As Julie Brunner learned more about Germany's health-care system, she couldn't help but think about the reform debate raging back home.

"Here we were in Berlin and nobody was fighting about who should be covered," said Brunner, executive director of the Minnesota Council on Health Plans. "They cover everyone and they don't fight about it."

Brunner was one of a seven-member delegation from Minnesota who visited Germany about a month ago as part of a series of trans-Atlantic dialogues on health care between the state and that nation. Last spring, Germans came here for a conference hosted by the Center for German & European Studies (CGES) at the University of Minnesota.

On Wednesday night, about 80 people heard Brunner and other members of the Minnesota delegation discuss their "a-ha moments" at a CGES salon on "Smart Health Care: Looking at Germany from an American Perspective."

A social ethic of solidarity
Moderator Steven Schondelmeyer, a U professor of pharmaceutical economics, said Germany's health-care system is based on the social ethic of solidarity. While Americans might associate the term solidarity with the Polish uprising led by unionist Lech Walesa, he said, the concept basically means that everyone deserves health care no matter their financial circumstances. (Princeton professor Uwe Reinhardt gives a detailed explanation in the New York Times Economix blog.)

Germans finance their health system with a 7 percent tax on employee wages and a matching 7 percent tax on employers, and the government covers care for the indigent. Medical school is funded by the state, which means no doctor leaves school with the six-figure debt common in the United States, and as a result Germany doesn't have a shortage of primary-care physicians as the United States, panelists said.

State Sen. Linda Berglin, DFL-Minneapolis, said her "a-ha moment" came while looking at comparisons of per-person spending for the United States and Germany. "They don't have any medical debt," said Berglin, who is chair of the Senate Health and Human Services Budget Division. She started wondering, "What is medical debt worth?"
 
"The way we pay is skewing us toward more expensive care," she said. "Most of us know we need more primary care physicians," but the lower salaries and medical-school debt drive doctors to high-paying specialties. "To me, when you look at the numbers comparing per-person cost, it isn't the whole picture. We need to insert into the conversation the medical debt we pay."

A 'doctor-centric' system
Cal Ludeman, Minnesota's commissioner of human services, said he was struck by the "doctor-centric" German system and two statistical averages that would be unheard of in the United States these days: 18 office visits per patient per year and 15-day stays in hospitals.

Ludeman, who oversees the state's government-supported programs like Medicaid, said he was interested in who decides how health-care dollars are spent each year in Germany. "The flow of dollars goes to the doctors association. … In America, it's complicated. … They say, 'Here you go, doctors — you figure out how it's distributed.' "

"They are used to a universal coverage environment," he also noted. "You don't hear a lot about cost-shifting."  

Connie Perpich, a lobbyist for Planned Parenthood of Minnesota and the Dakotas, said she felt "profound amazement" by the concept of "we all take care of one another."

Perpich, who once worked as a nurse's aide in Germany a few decades ago, said she also was surprised that nurses still aren't an important part of the health-care system as they are here. "We heavily utilize nurse practitioners," she said, adding that German nurses go through a three-year technical school vs. the typical four-year education here.

Family planning integrated into basic program
Another noteworthy difference for Perpich, whose organization has encountered a lot of backlash over reproductive health: "There are no family planning clinics in Germany — the services are all integrated into the basic German program."

Brunner, whose organization represents insurance plans in Minnesota, said the German approach to the pharmaceutical industry was impressive. "[The system says,] 'This is what we're going to pay you and if you don't like it, you don't get to sell drugs in Germany.' … If you look at the cost of drugs in Germany and here, it's stunning."

Berglin thought Germany's system of "evaluating new drugs that come into the market from a cost-benefit standpoint" might work here. "They look at the value added and what is its worth."  

So, what do Germans find interesting about Minnesota's health-care system?

"Germans … are really interested in the Mayo system" of team-oriented care as well as Minnesota's use of electronic records, Brunner said. "Our health information technology is so much more mature."

Related content:

Minnesota-Germany 'connection' providing healthy exchange of ideas
by Ann Alquist | June 16, 2008

• On Dec. 27 and 28, Minnesota's tpt station will air "Smart Healthcare: Looking at Germany," a program about the recent visit.

• Videos of previous health-care conferences can be seen here.