings, which were formally taken care of by the “Laender” (the States of Germany).

When yearly negotiations with the doctors union result in a 2.6 percent rise in wages, the hospital is forced to raise the money by its own means — and puts pressure on the heads of the medical departments. At present, there is an ongoing discussion about success-oriented contracts. The more a surgeon operates, the more he will earn, and the hospital will have a chance to survive.

Would you want a decision about an operation to driven by economic reasons or medical reasons? Should a patient really be an opportunity for economic improvement for a hospital? What does a doctor do when his administration tells him to get more profit out of his department?

There are still about 20 percent too many hospitals in Germany. The government will wait for the self-clearing process, a “survival of the fittest,” which somehow makes sense economically. After bankruptcy of the hospitals, the government will decide to support the system with tax money and will install more and more central control, hopefully for the good of the patients. Central control exists already through a national institute on quality control in medicine, which will definitely be strengthened in the near future.

The former medical system in Germany did function by the “solidarity” principle, but too many people did not pay in and took out too much, a situation worsened by reunification, unemployment and immigrants.

The state-driven socialistic system of the former “German Democratic Republic” — the formerly communist part of Germany — was ruined by the lethargy of unmotivated doctors who hardly had any means.

Our future will require an evidence-based system, with patient-oriented medicine and basic medical care for everyone, along with optional services.

Everybody should be able to have a car. Not everyone can have a Porsche.


Alfons Gunnemann is surgeon in chief of urology at Klinikum Lippe, a hospital in Detmold, Germany.