Fertility Treatment in Germany

Assisting couples to have babies is a very popular medical activity in Germany!

Starting in the beginning of the 90ies, reproductive medicine has gained increasing attention in the medical scene in Germany. Today, there are well over 100 fertility centres in Germany. While they are usually concentrated in bigger cities, it is also possible to find very qualified teams in medium size towns. Gynaecologists and specialists in reproductive medicine offer the full spectrum of up to date diagnostic and treatment strategies, often in close cooperation with other specialists, like urologists.

• Menstrual cycle monitoring and diagnosis
• Diagnostics
• Investigation of fallopian tube functioning and patency (endoscopy, contrast ultrasound)
• Investigation (spermiogram) and treatment of male fertility disorders, andrology, urology
• Hormonal diagnosis of all male and female sterility-related factors
• Human genetics
• Immunological diagnosis and treatment
• Polar body diagnosis (PBD)
• Diagnosis of trace elements, harmful substances and allergies
• 
  
• Treatment techniques
• Endoscopic treatment/operation of any disorders relevant to fertility (adhesions, endometriosis, myoma, uterine septum, etc.)
• Homologous insemination (IUI)
• Hormone treatment in follicle ripening disorders
• In-vitro fertilisation/embryo transfer (IVF/ET)
• Treating desire for children in patients with transverse spinal cord syndrome / paraplegia
• Cryoconservation of gametes (sperm and egg cells) and fertilised oocytes
• MESA/TESE (epididymal / testicular sperm extraction)
• Microsurgical refertilisation, particularly after tubal sterilisation
• Intracytoplasmic sperm injection (ICSI)
• Special strategies for high risk pregnancies
• Nutritional counselling
• Psychological counselling
• Support groups: therapeutic one-to-one and group counselling on the topic of desire for children
• Acupuncture as assisting therapy

Fertility centers are almost always organized on outpatient basiss, though they usually have a day clinic where patients can rest after strenuous procedures. However, as especially international patients will be advised to stay around for a number of weeks, the centers will cooperate with appropriate and attractive hospitals.
Fertility assistance is a medical area, where the general health insurance system in Germany generally will not cover the costs. So in this field, patients will usually have to pay the treatments privately. This has lead to substantial quality competion between the centers, and they have developed high levels of patient and service orientation aswell as attractive architectural ambiance.

International patients will profit from this and feel very welcome. Of course German Hospital Service Ltd. will be very happy to assist you to find the best center for your needs,

What a foreigner should know about hospital and doctor’s bills in Germany

Treatment in hospitals and private practices of physicians is never free. Someone will always have to pay – and as foreigners are usually not covered by social security health insurance (which is compulsory for the majority of German citizens) this will usually be the patient. (If he has private insurance coverage, he can claim reimbursement afterwards.)

For outpatient treatment in private practice, there is a special government-regulated price list called GOÄ –Gebührenordnung für Ärzte. Here, prices for most of the activities and procedures that can happen during diagnostics and treatment, are fixed. Rather, to be more exact, a baseline price is fixed, for example for a normal consultation (also by phone), the price is 4.66 Euro. This basic price can, legally, however be multiplied by a factor of up to 3.5, if the activity was more complicated than usual, or if the doctor has agreed beforehand with the patient, that a certain multiplication factor will be applicable. So, for every visit to the physician, there should be a detailed bill which shows all the activities which where done – sometimes it is worth checking whether you can remember that all those procedures shown on that list really took place. Increasingly often, the insurance companies also check the bills and sometimes dispute critical items.

The same procedure will also be applied when the medical activity took place in a hospital on inpatient basis, if the physician has concluded a treatment contract with the patient to this effect. Such contracts are possible

• Firstly, if the physician is employed by the hospital, and the hospital has granted him the right to treat and invoice private patients – a privilege which is usually given to senior consultants or department chairmen only (for these, it is simply part of the salary deal).
• Secondly, the “Belegärzte”, physicians in private practice who have a contract with a hospital that they may treat inpatients there, will write a separate bill for their efforts. In both cases, these bills will come on top of the hospital bill.
• And if more than one physician was involved in the treatment process (e.g. cardiologist, surgeon, radiologist), each of these will present his separate bill for his activities.

Here also, the GOÄ is applicable; here also, the multiplication factors can be effective. One important aspect is: The patient is entitled to personal treatment by the physician himself, delegation to subordinate physicians is legally correct only under very restricted circumstances.

The hospital system for calculating the invoice, is another, and rather complicated process: First, based on the prevailing diagnoses and the procedures that where done, a DRG will be defined. The DRGs (Diagnosis Related Groups) are published by a governmental agency every year, the list comprises more than 900 different case rates (Fallpauschalen). For example, the DRG I78Z would be coded for the treatment of simple injuries of the shoulder, arm or leg without any complications; I44B would describe the implantation of a knee prosthesis without complications. Each of these DRGs is associated with an exact case value (for I78Z it would be a value of 0.411, for I44B the value is 2.600 in the 2007 catalogue). This DRG-value is then multiplied by the base rate of the individual hospital for the current year, which is the result of yearly negotiations of the hospital with the health insurance companies. Most base rates will be in the range of 2600.- to 2900.-Euro. So, for the activity described by I44B, the hospital bill would be 7280.- Euro if its current base rate is 2800.-Euro. All hospitals are obliged to inform patients about this system and the currently applicable base rate prior to concluding the treatment contract. There can be other, additional rates for special activities or very expensive materials, but usually these DRG prices also include the costs of implant materials, expensive pharmaceuticals etc.

The important point is now, that the DRG bill also includes the costs of medical staff, i.e. the physicians. And for social security patients, this price will be the complete cost of treatment. However, if a patient has decided to opt for private medical treatment by the senior consultant or chairman of the department, this personal treatment bill (as described above) will come on top of the DRG bill, and the patient (or his insurance company if he has coverage for that) will be responsible for both bills. The basis for such dual billing must be a dual treatment contract, which means: If, and only if, the patient has signed the additional contract for the individual medical treatment, the doctor will be entitled to the payment of his separate bill. And the interesting part: There is no obligation at all, for any patient whatsoever, to contract for this additional, optional private treatment! It is your right as a foreigner with or without insurance coverage to decline this option and go for standard medical treatment. The medical standard of your treatment will not be really different, as the doctors who will treat you are under the supervision of the same chairman who offered personal treatment. All you have to do is decline the additional contract when signing the hospital admission contract papers, and the hospital staff is not allowed to pressurize you to sign the private treatment contract as well.

And one more point: While it is true, that the DRG System is mandatory for social security patients, that does not give the hospitals complete freedom to leave this system for foreign or other private patients. There is also a rule which prohibits that hospitals make different prices for different groups of patients. So only private clinics which have no social security contract, may devise their own pricing system.

The same is incidentally true for the other optional features, like single room privacy or accommodation in a 2-patient room. Here also, the patient is free to decide whether he wants to sign for the additional options, no coercion is permitted and only the prices which are published by the hospital for all patients may be applied.

All this tells you: While there is a lot of regulation about what is permitted in terms of doctor’s or hospital billing, there is also a big range for optional agreements. And it is up to the patient, which options he contracts, sometimes substantially increasing the costs of treatment.

Also: The assistance by a patient referral organisation like German Hospital Service Ltd, can be very valuable: During the admission process and after the treatment, when someone with the relevant know-how can check the bills to make sure that there are no mistakes.

Endoprosthetic Surgery Treatment in Germany

Artificial knee prosthesis, partial or total hip prosthesis can be considered standard treatment options in most clinics specializing on orthopaedics or casualty surgery in Germany. Other specialties, which are only offered by a few clinics, are artificial discs to return or maintain full functionality of the spine, or replacement surgery in the elbow or shoulder.

All these treatments are of interest to international patients for a number of reasons:

• The quality can be good to excellent because of high level of expertise and competition between hospitals
• Even patients at high ages can be offered these treatments, as the surgical management is highly sophisticated and tolerable even for frail constitutions
• The costs, while probably not cheap by international standards, are reasonable, and the implant materials will be of excellent quality. The cost estimates which hospitals will give prior to such operations are usually very reliable, as the procedure is well under control.
• For standard procedures international patients will not face any waiting lists: Every patient is welcome.
• Some of the more advanced treatments are not available in some other countries, or only since a very short time, while in Germany there is a lot of experience already. An example for this is ADR: Artificial disc replacement, which was established in Germany years ago.

When choosing the clinic for your treatment, there are some considerations to keep in mind:

• How far developed is the experience with your required procedure? For some treatments, like artificial knee implantation, a quality regulation is in force which requires, that a clinic must perform at least 300 of these operations per year in order to be permitted to continue offering them. For other procedures, it might make sense to study the quality report which each hospital has to provide, and which can be researched via internet.
• What is the qualification of the responsible physician? Is he an orthopaedic surgeon, a casualty surgeon or has he got the new certificate which combines both specialities?
• Well qualified clinicians are licensed to train assistant physicians. The number of years they may offer this training is a good indicator of the quality of the clinic and its medical spectrum.

During the time, when fear of getting blood preserves which might be contaminated in some way, all major clinics have introduced the option of having the patient’s own blood transfused. This means of course, that patients have to attend a number of appointments for blood donation well before the surgery date, in order to accumulate the necessary quantity of blood preserves for his treatment.

One other specialty about the German system should also be mentioned in this context: One branch of the German social security system is compulsory casualty insurance for workplace accidents. These insurance institutions, “Berufsgenossenschaften” run a number if hospitals, where, of course, the main focus is on the treatment of patients after serious accidents. In such a clinic, the surgeons who are responsible for orthopaedic medicine will usually have a lot of experience and a high level of expertise.

All this goes to show, that it is essential to have insider knowledge about the clinics and their specialties. Which is where referral specialists like German Hospital Service Ltd. come in: They can get access to all the relevant information and assist foreigners in their choice to find the best hospital. Important in this regard is, that the referral service is neutral and independent and not associated to certain clinics. German Hospital Service Ltd. is such an absolutely independent service provider.

What is the standard of Cancer treatment in Germany?

For international patients who need treatment regarding specific cancer conditions, German clinics offer a wide range of medical treatments and institutions.

For the rather frequent types of cancer, like colon, breast and prostate, the approach is usually a combination of surgery, radiation therapy and chemo-therapy. Hospitals are developing institutions called "centers", which combine the efforts of the different departments and ensure a treatment scheme which is carried out along agreed procedures, based on the consensus of all the faculties that have joined. Regular joint conferences discuss all the patients and define the medical strategy according to the guidelines of evidence-based medicine. A few of these centers, like "breast centers" or "intestine centers" qualify to undergo a special peer review process, for example by an institution called Onkozert, which awards them the label "Certified Center".

In these cases, if the condition is diagnosed early enough, the chances of completely curing the disease are frequently very good.

For the more rare types of the disease, special units in the big university hospitals have been established, where, for example, bone marrow transplants or special neuro-surgical operation techniques like the "Gamma knife" are a regular mode of treatment. Other clinics provide hypothermia treatment, special laser treatments for liver metastases or any other up-to-date therapy.

For all these big centers it is important to know, that they participate in the research for new cancer treatments by taking part in studies. So, if the patient agrees, it is possible to benefit from the latest developments, especially on the cancer drug sector.

Before this background, with the help of a qualified referral organisation like German Hospital Service Ltd., patients can be sure to find the best possible treatment for their cancer condition.

However, it must be understood. Even the best treatment procedure cannot promise to provide a cure to a cancer patient.

Especially, when the treatment starts too late, doctors will only be able to prolong the lifespan of the patient, while improving the conditions of life during that final stage.

Is it a good idea to plan the birth of your child in a German hospital?

For any hospital in the world, the obstetrics department is one of the very important clinics. Not because the medical challenges are so great, but because here the “clients” are not really sick, and usually the outcome is a happy one. Under marketing aspects, this is ideal for establishing a new client relationship which can, if the parents are happy with the treatment they received during the birth of their child, lead to a life-long relationship, even including the rest of the family.

German hospital managers have understood this very well. So most have spent substantial amounts to make these parts of their hospitals most attractive: Beautiful rooms with modern, family-oriented furniture at good hotel standard, special buffet style breakfast for the mother AND the father (who can also share the room with her, and stay overnight). Specially designed delivery rooms with all the equipment imaginable for any delivery method the mother could wish: big round beds, underwater- delivery tubs, supports and chairs, together with soft soothing music, special light effects, storage of all medical machinery out of sight make these “birth rooms” feel more like comfortable living rooms that anything else. And Fathers are really welcome to join their partners during these important hours; many clinics permit them even in the operating theatre during caesarean birth. Of course, medical standards like online monitoring of the pre-birth parameters of mother and child, all known methods of pain relief/suppression, the availability of a special operating theatre with surgery team in case of need (e.g. of a casarean birth) are ensured – but not in the foreground. Everything is focused on making the birth of their child the most emotional positive experience for the parents.

Some links showing beautiful clinic examples:

http://www.ukb.uni-bonn.de/42256BC8002AF3E7/vwWebPagesByID/64485F60B46B5750C1256E4B0057541B

http://www.vincentius-kliniken.de/vincentius/export/pics/kliniken/gyn/wanne.jpg

http://www.maerkische-kliniken.de/Klinikum/Kliniken_und_Institute/Fachabteilungen/Frauenklinik/DGeburtshilfe/Geburtshilfe.htm

http://www.klinikum-barnim.de/klinik_frauenheil

Due to this competition among hospitals, parents-to-be have developed the habit of travelling around to visit the various providers in their area, look at the facilities, speak to the doctors and the midwives, and then decide, where they want to go for giving birth.

Some additional aspects are also relevant for this “clinic shopping”: Is the doctor a specialist in pre-natal diagnostics? How high is the rate of caesarean vs. natural delivery? Does the hospital try to promote breast feeding or not? Are the midwives freelance or employed by the hospital? Is the doctor in private practice or hospital resident? Does the clinic have a quality certificate like KTQ, ProCumCert? Is there a paediatric clinic available in the same hospital? Does it provide care for prematurely-born babies?

One important criterium: How many births does the clinic have per year? German regulations have a tendency to restrict the license for obstetrical care to clinics that have more than 300 births, although the medical evidence, that this is really a valid quality benchmark, is under debate.

Luckily, in most cases, all this is not really necessary. But the main reason for going to a hospital for delivery (and not go to a “Geburtshaus” run only by midwives or stay at home and having “your” midwife come to your home) is that parents look for the extra safety, which easy availability of all the hospital staff and facilities gives them for any emergencies.

For international patients who consider coming to Germany for the “Big Day” all these criteria also apply. Referral organisations like German Hospital Service Ltd. will assist them to get the relevant information ahead of time.

But of course one little problem remains: The exact date of delivery cannot be planned. So the best you can do, is to travel to the city with the hospital you have chosen, ahead of time, and plan to stay at a nearby hotel until labour gets under way.

By the way: Under German law, a baby does not acquire the German nationality by being born there. So this would not be an argument for coming to Germany for the birth of your child. But the excellent medical standard, together with the special attention that hospitals offer to delivering mothers and their families can be a perfect reason.

Is language an issue for international patients in German hospitals?

Language can be an issue - especially if it is not English.

While it is fair to say, that just about all German physicians will be able to communicate very well with patients in English - even to the point of having psychotherapeutic sessions - this will not be generally true for the other hospital staff. Nurses and administrators ususally have a training, which has not emphasized the command of foreign languages.

And in our experience, also for the physicians there can be a problem when it comes to written communications, reports etc. Of course in the big university clinics, where the medical staff is also involved in research, which includes presenting papers to the international science community, this will not be an issue. But at smaller hospitals it might take a little longer to get a report in English.

Other languages will be definitely less common, with two exceptions: Now-a-days, many physicians from the Eastern European countries can be found in German hospitals, so there will be a fair chance to find someone who can speak Russian in most hospitals - frequently also among the nursing staff. And there is a strong tradition of physicians from arab-speaking countries like Iraq, Iran, Lebanon to spend at least part of their training in Germany - and many stay. So Arabic will also be availabe in most hospitals, though not in every department.

In effect, with one of these three languages, German Hospital Service Ltd. will be able to find a hospital where an international patient will be welcomed to his understanding.

Which quality management systems are used in German Hospitals?

German hospital legislation requires all hospitals to adopt „a quality management system”, but there is no regulation as to which system should be used.

Consequently, almost all the possible QM-systems and certifications have their customers: The JCC (joint commission certificate), the DIN-ISO 2000 etc., the European quality award EFQM and two specific systems, which were developed by the hospital scene together with the social security health insurance, KTQ (Kooperation fuer Transparenz und Qualität) and ProCumCert. These systems all have in common, that the general procedures for important activities have to be written down, followed and evaluated. In addition, factors like patient and staff satisfaction, financial solidity and leadership are important – though the weight differs between the systems. The PCC-certification was created for the many hospitals under church responsibility; here aspects of spirituality and religious orientation are additional criteria.

Over all, it is to my knowledge fair to say that KTQ and KTQplusPCC have the largest part of the certification market.

In addition, there is an increasing number of specialized certificates: Breast centers (mammary oncology), intestine centers (intestinal oncology) and others are certified by an institution called Onkozert; efforts in favour of breast-feeding are certified with a family-orientation certificate by the WHO; the WHO-initiative called health-promoting hospitals makes for an increasing network, also the initiative for smoker-free hospitals with 3 different levels of certification. Special institutions within hospitals again have their special QM-certifications: laboratories (DAR), radiology (governmental radiation control) etc.

Of course all these systems and procedures of quality management are focussed on the aspects of structural quality and procedural quality. Outcome quality is hardly an issue in these systems. And, of course, a measurement of outcome quality, moreover in benchmark comparison with other hospitals, is a difficult issue. Some hospitals have started to address it cautiously, by including additional data in their annual quality reports.

These reports are also required by law every two years and have to be published on the internet. They provide information on the hospital’s infrastructure, the most frequent medical procedures and also on the quality management system that is adopted by the hospital. On a voluntary basis, some hospitals also publish statistics like mortality rates, infection rates etc..

Two more quality management aspects should be mentioned:

For certain procedures a special government institution has published minimum quantity standards regarding the number of procedures per year. For example: A hospital, that has not performed a minimum of 50 total knee implant operations in one year looses the permission to continue offering this type of service.

And for an also increasing number of medical procedures hospitals have to provide a host of medical data to the central medical councils. These data are studied by special committees of physicians, and clinics or departments with big deviations from the standard are faced with critical reports that call for measures to improve the situation. But up to now, also because the criteria are very medical and their relevance is not always obvious to a layman, these reports are not available to the public yet.

What is the situation regarding legal liability for medical treatment in Germany?

Regarding the liability for any medical treatment activity, we have to look separately at what kind of claims could be raised.

• Claims for unsatisfactory results of treatment. ( "I spent a lot of money on the doctor and the hospital, but all their activities were to no avail. My cancer disease was not cured - or my left breast is still smaller than the right one.")
  For such claims, the legal system in Germany offers no legal grounds. The treatment contract, which is made between the hospital (or the doctor) and the patient does not entitle the patient to any guaranteed results. The contract only obliges the hospital or the doctor, to treat the patient according to up-to-date medical standards. But there will never be any contractual obligation to ensure a certain result.
• Claims for personal injury. As medical treatment is administered mostly by human beings, it is never possible to exclude the risk of any mistakes happening during treatment. A mistake could be, that the operation team forgets a medical instrument inside the patient' s body, or that the nurse gets the medication for patients mixed up, and causes serious health problems to a patient. Also, if the treatment was not given according to the state of the art, or a necessary diagnostic procedure was forgotten, that would be considered a mistake.
  For such cases, the legal system in Germany provides a number of claim possibilities. However, the claimant has to prove that a mistake was made, and that someone is personally liable for this mistakeL Liability can be based on intent or negligence, and even slight negligence can lead to full personal liability for all the financial damages that arise from the mistake. In principle, the claimant can demand to be restituted into a position as if the mistake had not occured (i. e. repair of damages). If that is not possible (e.g. the wrong leg was amputated), the financial consequences (treatment costs, reduced ability to work etc) have to be covered.
  However, the German system focusses more on the material damages. Immaterial damages, like compensation for pain, shock or emotional distress, are not considered as important and the sums of money which are awarded by courts for these reasons are low compared to, for example the United States.

For both types of liability, the hospitals and their doctors of course have their liabilty insurances. So the claims are not really dealt with by the hospital. The insurance companies decide, when they admit liability and offer payments or when they seek justice by court decision. And here also, there is a noteable difference to the situation in Germany: Most civil liability cases are really decided by the courts, and negotiated settlements are less frequent.

Is there a tax on hospital invoices which international patients can get refunded?

This is a question, that has been posed a number of times. The answer is: Generally not.
The fact is: For normal medical treatment there is a general exemption from the VAT (Value added tax), for non-profit hospitals (the vast majority of hospitals) as well as for private clinics. Medical services, at least as long as they are medically necessary, can be invoiced without VAT; consequently there is nothing to get refunded when the patient returns home.
By the way: The same applies for doctor's fees: Doctors do not qualify for VAT invoicing for medical services they provide.
Only in such cases, where no medical need whatsoever can be shown, for example plastic surgery for purely aesthetic reasons, this service will be considered to be simply commercial, and the VAT has to be added on the bill. And even in such cases, if the hospital normally has only medical treatment patients, the VAT will often be forgotten by the administration (how should they know, that there are no medical reasons for the treatment in this specific case?)
But of course, if a private clinic has specialized on such operations, or if a doctor also sells goods (like a special machine or drug) they will be in the focus of tax authorities and will add the VAT routinely.
But that will be a rare exception.

Is it possible to have major transplant surgery as an international patient in Germany?

It is not the most frequent type of medical problem which international patients look to get treated in Germany - but kidney transplants, lung transplants, liver transplants etc. are definitely among the desired treatments, which patient referral organisations like German Hospital Service Ltd., encounter among their patient requests.
And why not? A number of highly qualified transplant centers, usually in the big university clinics, perform these high-tech operations regularly and have a lot of experience. So why should international patients, who perhaps do not have these facilities in their countries, not profit from this expertise.
Right! They should, and in principle they can. With one big BUT: They need to bring their own live donor, if they need a live transplant. Why?
In Germany, like in most countries in the world, the demand for organs greatly exeeds the avilable donations. And although a europe-wide organisation, EuroTransplant, tries to coordinate the exchange by maintaining a huge data base of patients who are waiting for an organ and comparing the medical parameters of every organ that can be secured from accident victims etc., in many cases the wait on the list can be too long, and patients will not survive long enough for a suitable organ to be found.
Due to this grave shortage, it has been decided, that only patients who are residents of the EuroTransplant countries, can be eligible for the waiting list.
This means, that an international patient can only be considered for transplant surgery, if he has a relative or close friend who is willing to donate, for example, one of his kidneys to him. And in Germany, like in most other European countries, the donation of organs for financial considerations is considerd unethical and illegal. Every single case of voluntary donation is closely examined by an ethics committee before the permission for the transplant operation is granted.
So: While is may not be major problem in some countries to "buy an organ", it will not be possible to bring such a donor to a German hospital and have get the desired surgery.
Only if the donor is really a member of the family, and if it can be shown that the donor acts of his own free will and not under any pressure, the ethics committee will allow the doctors to begin the treatment.