Germany: An overview of the primary, secondary and tertiary care structures

Healthcare spending in Germany as a percentage of GDP in 2015 was 11.08%, equivalent to €4,029 per capita. Its healthcare system is largely financed by a statutory health insurance program, facilitated through over 120 public health insurance funds (Krankenkassen) that reimburse contracted public and private sector providers.

This article will provide an overview of the organization, volumes, and trends in Germany’s primary, secondary and tertiary care structures.

Primary Care

  • Approximately 3.8 (per 1000 population) physicians provide primary and secondary care in Germany. This is just above the EU15 average. Nurse volumes are also above average.
  • Most of the ambulatory care (in the primary and secondary sector) is provided by private physicians (Niedergelassene Ärtzte).
  • Around 55,800 GPs are accredited by the Statutory Health Insurance fund.
  • Patients are free to choose whichever primary care provider they wish.
  • Germany has one of the highest consultations per resident in the world.
  • GPs have decreased in volume by 10% over the last 10 years. Particular concern for shortages are present in rural areas. Insurance funds identify 10% of the health jurisdictions as underprovided.
  • Primary care is considered expensive, not very efficient and one of the areas opportune for reforms, regarding innovative methods and technologies for optimization.
  • High admission rates in hospitals for chronic conditions are attributed to a lack of organization in the primary care sector to care for long-term cases, e.g. congestive heart failure and diabetes.

Secondary Care


There are about 1,700 hospitals with a total of 456,800 beds.

  • 460 are publicly owned.
  • 591 are private non-profit hospitals, and operate under the same regime as public hospitals.
  • 577 are private for-profit hospitals; mostly part of hospital chains


  • Around 65,5000 specialists are SHI-accredited.
  • Reimbursed specialist care is only possible with a referral; however, referrals are said to be easy to obtain, leaving relative freedom to the patient to choose their specialist.
  • A trilateral committee consisting of a Land, hospital and sickness fund representative, decides over the number of beds and hospitals needed for a given region.
  • Land hospital plans decide over investments to be made in hospitals, and further rule how many beds of which specialty field should be allocated.
  • Since 2005 there is a 60% increase of outpatient services. German hospitals are gradually adopting more outpatient services as part of integrated care tracks and national disease management programs.
  • Since 1990:
    • Public hospital volumes have decreased by 35%
    • Private not-for-profit hospitals have decreased by 10.5%
    • Private hospitals have increased by 135%
  • University hospitals dedicate 5-15% of their beds to private patients.
  • Non-core activities are increasingly outsourced to commercial providers, e.g. laundry, catering, lab work, etc.
  • Hospitals operate in a competitive context; they need patient and admission volumes which lead to a race between hospitals to obtain the highest specializations and the greatest patient shares.

Secondary Care data (2014)

Public hospitals 456
Private not for profit hospitals 586
University hospitals 35
Military & Police hospitals 5
Private for profit hospitals 573
Total nr of acute hospitals 1,655
Hospital beds 456,793
# OR’s (Excl Delivery Rooms, ER intervention rooms,…) 8,275
# ICU beds (Excl Neonatal beds) 26,472
# REC beds (equipped positions only) 11,009
# Hospital Admissions/in-patient (m) na
# Anesthesia’s  (m) na
# Specialists 220,613
# General (practitioners) 43,157
Occupancy Rate (hospital beds) 77,4
Average Length of Stay (days) 7,3
Primary Care Medical Centers na
Tertiary Care Institutes na

Tertiary Care

Long-term care
  • Long-term care (LTC) is financed through statutory long-term care insurance, which is a combination of mandatory private care insurance specifically for long-term provisions and mandatory social care insurance.
  • Investments for inpatient (and sometimes ambulatory) LTC infrastructure are made by the Länder.
  • Ambulatory care is paid for through fee-for-services; inpatient care is paid for per diem.
  • LTC under SHI is only available upon application.
  • Approximately 4% of the population benefits from LTC insurance benefits.
  • Beneficiaries can choose between:
    • A monetary benefit
    • Domestic nursing care
    • Nursing home care
    • Care needs are categorized into 3 different levels, depending on the degree of care needed.
    • Around 65% of outpatient long-term care institutions are owned by private for-profit parties, 33% by non-profit groups, and 3% are public.
Rehabilitative care
  • Is a statutory right under SHI; the patient pays a copayment of €10 for maximum 28 days a year.
  • State coverage includes medical, non-medical and financial support.
  • In order to obtain SHI rehabilitative care, the given physician must contact the SHI on behalf of the patient and verify the eligibility of the patient for such care. Accordingly, the respective Krankenkasse of the patient will decide over the duration and scope of the rehabilitative care.
  • Only recognized rehabilitation facilities may provide SHI-reimbursed care.
Geriatric care
  • There are approximately 800 geriatric clinics in Germany.
  • There is a particular type of rehabilitative care called ‘geriatric rehabilitation’, created to provide a wholesome care package addressing the needs typical of the elderly (+70 yrs).
    • It is expensive, not widely known about, and often not covered under SHI.

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