gms | German Medical Science

Objectives: The German healthcare system consumed almost 13% of GDP in 2023 [1], more than any other EU-country. The number of hospital beds is also above average [2] while the available outcome indicators suggest a rather unsatisfactory performance. In addition, there are major challenges due to an ageing society. The aim of this study is to uncover potential (technical) efficiency gains for Germany by analysing the input-outcome relationship of 27 countries.

While the search for efficiency gains in healthcare systems has a long tradition, we offer several conceptual and methodological innovations to improve the quality of the computations and facilitate the interpretation of the results.

Method: Non-parametric input-oriented Data Envelopment Analysis (DEA) is used to measure the relative efficiency of individual healthcare system based on input-outcome combinations. DEA calculates both overall efficiency as well as efficiency scores for each indicator included in the equation. From a conceptual perspective, nine indicators for different levels of health production are included based on the throughput model of Pfaff et al. [3]. Our study combines country-level data (OECD) with household-level panel data (SHARE) for 2019, providing comprehensive data on the health of older people [4]. Thus, ensuring a high-quality database. Finally, we perform a cluster analysis (CA) based on socio-demographic, economic factors, and preventive measures to further improve the validity of our results.

Results: Across all countries, the DEA shows that Germany ranks 11^th, which clearly indicates efficiency gains. Within-cluster analysis reveals that system efficiency is well below that of the Netherlands, France, and Switzerland. The more detailed analysis shows that Germany is average or well below for two of the three outcome indicators we selected, i.e. avoidable mortality and self-rated health. On the input side, there are potential efficiency gains due to the low level of digitalisation and the fact that Germany has the highest number of hospital beds in the sample. The level of households’ out-of-pocket payments is at a more efficient level in comparison. Accordingly, the number of skipped doctor visits indicates an efficiency problem due to waiting times and unavailability rather than costs. On the side of outputs, a high level of hospitalisation inhibits efficiency.

Discussion: While in Germany the households’ out-of-pocket spending for healthcare services tends to be at a rather efficient level, serious deficits currently exist due to a high number of beds and the associated high hospitalisation rates. At the same time, it should be noted that the outpatient sector may not have sufficient capacity. Further efficiency gains are possible through digitalisation. Another interesting aspect that emerged as a by-product of the analysis appears to be the extent of the preventive measures introduced. Here, some countries with more interventions show lower avoidable mortality and lower figures for harmful lifestyles. One possible limitation of our study is that the data originates from the time before the pandemic. Due to this enormous exogenous shock, the current values could deviate.

The authors declare that they have no competing interests.

The authors declare that an ethics committee vote is not required.

This contribution has already been presented: EuHEA Konferenz Vienna 2024 (30.06.2024 to 03.07.2024), Abstract submitted and accepted as oral presentation. Abstract title: Efficiency of the German healthcare system - uncovering efficiency gains in cross-sector structures. Authors: Franz I, Cacace M, Bitzer EM.