A study has provoked controversy in Germany because it shows that the country’s healthcare system has two tiers (International Journal of Equity in Health 2008;7:1; doi: 10.1186/1475-9276-7-1).
The study, by the Institute of Health Economics and Clinical Epidemiology of Cologne University, has shown that patients who have statutory health insurance have to wait about three times longer for an appointment with a specialist than members of private health insurance schemes.
The German health minister Ulla Schmidt said that this is illegal, but the president of the German Medical Association, Jörg Hoppe, admitted that there are differences in the service provided to the two groups. He pointed out that with fixed healthcare budgets per quarter provided to doctors by the state health insurance organisations appointments for patients with statutory health insurance had to be delayed for financial reasons; otherwise doctors would have to work unpaid.
About 90% of the German population is covered by statutory health insurance, and the rest, who have higher incomes, have private insurance. Specialist treatment is mainly provided by doctors in their practices and, to a lesser extent, by hospital outpatient departments. A small percentage of the medical practices treat only private patients. Treating private patients is as much as 35% more lucrative.
For the study, 189 specialist practices in the area of Cologne-Bonn were telephoned by people posing as patients who asked for an appointment for an allergy test and a pulmonary function test; a pupil dilation test; gastroscopy; a hearing test; or magnetic resonance imaging of the knee.
The shortest waiting time for patients with statutory health insurance was 6.8 working days for a hearing test (2.2 for private patients), and the longest was 24.8 working days for gastroscopy (11.9 for private patients). On average private patients got appointments three times quicker.
Although the study did not show any difference in the quality of treatment between the two groups, the first author, Marcus Lüngen, director of the Cologne institute, said that the delays constituted a disadvantage.
The main reason for the difference in waiting was the fixed budget of practices, he said. Appointments were delayed to the next quarter when reimbursement was guaranteed. Private patients got preferential treatment because doctors were in competition to attract them.
“All patients profit from this additional income from private practice, because [a doctor] can make investments [in his or her practice],” said Andreas Köhler, head of the National Association of Statutory Health Insurance Physicians, who are responsible for providing outpatient care in Germany.
He denied any difference in the treatment of the two groups and pointed out that quality assessment was more advanced in statutory rather than in private practice.
The Association of Private Health Insurance Companies said that the findings were the natural consequences of the government’s rationing policy in health care. A spokeswoman of the largest statutory health insurance company, AOK, pointed out that their members were guaranteed short term appointments. If patients fail to arrange one themselves, AOK arranges the appointment.