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National Agenda : Anatomy of Germany's Nationwide Health Care System : The much-admired program is beset by problems, including a bureaucratic logjam.


BERLIN — Her waiting room empty, her last patient out the door, Dr. Sieglinde Brandstaeter stared at the four-inch-high stack of cards in front of her.

The cards constitute the other part of her work--the part that usually begins after 10 to 12 hours of dispensing medical treatment and advice, when the overworked pediatrician dutifully sits down to face her paperwork.

Like almost all of Germany's 98,000 private physicians, she must categorize and submit detailed accounts of her treatments to an administrative clearinghouse for payment, in what has gradually become a bureaucratic nightmare.

"When I sit here late at night, I'm so exhausted I can hardly see," she said. "Somehow, it's all gotten steadily worse."

Growing bureaucratic demands are only one problem that plagues Germany's much-admired national health care system--a system that historically has enjoyed such success that it has been oft-mentioned as a potential model for Clinton Administration reformers.

As President Clinton searches for ways to extend America's medical care system to all, and at the same time to contain its exploding costs, the struggle to sustain Germany's successful program is a reminder that even the industrialized world's best health care systems find themselves confronting enormous problems.

"This is a system that can't be sustained in its present form," claimed Hans-Juergen Thomas, chairman of the Hartmann League, Germany's most powerful association of medical professionals. "The doctor is under growing financial and professional pressure, and sooner or later this is going to take its toll on patient care."

Despite its problems, it's not hard to understand why Germany's 110-year-old system caught Clinton's interest. After all, it already has achieved much of what reformers in the United States can merely dream of: universal, unlimited medical coverage that provides access to uniformly high-quality services for everyone, all with disciplined cost controls.

Germany's health care costs annually run about 8% of gross national product, compared to the 12% of GNP shouldered by Americans. Further, the German costs have risen far more slowly than in America--about 20% in the 1980s, compared to 50% in the United States. Mainly because of recent reforms, Germans' costs actually declined by 1.5% in the first quarter of this year.

That this system also offers patients the freedom to choose their own doctors, and doctors the freedom to work privately, free of any large, centralized control, merely adds to the attraction for Americans.

The German system, in brief, works this way: Germans pay into one of more than 1,200 government-supervised health insurance funds, their fees being split 50-50 with employers. (The government covers half the cost for pensioners and the jobless.)

The insurance funds then pay the doctors. Hospitals are on a separate budget, with a separate staff of salaried doctors.

For the patients, this system offers quality care with hardly any paperwork and no financial worries. To be sure, their monthly contributions to the health insurance funds can run as high as $400. But they buy both total health care security and entry into a giant medical "playground."

For example, a new mother who underwent an unexpectedly complicated birth that included a Cesarean followed by a 16-day stay at a large Berlin hospital was presented the bill for her and her new baby's care: $20. There was a fee of $4 for each day's stay exceeding 11 days, a hospital staffer explained. No other money changed hands; no claim forms were required from the patient. Whether for a routine visit to the doctor's office or major surgery, the same rules apply.

Adequate funding means the German system works without the horror stories of gradually collapsing services and yearlong waits for routine surgery associated with some other state-run programs, such as the British national health system.

Consider the health care perks to which Germans are entitled:

* Payment of all costs exceeding $16 incurred in traveling to and from the place of medical treatment.

* Access at nominal cost to the uniquely German "cure"--a four-week holiday at a health care retreat where, for example, overworked managers can decompress and get a crash course on how not to abuse their bodies, or where a mother can escape family stress, discuss problems with other mothers and be reassured that the health care system will deliver hot meals to her family's door each day while she's away.

* A death payment of $1,250 issued to the next of kin.

Health care administrators here say the key to controlling costs has been the steady refinement of a system first implemented by Otto von Bismarck in the 1880s as part of a fledgling welfare state to quell worker unrest and undercut trade union influence.

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