Germany, by many measures, has one of the world's most successful health care systems — providing good care for everybody for much less than many other countries spend.

Nearly every German has ready access to doctors, cheap drugs, high-tech medicine, dental care, nursing homes and home care. All this — and Germany spends about half what the United States does per person.

"The system is really good," says Dr. Christoph Leibl, a general practitioner in the little middle-class town of Willich, near Dusseldorf in western Germany. "As far as the medical treatment and stuff is concerned, in my opinion it's very good."

One way it accomplishes this is by putting doctors on a budget.

How Doctors Get Paid

Nearly all hospital-based doctors are salaried, and those salaries are part of hospital budgets that are negotiated each year between hospitals and "sickness funds" — the 240 nonprofit insurance companies that cover nearly nine out of 10 Germans through their jobs. (About 10 percent, who are generally higher income, opt out of the main system to buy insurance from for-profit companies. A small fraction get tax-subsidized care.)

Office-based doctors in Germany operate much like U.S. physicians do. They're private entrepreneurs who get a fee from insurers for every visit and every procedure they perform. The big difference is that groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets.

Those doctor budgets get divided into quarterly amounts — a limited pot of money for each region. Once doctors collectively use up that money, that's it — there's no more until the next quarter.

It's a powerful incentive for doctors to exercise restraint — not to provide more care than is necessary. But often, the pot of money is exhausted before the end of the quarter.

That's why Leibl is chronically angry.

"I don't get paid at the moment," he said recently, near the end of a quarter. "I haven't been paid for what I'm doing for the last two or three weeks."

He has to wait until the beginning of the next quarter before the sickness funds will start paying the bills he submits. Some German doctors simply close their doors and take a vacation at the end of every quarter.

Leibl says he feels "abused, exploited in a way" by this system, "because the work we are doing actually is pretty demanding. And I have a lot of responsibilities. And I think that should reflect in what I get paid."

In some parts of Germany, doctors are going on strike over what they get paid.

Differences in Costs

It's not that German doctors live in poverty. The average German primary-care doctor makes around $123,000 a year before taxes. That's about one-third less than the U.S. average.

"I think the biggest difference between the U.S. system and the German system is that everything is cheaper," says Karl Lauterbach, who is a doctor, a professor at the University of Cologne and a member of the Bundestag, the German parliament.

When Lauterbach says everything is cheaper in Germany, he means things like hospital care, prescription drugs, MRI scans and heart bypass operations.

On top of that, administrative costs are almost 50 percent lower. That's not because the German health system is simple and streamlined. With its employer-based system, multiple insurers and ever-changing rules, German health care is as complicated in many ways as the U.S. system. But administration is much simpler because nearly everybody gets the same benefits, payment rates are uniform and virtually everybody is covered.

But the biggest reason German health costs are so much lower, experts say, is that doctors are paid less. This largely reflects Germany's concerted efforts to keep costs down over the past two decades.

Dr. Heinz-Harold Abholz, a professor of general practice at the University of Dusseldorf, says he earned a lot more 20 years ago.

"I get a third of the money I earned in the 80s," Abholz says.

Abholz understands why older German doctors miss the good old days. But he says they still do OK.

"German doctors are the best-earning professional group in Germany," he says. Abholz cites federal tax figures that show German office-based doctors earn more than independent lawyers, architects or engineers.

Contending with House Calls

And not all German doctors are unhappy with their system. Dr. Achim Mortsiefer is a general practitioner. Like Leibl, he's in his early 40s. His office is in a pleasant residential neighborhood of Cologne, one of Germany's largest and oldest cities.

Many afternoons, Mortsiefer locks up his office and sets off to do something nearly unheard-of in the United States — house calls. Almost all German general practitioners do them.

"We [will] visit two patients that I visit every four weeks and just have a look at them," Mortsiefer says, as he puts his bag into a car jammed with children's toys.

The patients he's visiting depend on house calls. Elspeth and Edwin Fedrowitz live in a small, crowded fourth-floor walk-up. Edwin's legs were amputated nine years ago because of blood vessel disease. There's no elevator. He says he hasn't been out of the apartment in four years.

Elspeth has a never-ending list of problems — back pain, chronic anxiety, exhaustion from looking after her husband. Mortsiefer's gone way beyond his role as a doctor to help them. He found the Fedrowitzes a ground-floor apartment that would have made life much easier. But they've lived in their current apartment for 48 years and refuse to leave.

Mortsiefer checks Edwin's legs, writes them both prescriptions for high blood pressure and gives Elspeth some pain medication. He says his "auf wiedersehens" and descends the terrazzo stairs, clearly frustrated he can't do more for them.

"Very difficult patients," he says as he starts his car. "They smoke — they still both smoke! And if I recommend some new treatment they always say, 'No, we don't need that,'" Mortsiefer says.

Clearly, Mortsiefer spends more time worrying about his patients than about his own income. He acknowledges that the extra payment he gets for house calls isn't much – 20 euros, or $31. A German plumber gets more.

And because it's the end of the quarter, Mortsiefer says with a rueful laugh, he may get nothing at all for his visit to the Fedrowitzes. But he doesn't dwell on that. Some doctors, he says, calculate how much is left in their quarterly budget every day.

"The problem is," he says, "if you think about money the whole day you will be unhappy. That's an old rule of life, isn't it?"

Getting a Reality Check

Mortsiefer and Leibl represent two poles of the debate among German doctors about health care cost control. To get a reality check, we pay a call on a trusted friend. I met Juergen in der Schmitten 17 years ago when he was a medical student. Now he's a 42-year-old general practitioner in Meerbusch, a picture-book suburb of Dusseldorf.

When we arrive it's bedtime for Juergen's 5-year-old son, Kilian. They're reading Winnie the Pooh in German.

Juergen, his wife Sibylle, a freelance graphic designer, and Kilian live in a modest two-story row house. It cost about $385,000 two years ago. Juergen had to lay out another substantial sum to buy into a medical practice with two partners. So he has a lot of debt and no savings. He drives a five-year-old Audi.

Juergen works long hours — moonlighting after-hours for a 24-hour on-call service — to bring in an income a little better than the average general practitioner in Germany.

He weighs in on how things have changed for doctors since he was in training.

"The atmosphere, the feeling on the side of physicians — and perhaps also patients — that things are getting worse," he replies. "I think that's the most striking change, really."

He says something we've heard from other Germans — even those who aren't very sympathetic to doctors. Germans are worried about the future of health care. Already nearly one in five Germans is over 65 — a ratio the U.S. population likely won't reach until 2030.

"If the society's aging, if the society wants to have more expensive medicine, then it'll have to pay for it," Juergen says. Doctors, he says, "are not the ones who will work more and more and more and not see an increasing income for that."

He says Germany will have to spend more on health care in the coming years. But here's the thing: Germany can spend more, cover nearly everybody and still not spend nearly as much as the United States does.

Radio piece produced by Jane Greenhalgh.

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