109 issn 1822 – 8402 european integration studies. 2010. no 4 SOCIAL SECuRITY SYSTEMS Of LITHuAnIA AnD GERMAnY: DIVERSITY of approaches Juozas Merkevicius, neringa Bernotienė Vilnius Gediminas Technical University Abstract The healthcare system forms premises to carry out citizen’s health protection, provide health care services to the customer – the patient. The health system, its financing, structure, the peculiarity of interaction between its elements are defined by the health protection policy carried out by the country, which is determined by the countries regime, traditions, moral values, economical, political, demographical and other factors. The health protection policy forms strategic aims and the priority directions of action in the questions of health protection. Many of the economic and management law are applicable in the health protection sector. The growth of the healthcare market of European union is caused by the technical medicine progress, the more diverse choice of healthcare services, the expectations of patients, and the development of information and communication technologies. Acquired pharmaceutical and medicine technology innovations allow offering patients a large variety of choices to improve health. Although, health protection is one of the sectors, where specific distortions arise because of the market, so government participation and resource distribution is necessary. Discussions arise both in the society and different institutions, about the range of government intervention that will bring the optimal benefit, how to not create preconditions for unnaturally high demand for medical treatment services and medicaments, still guaranteeing free health protection. This way, during the formation of the health protection policy the choice between innovations and economic growth promotion, expenses control and cost reduction, searching for the benefit and effectiveness ratio. Also, the democratic society principles and the mutual respect between the services provider and consumer should be implemented in the health protection domain. Judging from the above regulations, we can assume that the question of health insurance is one of the most important health protection policy questions in the European union. The paper by using comparative analysis method analyzes the health care systems of federal Republic of Germany and the Republic of Lithuania. In the article is described concept and types of health insurance, is made comparison of circle of insured persons of the analysed countries, their rights and responsibilities. There is made analysis of management and funding of health care systems. Lithuanian and the German health care systems have common features and differences. In both countries the health care institute has retained the essential features of the compulsory health insurance. Lithuanian and German health care systems distinguishes between mandatory and voluntary health insurance. The compulsory health care scheme aims to involve all groups of persons. The countries concerned are different moral values, the ideological foundation of health insurance. Lithuanian and German health care systems are different in health insurance coverage, determination of underwriting fees and collection mechanisms, many other factors. Keywords: Health care system, health insurance in the federal Republic of Germany, health insurance in the Lithuanian Republic, management of health care system. Introduction Health insurance is one of the most common ways to receive financial resources, which can be used to finance the healthcare system. The Institute of Obligatory Health Insurance is vital to the healthcare systems of both the Federal Republic of Germany and the Republic of Lithuania. However, it is noticeable that the obligatory health insurance system alone cannot meet the new challenges arising in fast-changing environment or solve the problems of the growing healthcare service costs or the suitability and accessibility of the services. More often the elements of the market are integrated into the health insurance system, the importance of other financial sources– surcharges, voluntary health insurance, is increasing Research problem and relevance. The Republic of Lithuania and the Federal Republic of Germany differ in their economic development level, their health system ISSN 1822-8402 EUROPEAN INTEGRATION STUDIES. 2010. No 4 110 models, many healthcare indicators, but part of the health protection problems is common. Because of the aging resident population, the increasing average lifespan, a larger part of the population needs long-term treatment, rehabilitation and nursing means; also more expensive medicine, examinations and treatment procedures are prescribed more often. All of this leads to the increasing of healthcare costs. Every problem requires and optimal decision method – equilibrium must be found between a quality, accessible, corresponding to the expectations of the patient, service and an effective use of resources. To solve this task the health insurance institute is important, for the most part deciding the possibilities of quality or accessibility of the offered healthcare services. The Federal Republic of Germany has a social insurance, or so called Bismarck health system model, when a large part of funds, intended for healthcare financing, is received from health insurance (Sinn, 2005). Lithuania has a mixed model, which has both Bismarck and Beveridge systems elements and a dual service financing – from the state budget and health insurance funds. This fact presupposes that Lithuanian and German health systems have both similar and diverse features. Problems of Lithuanian public sector in various aspecs were analyzed by many different scientists: B. Melnikas, J. Samulevičius (2009), A. Makštutis, R. Smaliukienė, J. Vijeikis (2009), N.K. Paliulis, N. Jurkėnaitė (2009), Ž. Tunčikienė (2009), J. Vijeikis (2008), O.G. Rakauskienė, E. Chlivickas (2007), G. Davulis (2006). There are articles taking attention to aspects of organization of public sector (Bivainis, Drejeris, 2008) and issues of planning (Bivainis, Tunčikienė, 2007). There is less literature concerning health insurance in Lithuania. Health insurance problems and various features were evaluated by Lithuanian scientists: A. Dobravolskas (2009), G. Černiauskas (2009). Analyzing the literature, where the financing of the Lithuanian and German healthcare systems, using health insurance, is compared, we can assume that the health insurance institute in Lithuania got more attention at the origin of its sources. In the publication of Sveikatos Ekonomikos centras (1996), other countries‘ health systems are compared, including health insurance, it is evaluated which health insurance model would be best suited for Lithuania, analyzing the experience of other countries. In G. Černiauskas and M. Schneider (1999) work the changes in the Lithuanian health system are analyzed and a health insurance evaluation is provided. The development of health insurance in Lithuania, Lithuanian insurance system and its improvement are analyzed in some Master‘s dissertations. In most of the dissertations concerning Lithuanian health insurance system, the health insurance is analyzed from an economic – effect (result) point of view, and not the legal (cause) aspect. Publications, prepared by world health organizations, analyze different countries‘experience in financing healthcare systems, the main, general features of health insurance and its peculiarities in different countries. Literature in Lithuanian language about the German health insurance system or where Lithuanian health insurance system is compared to other European Union old-times‘systems is missed. Meanwhile, continuing the reform of Lithuanian health protection system, searching for successful solutions for solving health protection problems, not only Lithuanian national health system experience is valuable, but other countries, including more industrialized ones, which have a longer experience in health insurance practice, proficiency as well as their decisions in solving new problems, and mistakes that were made. There is no doubt, that a wider standpoint, abundance of information allows the appearance of new viewpoints, widening the discussion (communication) circle, form new ideas and alternatives. Meanwhile, the experience, amounting to over 120 years, of the Federal Republic of Germany, which currently is carrying out a reform of it‘s health system and searching for ways to adapt to new demands, as well as improving the health insurance institute, could be useful in widening the boundaries of discussions, connected to health insurance, and creating alternative health insurance opportunities, forming a medium for healthy competition, for the final aim to be reached – providing of quality healthcare services, including disease prevention, treatment and rehabilitation, to every citizen of the Republic of Lithuania and service consumer, - the satisfaction of the patient. We shouldn‘t forget, that a healthier, more able-bodied society is one of the important contributors to the economic growth of the country or the formation of a civil society. Research object: Federal Republic of Germany and the Republic of Lithuania healthcare systems. Research aim: to analyze the health insurance systems of Lithuania and Germany, determine their advantages and differences. Research tasks: to analyze and compare the type of insurance applicable in Lithuania and Germany, the peculiarities of financing, prohibited person group and their rights and duties, institutions that carry out the health insurance. Research methodology: the comparison analysis of Lithuanian and German health system done by world health organizations, other scientific or methodical literature, statistic collections and other scientific literature sources. Decentralization One of the key elements of the healthcare system of the Federal Republic of Germany – decentralization, ISSN 1822-8402 EUROPEAN INTEGRATION STUDIES. 2010. No 4 111 is supported by federalism – the division of decision making power between the federal authorities, authorities of separate territories in the country and the delegation of public authority power to corporal establishments – organizations of service providers and buyers, like doctor and dentist associations and patient funds (World Health Organization, 2006). On the country level, the decisions on healthcare problems are made by the Federal Health Protection Ministry. The ministry decides on international and national health policy formation questions, personal healthcare, social health care and pharmaceutical activity strategic planning questions. The Federal Health Protection Ministry prepares projects of health system legislations, performs controlling of the healthcare system, licensing and overview functions. On the regional level 16 lands don’t have ministries that would take care of health protection problems, in some lands the health protection ministries are merged with labour and social protection, environment protection, family and youth matters. Often health protection questions are solved in one the divisions of the ministry (public health services and environment hygiene questions, AIDS prevention and so on) (Busse, Riesberg, 2004) In the Republic of Lithuania, key healthcare questions are solved in the Health Protection ministry of the Republic of Lithuania, which prepares legislation projects, forms and carries out health protection policy, determines the main directions and priorities of the national health system development, performs health system control (Health protection ministry regulations). Municipal institutions are given the task to array out primary person healthcare and a part of the secondary healthcare (Health system legislation, 1998). The heads of the regions are tasked with performing secondary person healthcare. Thus we can come to a conclusion that both the Federal Republic of Germany and the Republic of Lithuania healthcare systems are decentralized, in the Federal Republic of Germany this is based on German lands, territories (Homburg, 2003), and in the Lithuanian republic – based on municipalities and regions. private and public sector relation Another important feature of German healthcare system is the privatization of the systems elements. Unlike other spheres, public and private sectors in healthcare can be divided by their ideology and not any other criteria. Although in some spheres of healthcare private service providers dominate, like dentistry. Until 2004, ambulatory care services in the former Federal Republic of Germany territory were conducted on an office principle, whereas in the former East Germany still has policlinics. In other sectors private non-profit and profit seeking service suppliers exist together with public, for example in the hospital sector. A large quantity of hospitals, including private, profit seeking ones, treats patients with obligatory health insurance and their activities are regulated by the same rules. Only few private, profit seeking hospitals are not included into the so called hospital plan and don’t treat patients with obligatory health insurance (Busse, Riesberg, 2004). At the same time, most of the institutions providing healthcare services in the Republic of Lithuania are public, unprofitable organizations. The private sector is more dominating in dentistry, plastic surgery, psychotherapy and gynaecology spheres (Černiauskas, Murauskienė, 2000). Comparing the two countries, it is clearly seen, that in the Federal Republic of Germany, the private healthcare sector plays a more important role, meanwhile in Lithuania it can be still considered as forming. Healthcare financing The financing of the bigger part of German healthcare system by the obligatory health insurance, controlled through the Patient funds, is common to the German health system. The rest part of financing is received from various sources, applying a decentralized funds distribution. Funds, appointed for health protection are received from different ministries: Health Protection, Defense, Internal Affairs, Education and science (Busse, Riesberg, 2004). In 2005 total expenses on healthcare in Germany made 10,7% of GDP, 76.9% of healthcare service total expenses, or 8,6% of GDP was covered from Patient funds. In 2004 total expenses for healthcare made up 10,6% of GDP (World Health Organization, 2006). Evaluating 1996-2005 interval, total expenses part of GDP remains constant, fluctuations happen in the boundaries from 10,2 to 10,8% (WHO, 2008). Expenses on healthcare in Lithuania consist of government and municipal budget expenses and Obligatory health insurance fund expenses. The ministry of finance expenses, appointed to health protection, is distributed not only through the Health Protection Ministry, but also thorough other ministries- like Social Protection and Labour. Total expenses, as a part of GDP, for healthcare made up 5,89% in 2002, 5,56% in 2004, 5,79% in 2008 (LSIC, 2009a). In 2008, 75.5% of the healthcare expenses were government expenses. In the mean time the expenses average of the European Union in 2002 was 9% of GDP (Busse, Riesber, 2004). Comparing a 10 year period of 1995-2005, the alteration of the total expenses as a part of GDP indicator is minor and fluctuated around 5,5% of GDP. Analyzing the government expenses for healthcare as part of GDP for that same time period, we also don‘t see any noticeable changes: 4,13% of GDP in 1995 and 4% of GDP in 2005 (Busse, Riesberg, 2004) There is no unanimous health protection budget ISSN 1822-8402 EUROPEAN INTEGRATION STUDIES. 2010. No 4 112 that is sorted through the Ministry of Health Protection neither in the Federal Republic of Germany nor in Lithuania, which lets us perceive health protection as a complex and environmental protection, social protection problem. Health protection in the Federal Republic of Germany receives considerably larger percent of funds from GDP. Judging by the 9-10 year changes in the funds from GDP, which are used for health protection, both countries maintain quite a stable percent with minor fluctuations. personal healthcare system Both Lithuanian and German healthcare systems consist of a network of ambulatory healthcare and stationary personal healthcare institutions. Ambulatory healthcare in Germany is mostly provided by general practitioners working on contract and specialists involved in personal practice. Patients can choose a doctor, psychotherapist, dentist, institution that provides obligatory help. The so called gate system, when the patient is sent to a specialist by the general practitioner, is still not implemented enough, although their competence in coordination was strengthened in the last few years and since 2004 Patient funds were obliged to provide the patient direction models. Doctors providing ambulatory services also provide most of emergency aid services. Most family doctors visit patients’ homes (Busse, Riesberg, 2004). Such services are provided only by some of the specialists. Offices, providing immediate service during the non-working hours include consultations by telephone, patient examination at home. Stationary healthcare services in the Federal Republic of Germany are offered by both public and private stationary healthcare service providers. Although the number of beds per 1000 residents and the average time of lying were significantly reduced to 6,3 beds per 1000 residents and 9,3 days, Germany is still the leading country by these indicators of the 15 European Union countries, that became EU members before May 2004. (World Health Organization, 2006). In 2002 in Germany there were 2221 hospitals, that had 547 284 beds (6,7 beds per 1000 residents). 274 of those were psychiatric hospitals that had 42600 beds, 1898 general profile hospitals that had 504684 beds. 24. The number of hospitalizations per 100 residents in 2005 was 22,66. The total number of general hospitals consisted of 712 public, 758 private non-profit and 428 private profit- seeking hospitals. The bed relation was as follows 54, 38 and 8 percent for public, private non-profit and public profit-seeking hospitals (Busse, Riesberg, 2004). The number of beds in university hospitals made up 8,3% of the total number of hospital beds. In 20021343 institutions, that had 184 635 beds (2,2 beds per 1000 residents) were assigned for prevention and rehabilitation treatment in addition to short-term treatment. Comparing to general profile hospitals, the number of long-term treatment hospitals consists of 17% of public, 16% of private non-profit and 67% profit-seeking institutions (Busse, Riesberg, 2004). In Lithuania, personal healthcare services are provided mostly in legal status hospitals of public institutions and two largest universities – Vilnius and Kaunas clinics. In 2008, private hospitals don‘t even reach 10% of total number of Lithuania hospitals. IN 2008 there were 149 hospitals in the Republic of Lithuania, 67 of them were general profile hospitals, 49 hospices, 29 specialized hospitals and 4 rehabilitation hospitals (LSIC, 2009b). Following the tendencies of change of bed numbers, a decline in number of stationary beds, from 98,8 in 1999 to 84,6 in 2004 and 81,7 in 2008 per 1000 residents, is noticeable. The average lying time in the stationary in 2005 was 10,2 days, number of hospitalizations per 100 residents – 23,8 in 2005 – higher than the average of the EU countries, even that the average of the countries that became EU members after May 1, 2004 (LSIC. 2009c). Ambulatory healthcare services are provided by policlinics, primary healthcare centers, ambulatories, general practitioner‘s rooms. There are 441 ambulatory healthcare institutions. Primary private healthcare institutions come up to 174. Comparing stationary services, private service providers dominate in Germany, and public hospitals that have a legal status – in Lithuania. Such indicators as the tendency of reduction of beds in stationeries, hospitalization numbers per 100 residents and the average lying time in stationeries are very similar for both countries. Germany and Lithuania have similar personal healthcare system structures, but the model of healthcare specialists being accessible through general practitioners, family doctors, has been put to practical use in Lithuania first. Human resources In 2002, 4,2 mln. people, or 10,6% of all working population in the Federal Republic of Germany worked in the healthcare sector. 37% are work part-time and 63% a full-time. In 2003, there were 3,37 doctors per 1000 residents, 9,72 nurses and 0,78 dentists per 1000 residents in Germany. Starting with 1997, human resources remained quite stable, although the number of part-time workers increased. Over the last 50 years the number of doctors has increased drastically. On the other hand, the number of qualified general practitioners has declined, comparing to the total population and especially with the total number of doctors. 52% of accredited primary-level physicians work as family doctors, 48% - as specialist in the ambulatory care field (Busse, Riesberg, 2004). From 1990 till 2002 the number of doctors has risen by 20% and is close to the average ISSN 1822-8402 EUROPEAN INTEGRATION STUDIES. 2010. No 4 113 of the European Union. The number of nurses has risen by 8% in 2001 and is higher than the EU average. Since 1995, the number of doctors in Lithuania per 10000 residents remains quite stable. 40,8 doctors per 10000 residents in 1995, 39,7 doctors per 10000 residents in 2003, 40,01 – in 2008. In the mean time a increase in the number of dentists is spotted. In 1995 – 4,8 per 10000 residents, 6,9 per 10000 residents in 2003, and 7.11 in 2007 (LSIC. 2009c). In 2006, the number of doctors per 10000 residents in Lithuania was higher than in Germany, but a slightly smaller number of nurses and dentists. Both in Germany and in Lithuania the number of doctors, nurses and dentists per 10000 residents is higher that the European Union average (LSIC, 2009d). The role of associations In Germany healthcare service providers are represented by doctor and dentist associations. Regional doctor associations can be found in every German land. Dentist associations are similar. Regional associations form a federal doctor association and a federal dentist association. The German Hospital Organization represents hospital interests. It consists of 16 lands of Germany hospital organizations and 12 hospital associations, representing various hospital types, for example: university, profit-seeking and other (Busse, Riesberg, 2004). In the republic of Lithuania, among the significant associations, the Doctor Union and the Medicine worker professional union are mentioned for the healthcare service providers. (Černiauskas, Murauskienė, 2000). In Germany, regional associations and unions of doctors, dentists and hospitals are formed, which make up federal-level associations and are very important when representing the interests of service suppliers. Although the role of service provider associations is increasing in Lithuania, it can hardly be said that they take part in sales contract making as an equal partner for patient funds, strongly influencing price making of healthcare services or other contract elements. Conclusions 1. Both the Republic of Lithuania and the Federal Republic of Germany use health insurance as one of the means to finance the health system. In both countries the health insurance institute has cleared the main features of health financing: obligatory for most of the population, fees not affected by risk, patient fund participation in the health insurance system. However there is a difference in moral values, which are the ideological foundation of current health insurance system. In the Federal Republic of Germany, health insurance is thought of as an obligatory element of the civil community, whereas in the Republic of Lithuania – as an economic system of healthcare means. 2. In the Constitution of the republic of Lithuania, unlike in the Federal Republic of Germany, a person’s right for free treatment is guaranteed, thus the government takes up responsibilities that do not always correspond to the financial possibilities of the country and creates premises for patients to get expectations that are not always economically based. 3. Both in the Republic of Lithuania and Federal Republic of Germany legislation obligatory and voluntary health insurance kinds are mentioned. The volume of voluntary health insurance in the Republic of Lithuania and the Federal Republic of Germany differs. Republic of Lithuania health insurance law determines the additional voluntary health insurance, and the Federal Republic of Germany legislation – alternative voluntary health insurance, that allows leaving the obligatory health insurance system. The legislation of the Republic of Lithuania does not regulate the voluntary health insurance enough. Legislation of the Federal republic of Germany determines long-term nursing health insurance, which must cover the costs that are connected to long-term nursing. Legislation of the Republic of Lithuania does not discern a separate long-term nursing insurance. 4. Both in the Republic of Lithuania and in the Federal Republic of Germany, legislation states that obligatory health insurance is mandatory for all resident groups. The legislation of Republic of Lithuania determines the insurees with a health insurance, regulates individuals who are insured by government funds. Legislation of the Federal Republic of Germany consolidate individuals, who have the obligation to be insured by the obligatory health insurance, individuals who are exempted from this obligation, and individuals who have the right to leave the obligatory health insurance system, choosing voluntary private health insurance. Unlike in the Republic of Lithuania, family insurance has been established in Germany – when all persons are connected by family bonds with the insuree are also insured. 5. The rights of the insurees are similar, additionally, in Germany, insurees can choose the patient fund, which adds one more market element – competition, and thus affect the insurance fee regulation. The legislation of the Federal republic of Germany states the personal responsibility of the insuree for his own health preservation and improvement. In the legislation of Republic of Lithuania there is no statute on personal responsibility in the health insurance. Representatives of patients and insurees with an obligatory health insurance are invited to participate in the decision-making process in the Federal Republic of Germany, whereas in Lithuania representatives of insurees and patients are included into the Obligatory health insurance council. 6. The health insurance funds of the republic ISSN 1822-8402 EUROPEAN INTEGRATION STUDIES. 2010. No 4 114 of Lithuania, together with budget funds, form the Obligatory health insurance foundation, where funds are accounted separately from the government and municipal funds. The health foundation of the Federal Republic of Germany that collects health insurance fees and budget funds, for individuals whose insurance is covered by government funds, and distributing funds to the patient funds is establish in 2009. Before this time the Patient funds in the Federal Republic of Germany gathered the fees themselves. 7. Both the Republic of Lithuania and the Federal Republic of Germany health insurance fund distributions structure is similar: funds, for paying for healthcare services that were provided under contracts with service suppliers; reserves funds, patient fund administration funds. Most of the funds consist of fees that are connected to work-related relationship income and are paid by the employee and employer. Unlike the Republic of Lithuania, the legislation of Federal Republic of Lithuania determine the lower borders of income, below which the person is exempted from paying the insurance fees, and upper borders, when a person receives the right to leave the obligatory health insurance system. The size of the insurance fee in the Republic of Lithuania is determined by the government, in Germany – patient funds, although laws determine boundaries for this right. The legislation of the Federal Republic of Germany determines that from 2009, the size of the health insurance fee is determined by the government. 8. Only one insurer carries out health insurance in the Republic of Lithuania – the State patient fund and the territorial patient funds that have agreements with the service providers based on territorial principles. Legislation doesn‘t denote the right to choose a fund. Legislation in the Federal Republic of Germany denotes 7 types of patient funds and a person has the right to choose one. A larger number of suppliers can promote higher competition and be beneficial to the consumer, but also increase the administration costs of the patient funds. Patient funds are under the governable by the Ministry of health protection, to which the health insurance law provides vast authorizations in the health insurance process, thus not allowing the health insurance process to gain a self-regulatory nature. 9. The duty of patient funds to form contracts with healthcare service providers and to execute payments for the provided services according to the contracts is regulated both in the Republic of Lithuania and the Federal Republic of Germany. The legislation of the Republic of Lithuania establishes an obligation for the patient fund to perform a quality control function for the provided healthcare services. The responsibility for service quality and sufficiency in the Federal Republic of Germany is determined for both patient funds and healthcare service suppliers. Republic of Lithuania patient funds additionally perform functions that are connected to the Obligatory health insurance foundation. 10. The trend for both Lithuania and Germany health systems to obtain more common traits is quite visible. For the Federal Republic of Germany to implement those health insurance elements that exist in Lithuania nowadays – founding a Health insurance foundation in the federal Republic of Germany in 2009 that collects health insurance fees and payable funds, similar to the Obligatory health insurance foundation, when the government determines the size of the insurance fees. References Bivainis, J.; Drejeris, R. (2008), The complex assessment of new service development. 5th international scientific conference „Business and management’ 2008“. Vilnius, Lithuania 16-17 May 2008. Selected papers. 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