Assessment of health system performance in Germany: Survey-based insights into the perspective of people with private health insurance.

Introduction: The World Health Organization (WHO) defined intermediate and overall goals to assess the performance of health systems. As the population perspective becomes more important for improving health systems, the aim of this study was to gain insights into the perspective of people with private health insurance (PHI) in Germany along the predefined WHO goals.

Methods: A cross-sectional survey was conducted in 2018 among people with PHI in Germany. The questionnaire included items on all intermediate (access, coverage, quality, and safety) and overall WHO goals (improved health, responsiveness, social and financial risk protection, and improved efficiency). Descriptive analyses were conducted for the total sample and subgroups (gender, age, income, and health status).

Results: In total, 3601 respondents (age 58.5 ± 14.6; 64.7% male) assessed the German health system. For example, 3.3%-7.5% of the respondents with subjective needs reported forgone care in the past 12 months due to waiting time, distance, or financial reasons and 14.4% suspected medical errors in their care. During the last physician visit 94.2% experienced respectful treatment but only 60.6% perceived coordination of care as good. Unnecessary health services were perceived by 24.2%. For many items significant subgroup differences were found, particularly for age groups (18-64 vs. 65+).

Conclusion: Conducting a health system performance assessment from the population perspective gained new and unique insights into the perception of people with PHI in Germany. Areas to improve the health system were seen in, for example, coordination of care, financial risk protection, and quality of care, and inequalities between subgroups were identified.