By John Carruthers, assistant editor, August 01, 2013
As Europe’s largest economy and the world’s first country with a national health insurance system, Germany balances the demands of universal coverage with the challenge of an aging population and low birth rate. For German dermatologists, that means a projected gap in physician supply and issues in both urban and underserved rural areas that closely mirror the challenges of declining reimbursement and difficulty accessing new treatments faced by U.S. dermatologists.
Universal coverage and specialist access
In Germany, health insurance is mandatory for the entire population. As such, each citizen has access to both hospitals and physicians in private practice. For citizens with higher income, estimated at approximately 10 percent of the population by private practice dermatologist Matthias Möhrle, MD, there is the option to leave the public plan and purchase private insurance, with one’s employer covering roughly half the cost of the plan. These plans are for those with full-time employment who earn more than EUR 4,350 per month (about $6,000) in gross salary. The option allows people on private insurance to lower their premiums and receive reimbursement for a year of not using the insurance. In addition, some plans cover a broader array of diagnostic procedures and therapies. In both scenarios, he said, direct access to specialists is possible for patients without a referral. Many hospital dermatology departments, however, require a referral from an outside dermatologist, as they employ highly specialized dermatologists. [pagebreak]
The insurance system is funded through a combination of employee contributions, employer contributions, and government subsidies that vary based upon income level. In most cases, according to dermatologist Christoph Löser, MD, director of a community-based teaching hospital in the Rhine Valley, all costs related to serious illness are covered.
“You will never hear that anyone is not able to afford’ necessary treatment in Germany. All sorts of specialists are easy to access,” he said.
The health system operates on a decentralized model, with private practitioners providing ambulatory care and independent hospitals (the majority of which operate as nonprofits) providing inpatient care. Dermatologists operate far more frequently in hospitals in Germany than they do in the U.S. due to the reimbursement system.
Regulation of physicians in Germany is handled at the institutional level, which both Dr. Löser and Dr. Möhrle say creates a great deal of conflict. Rather than a national body, regulation is largely handled by the institutions that employ physicians.
“Medical doctors are a so-called free profession,’ which means most regulation is done by our own institutions, not by the state. This is sort of democratic, but there is conflict of interest and lobbying involved regarding different specialties and differences between ambulatory care which is allowed to be given by hospitals as compared to service by private practice,” Dr. Löser said. “Regarding dermatology, especially in skin cancer treatment and follow up, current regulations regarding the level of care that ambulatory dermatologists are allowed to deliver can cause considerable problems in providing the quality of care patients are entitled to.” [pagebreak]
In addition, Dr. Möhrle said, getting into private practice can prove difficult for many physicians because ambulatory care is reimbursed at a far lesser rate than inpatient care. Inpatient services rendered to public insurance patients are reimbursed through a system of diagnosis-related groups, while ambulatory care is paid for through a mixture of pre-paid capitated sums, lump treatment sums, and fee-for-service determined by the country’s point-based scale. Physicians’ capitation volume is tracked quarterly, and the volume itself varies between specialties, regions, and patient morbidities.
“The access to go into private practice within the public health system is limited. In most areas a doctor willing to go into practice has to succeed and buy an office from a colleague going into retirement. Ambulatory services offered by hospitals are better remunerated than in private practice. And in addition, hospitalization is far better remunerated, such as for surgery in skin cancer patients,” Dr. Möhrle said. “The ambulatory treatment of standard dermatologic patients with the normal public insurance is not cost-effective in private practice without fees of about 15 Euros per trimester regardless of how often the patient is seen. Dermatologists compensate for this by surgical procedures, microbiological testing, or allergological testing, which are covered by the public insurance, or by cosmetic procedures, which are paid for by the patients themselves and not by public insurance.” In addition, Dr. Möhrle said, the payment values in the German system have not been updated to reflect the cost of providing care since 1996. [pagebreak]
Demographic shifts and challenges to delivery
While access to both primary and specialist care is free to most anyone, the demographics of Germany society will pose ever-greater challenges to efficient and effective care delivery, according to Dr. Möhrle. With a low birth rate and an aging population (see sidebar) as well as low net immigration numbers, the social welfare system, including health care, will be under increased pressure. In addition, Dr. Möhrle said, the incidence of skin cancer is projected to rise significantly as the population ages.
“Facing the demographic evolution of the German population, dermatoses of the elderly will significantly increase, including rising numbers of skin cancer,” Dr. Möhrle said. “There will be a lack of physicians in the upcoming years. This shortage of doctors will be more pronounced in rural areas, and for general medicine rather than for specialists in cities and in more developed regions.”
In attempting to deliver more efficient care, Dr. Möhrle has found that the smaller team in his relatively new private practice setting allows him the autonomy to make quicker decisions and offer better and more efficient treatments.
“When I compare the work in private practice with that in a university hospital, I would say that a more personal contact, a better organization, and a smaller and qualified team makes patient care more efficient,” Dr. Möhrle said. “In dermatologic surgery and vein surgery the use of tumescent local anesthesia, endoveinous therapy, and micrographic surgery is quite efficient.” [pagebreak]
Unique therapies, increased specialization
As inpatient dermatology is much more pronounced in Germany than it is in the U.S., dermatologists training there have a unique perspective on the evolution of skin diseases, according to German-trained Boston University dermatologist Thomas Ruenger, MD, PhD.
“That is a big plus for the specialty and for specialty training because it gives the trainees opportunity to see skin diseases evolve day to day and see how their patient gets better there,” Dr. Ruenger said. “A U.S. resident can prescribe treatment and see a patient back in six weeks. How quickly something has improved cannot be monitored the same way.”
In addition, Dr. Ruenger said, residents training in a specialty receive far more autonomy than their U.S. counterparts.
“Residents in Germany are not as much regarded as trainees. They are hired as assistant physicians and learn by doing. There is not as much of a commitment to formally training those assistant physicians, so they do this by taking on many more responsibilities than the residents in the U.S. do,” Dr. Ruenger said. “In the U.S., every decision is still supervised by an attending. That attending sanctions every decision, which is much different in Germany. There, assistant physicians take on that responsibility much earlier.” [pagebreak]
One of the significant differences in technique between German and U.S. dermatologists is the practice of Mohs micrographic surgery, according to Dr. Möhrle. In Germany, dermatologists utilize microscopically controlled surgery on paraffin-fixed sections, known colloquially as “slow Mohs.” This involves a patient’s wound being left open under a secure dressing for at least a day while the slides are analyzed. This can be a multi-day process of surgery and analysis. The process allows dermatologists to better analyze the roots of some tumors that might be difficult to see on regular frozen slides, he said. This includes lentigo maligna, sebaceous carcinoma with intraepdiermal pagetoid spread, and acrolentiginous melanoma in situ.
In addition, the responsibility for treating skin cancer is much more incumbent upon dermatologists.
“Dermatologists in academic centers also treat advanced skin cancers with chemotherapy, with immunotherapies, and don’t refer those advanced cases to oncologists,” Dr. Ruenger said. “Oncology for skin cancers and skin malignancies is handled by the dermatologists. That’s an experience that American dermatologists do not have.”
Germany at a glance
Population: 81,147,265 (worldwide rank: 16)
Gross domestic product (GDP): $3.123 trillion (16)
Age demographics: 0-14 years old, 13.1 percent; 15-64 years, 66.1 percent; 65+, 20.9 percent
Median age: 55.7 years
Annual death rate: 11.7/1,000 (36)
Life expectancy: 80.32 (28)
Health expenditure: 11.6 percent of GDP (11)
Physician density: 3.53/1,000 patients
Source: CIA World Factbook, 2013
About the contributors
Christoph Löser, MD, is the deputy director of a community-based teaching hospital in Ludwigshafen.
Matthias Möhrle, MD, works in a private dermatology practice in the town of Tuebingen. Previously, he worked at the University Hospital in Tuebingen for 18 years.
Thomas Ruenger, MD, PhD, is the professor and vice-chair of dermatology in the department of dermatology at the Boston University School of Medicine. A native of Germany, he trained in that country before coming to Boston University in 1999.