A psychiatrist (and friend) from Germany responded to one of our recent blogs about the healthcare exchanges set to launch in 2014. He found it bizarre that Americans without health insurance will have to pay a small penalty, which will go up over time.

-Since I am German, it is always hard for me to understand the problems that you have with your existing (and hopefully changing) healthcare system. It would not occur to anyone here in Germany to penalize someone who doesn't have health insurance; not having health insurance is punishment enough!

My friend, Peter Schraermeyer, is a supporter of his own country's health system, but recognizes its flaws, including some of the same issues of overutilization and lack of evidence-based medicine that we experience in the United States.

Schraermeyer pointed out that by law everyone must have the same minimum level of health insurance in Germany. Each worker chooses a sickness fund (insurance risk pool), as opposed to the U.S. system, in which employers choose plans for workers. German employees and retired people earning less than 52,200 Euros (about $68,000) a year are insured under the public system, but those above that income can opt out and purchase private, commercial insurance. Once Germans choose private insurance, they cannot change back to public insurance unless their salary falls below 52,200 Euros, they lose their job, or they fall under a few other special circumstances. The cost of government insurance is 15.5 percent of eligible gross salary up to a monthly income of 3,937 Euros (about $5,119), paid half by the worker and half by the employer. Private insurance is generally more expensive than the public option for middle-aged and older people, but less for young people; it can also provide richer coverage.

However, lately private insurance premiums have increased so sharply (by as much as 50 percent) that some Germans with private coverage are seeking to switch to the national plan (and there are a few loopholes that allow that).

Premiums are rising in Germany for the same reason they have been rising in the U.S. increased costs and utilization (including unnecessary utilization). Schaermeyer notes that providers take advantage of richer benefits (just as they do in the U.S.):

-The hospitals and doctors in Germany are happy to have any patient who is not insured by the government, because that means the patient is privately insured and that generates much more money for the providers, notes Schraermeyer. Here one speaks about a two-class medicine system, whereby the second class, or government insurance, is perfectly fine; the first class, or private insurance, provides more luxury but can also be harmful (or at least unpleasant). Physicians and hospitals taking advantage of private insurance may offer up therapeutic options that are totally unnecessary. Their motive is monetary rather than altruistic.

Schraermeyer speaks as a patient and a physician. He knows colleagues who have gamed the system, and he knows of patients who undergo unnecessary treatments. Still, given a choice, he'll stick with Germany's healthcare system rather than that of the United States.

-When you ask whether the German system is good, the answer is jain ja und nein, or yes and no, Schraermeyer said. What is important above all for the patient is that one doesn't hear nein when he or she is sick, and that therapeutic decisions are made in accordance with evidence-based medicine, and not to meet certain revenue goals.

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