Like many other countries in the world, Germany has a two-tiered health-care system: statutory (public) insurance as the default for everyone and private insurance for those who can otherwise afford it. And like the same, respective systems the world over, the premiums are income-based: your actual income for the statutory insurance and your health status and therefore the income risk for the private insurance companies.
And then there’s something weird and complicated between those two tiers for German civil servants …
Officially we’re privately insured, but, perhaps in a nod to the statutory insurance where the employers pay half the premiums of their employees, the government (as our employer) takes over 50% of the costs. (Actually it’s a minimum of 50% and goes up depending on how many dependent kids you have, but let’s leave this unnecessary complication to the admin types, shall we?) However, instead of the simple, efficient solution of also paying 50% of our premiums, they pay 50% of our actual health-care costs through something relatively untranslatable called the Beihilfestelle.
(Ok, of course Beihilfestelle is translatable. But it becomes either something nondescript and nonspecific like “aid office” or, according to Google, something utterly bizarre in the form of “lubricate office”. So I’ll just stick with Beihilfestelle.)
Now, I have absolutely no idea what the benefit to this system is instead of creating jobs for a good number of (suitably lubricated) admin types and a good deal of unnecessary work for the patients. At least here in Germany, privately insured patients get billed directly by the doctor and then get reimbursed by their insurance company for what they’ve already had to shell out. But, because of this half-and-half system, civil servants in Germany practically have two insurance companies and so double the amount of paperwork. Accordingly, all the bills come in duplicate, the original and a copy, with the only distinguishing feature of the latter being that it has the word “copy” on it. (Seriously.) The original goes to the private health-insurance company and the copy goes to the Beihilfestelle. And, for some reason, this sorting arrangement is very important, because from personal experience I know that both the private health-insurance company and the Beihilfestelle will refuse to reimburse you if you send them the wrong version.
Rumours abound as to the privileges of being privately insured, from being able to jump the queues to having separate entrances to avoid having to mingle with the low-income diseased crammed into the waiting areas, but I haven’t seen that much of a benefit other than having more procedures covered. Haven’t even enjoyed the luxury of a private hospital room (or, more to the point, my former hospital roomies haven’t enjoyed me having this luxury on behalf of my snoring) because the Beihilfestelle, being part of the government where unnecessary waste is naturally frowned upon, won’t pay for it. Instead, the real benefit to private insurance seems to lie mostly with the doctors.
You see, the really interesting, if painful, part of being privately insured comes from being billed directly. As such, you get to see what everything costs, from the proverbial tongue depressor on up, as well as how the doctors “massage” the bills slightly to make their bottom lines that little bit healthier too. (More rumours, but you do hear whispers from time to time that the only reason that most doctors in Germany manage to stay out of the red is because of the private patients.) In fact, the payout seems to be that good that some doctors, either the really good ones or the ones with really expensive car payments, only take private patients.
Most of the financial make believe is relatively benign. For instance, just saying hello automatically makes the doctor about 10 EUR richer. Officially it’s listed on the bill as a “consultation”, but I’ve paid for more than enough consultations that were nothing much more than mere felicitations. And then during the corona pandemic, each bill had an extra surcharge of 6.41 EUR for the “necessary preventive and protection measures”. Six euros and change for a disposable mask and a couple of squirts of alcohol? Dunno …
Sometimes, however, the doctors really do just completely make stuff up …
For instance, one time I got some stitches removed from a head injury that I received in a rugby game. Not only did the bill arrive a whole year after the visit, but nearly half its total of 55 EUR was constituted by a 26-EUR “comprehensive neurological examination” that never happened. (And, more to the point, that should have happened when the injury was still fresh and I was getting the stitches, not two plus weeks later.) Maybe the examination was to see whether or not I could understand the doctor’s greeting through his corona mask, but both these procedures were already covered elsewhere in the bill (i.e., under “consultation” and “protective measures”).
Another money maker for the doctors derives from each procedure having a base weighting factor according to how difficult it is. These typically range from 1.0 to 2.3. (And thereby generally exceed those used by the statutory insurance for the same procedure, which explains why doctors love private patients.) For instance, because northern Germans aren’t renowned for being that talkative, that 10-EUR consultatory felicitation has a built-in difficulty factor of 2.3 already calculated in. However, at their discretion, the doctor can up that factor up to 3.5 (and, in extreme cases even more) for difficult cases, making the potential to earn an extra, easy 50% just by claiming that one or more procedures was more difficult than usual.
All told, not some of the greatest crimes in the world today and ones that I could probably live with. Except …
… the problem is that you do need to question some of the costs from time to time to avoid helping directly finance your doctor’s new car. (Or their kids’ new teeth or whatever.) My private health-insurance company will pay for just about anything (except insurance cards), no questions asked. The problem again is the Beihilfestelle, which goes through each bill line by line to ensure that our tax money can be suitably squandered elsewhere. And any line that ain’t ordnungsgemäß doesn’t get refunded in full. The rejections usually have to do with the difficulty factor being set too high without any appropriate justification. Just as in international diving competitions, anything with a degree of difficulty of 2.3 or less is generally ignored. But, go above 3.0 and the judges start paying attention.
Fortunately, however, doctors are always extremely grateful whenever you question their judgement. I’ve literally had one doctor yell at me in their own waiting room in front of the other patients because I was questioning one of their bills. And, to be honest, I wasn’t even really questioning it, but just asking them to provide more justification for some of the 3.5 weightings that the Beihilfestelle refused to pay out in full. (But, given that this was the same dentist who had the gall to charge us for pulling the wrong tooth from one of my daughters, their outburst is perhaps not that surprising in hindsight.) The usual counterargument brought up by the doctors in such cases is to quote the appropriate chapter and verse from their legal bible, the Gebührenordnung für Ärzte und Zahnärzte (GOÄ), the set of laws that dictates how all fees are to be set and, in particular, that the doctors, and only the doctors, can determine how much each specific procedure will cost (GOÄ §5 Abs. 2).
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In Germany, any appeal to the symbol § is usually just a lazy attempt to coerce some behaviour through legal posturing intended to scare off the faint of heart. Just as with the real Bible, however, context is important. Pick and choose your verses, or parts thereof, carefully and you can support almost any position you want from the Bible, including that “There is no God” (Psalm 14:1). (I learned about this latter, beautiful irony from Henry Gee’s book The Accidental Species: Misunderstandings of Human Evolution. What Henry didn’t point out though is that this sentiment is also repeated in Psalm 53:1 or that the respective passages could alternatively be found in Psalms 13 and 52 depending on which translation of the Bible you prefer. In other words, context here is really important.) So although doctors love quoting § 5 Abs. 2 of the GOÄ—Thou shalt determine thine own renumeration—they completely forget to tell you about, or are simply just plain ignorant of, § 12 Abs. 3: Thou must justify it, especially upon request.
And this is exactly the kind of chapter-and-verse argument that I’m had just recently. (To make it even worse, the argument is not even with the doctor, but with the middleman agency they’ve hired to collect their fees for them. And just the fact that there are collection agencies around for just this kind of thing sort of gives you a hint as to how much money there is to be made from private patients.) Again, in response to my questioning several upweighted procedures that the Beihilfestelle refused to pay out fully, they’ve quoted § 5 Abs. 2 back to me, but admittedly also made an oblique reference to § 12 Abs. 3 in stating that the justifications provided for all the 3.5 weightings are sufficient in their opinion. Now given that the entire text associated with one of the procedures in question is literally only “infiltration anaesthesia”, I find their second argument hard to believe. It’s even harder to believe in German where infiltration anaesthesia is only a single word (Infiltrationsanästhesie) that can logically either describe the procedure or provide the justification for it, but not both simultaneously.
But, of course, leave it to the Beihilfestelle to get the last, purely bureaucratic word in here …
After too many weeks, I finally did get a kind of justification from the doctor for all the 3.5 weightings. But instead of simply justifying each position individually with a single, additional line (which is all the Beihilfestelle wants; from experience, they don’t really care what the justification is so long as there is one so they can check it off their list), he found the time to write me an entire page about how difficult and complex the entire procedure is from the get-go. (That is, his secretary found the time to copy-paste a letter with his electronic signature to me because it was clear that my complaint wasn’t the first one on this score.) After hopefully passing this letter on to the Beihilfestelle, my “appeal” (which I didn’t realize it officially was) was hopelessly turned down in a single paragraph because I had missed the deadline for it: over a month had passed since they made payment on the bill. And to support how I could possibly miss this oh-so-obvious point, they themselves cited their own sets of arcane letters, numbers, and symbols: VwVfG, § 7 and VwGO, § 70 Abs. 1.
In the end, paperwork and pointless polemics aside, I don’t believe in a two-tiered health-care system. (And especially not the halfway house that we German civil servants have.) Not wanting to get too awfully political about it, but access to medical care should not only be a universal right but an egalitarian one as well. Unfortunately, as in so many other cases, belief systems are easily undone by cold, hard reality. I could have voluntarily opted for statutory insurance except that the government, despite still being my employer, no longer takes over 50% of the costs / premiums in this situation, leaving me to pay about double in premiums for less coverage for me and especially for my daughters. That much of a martyr for this particular belief system (or economic imbecile) I’m not and so don’t really mind being essentially forced to be privately insured, where its better coverage for burn injuries will help for those convictions for which I really am willing to be burned at the stake for.
Or when I get older and decide to go to a drive through for some coffee …
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