What can we learn from German health incentive schemes?

BMJ 2009; 339 doi: (Published 24 September 2009) Cite this as: BMJ 2009;339:b3504
  1. Harald Schmidt, research associate1,
  2. Andreas Gerber, senior researcher2,
  3. Stephanie Stock, senior researcher2
  1. 1LSE Health, London School of Economics and Political Science, London WC2A 2AE
  2. 2Institute of Health Economics and Clinical Epidemiology of the University of Cologne, 50935 Cologne, Germany
  1. Correspondence to: Harald Schmidt{at}
  • Accepted 16 August 2009

Incentives aimed at changing individual health behaviours are well established in Germany. Harald Schmidt, Andreas Gerber, and Stephanie Stock describe how they work and discuss some of the difficulties

Germany first introduced incentives aimed at individuals into its statutory health insurance scheme in 1989, offering reduced copayments for dental treatment to people who attended regular check-ups. Since then, many other incentive schemes have been launched. Some welcome these, but others question their rationale and effectiveness and worry that a focus on individual behaviour detracts from taking action at the social level. Despite these concerns, other countries, including the United Kingdom, have shown interest in incentive programmes.1 2 3 We look at the lessons to be learnt from Germany’s experience.

Rationale for incentive systems

German incentive schemes have three main goals:

Improve population health—As elsewhere, chronic diseases are on the rise in Germany. Although evidence on the role of the social determinants of health is becoming increasingly irrefutable,4 even the most health conducive environments do not, by themselves, make people healthy. Targeting individual behaviour is therefore viewed as a complementary way of improving population health.

Maximise efficiency of services—Individual behaviour also has implications for the efficient operation of a healthcare system. Many incentive schemes seek to encourage responsible use of resources—for example, by rewarding compliance with treatment or minimising use.

Enhance competition between sickness funds—Germany’s social health insurance system has around 200 sickness funds, and citizens have free choice of fund.5 Incentive programmes serve as tools for attracting and retaining clients, in much the same way airlines or supermarkets use loyalty schemes.6

Some incentive schemes seek to satisfy all three of these goals, whereas others may focus on one or two of them.

Incentive systems in practice

Sickness funds offering incentive programmes are bound by the provisions set out in …

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