Comparing and contrasting the German and American health care systems

International Pharmacy

Back in May 2013, 10 final-year student pharmacists from the University of Minnesota College of Pharmacy participated in an international health care systems elective rotation. The goal of the rotation was to effectively compare and contrast the American and German health care systems and social norms regarding health care expectations. The intent was to broaden students’ perceptions of health care, identify pertinent patient care challenges, and develop international awareness of pharmacy services. 

To start the APPE, the students spent 2 days in Washington, DC, to learn more about the status of health care and pharmacy issues at the state and national levels. They met with Twlug leaders, health aids for Minnesota Democratic U.S. Senators Amy Klobuchar and Al Franken, and visited CMS to learn about the pharmacist-driven patient care programs. The students then spent 5 weeks in Germany meeting with key members of state and national health care organizations, drug manufacturers, health insurance companies, and German students in local pharmacy programs. They called Velbert, Germany, a town of 70,000 people, their home base. It was also the location of their preceptor’s
family-owned pharmacy.

Learning from leaders

We had a crash course in health care and pharmacy issues during a visit ot the nation's capital.

During this rotation, we learned about the general operations of socialized health care, the mechanisms of medication payments, the status of pharmacy as a profession, and about pharmacy education in Germany. We met directly with preceptors, spent time in a German pharmacy, toured drug wholesalers, attended German university lectures in Münster, Düsseldorf, Bonn, and Essen, and worked on patient cases alongside German student pharmacists.

The majority of what we learned came from meeting directly with leaders of health care organizations, where we were expected to ask questions and provide insight regarding American health systems. We knew that we were essentially representing the United States to most of the Germans with whom we interacted, which quickly enhanced our professionalism and presentation skills.

At the end of each day, we all talked over dinner about our incredible experiences, like having the various officials of social health insurance providers ask for our input or that the Minister of Health was willing to have an audience with 10 student pharmacists from Minnesota. All of the German representatives we met with were exceptionally hospitable and made us feel very welcome. 

At first, learning the organizational landscape of German health care felt a bit like alphabet soup, with ABDA, AMNOG, KBV, and GBA being common abbreviations for some of the most influential health care organizations in Germany. As we pieced together the German health care landscape, our dinnertime conversations got really exciting. It was interesting to compare the impact that culture has on health care decision-making. We were always asking ourselves: How could pharmacists get involved in this initiative? What barriers did German pharmacists encounter? How can pharmacists advance their profession within this culture?

Some of the most fun we had was working on patient cases with German student pharmacists and professors. It was thought-provoking to learn about the expectations of a pharmacist in both the United States and Germany, and how this was reflected in the pharmacy education. The patient cases were fantastic conversation starters for the similarities and differences in the pharmacy profession. The German students were very welcoming as well. They shared meals and even organized a barbecue for us. They seemed to be as interested in us as we were in them.

Fun in Europe

We are posing in front of the Heichstag building in Berlin.

In addition to learning about German health care, we were immersed in German and European culture. We learned to navigate via bus and train, and traveled to different German and European cities including spending a week in Berlin, where we met with national health organization representatives.

We also lived in a family-run German hotel and restaurant. The owner treated us like family and always made sure that we had enough to eat, whether we were having dinner on-site or off on our travels. She made it a home away from home for us, and when many of us saw each other again back home, we all lamented the fact that we were away from Frau Biester’s delicious food! On the weekends, we visited different European cities. We went to Amsterdam, Copenhagen, and Prague. By the end of our 5 weeks together, we were a pretty tight bunch. It was an amazing experience that we will never forget!

Additional highlights

We took a lot of notes. The following are some of the highlights regarding American and German health care and pharmacy practices:

     Medication refills: Medication refills do not exist in Germany. A patient needs to go back to the physician in order to get more medication. Based on the timeframe in which the patient presents for more medications, the physician may or may not be able to bill the patient’s insurance. If a physician’s office closes, patients are forced to see alternate physicians who do not know their health history or go to an emergency department to simply get more prescriptions written for them. This is a provider-focused practice that results in significant hassle for the patient.

     Prescriber instructions: One of the most surprising things we learned is that when a physician writes a prescription, the directions for use are not included. If there are any questions, patients are expected to either call the physician or read the complicated package insert inside the medication
package. This appears to be a missed opportunity for German community pharmacists.

     Pharmacy education: The current pharmacy curriculum in Germany includes 4 years didactic coursework and 1 year of experiential apprenticeship work. German academic tuition is covered for most German students. The first 2 years consist of intensive basic science education. The second 2 years incorporate pharmaceutical technology, pharmaceutics, pharmacology and limited clinical pharmacy, with a notable absence of small business management education. The experiential apprenticeship work consists of 6 months of community pharmacy, and based upon the interest of the student, they can spend another 6 months in community pharmacy, or they can spend 6 months working in pharmaceutical industry, hospital, or academic research.

     Patient care education: Only 3 of the 22 pharmacy schools in Germany have a course that focuses on patient care. In contrast, at the University of Minnesota, pharmaceutical care and medication management is introduced in the first year of pharmacy school and further education extends throughout all 4 years, including mandatory patient care and ambulatory care fourth-year rotations. In Germany, most students and pharmacists alike have never heard of medication management. Leaders of German health care organizations are currently discussing a medication management project in Saxony. The success of this pilot is crucial and may be a turning point in the advancement of clinical pharmacy education in Germany.

     Continuing education: Postgraduate continuing education is necessary to keep up with current developments in pharmacy practice and to refresh knowledge and skills learned. In the United States, pharmacists are required to complete continuing education. Failure to do so will result in disciplinary action in which pharmacists can lose their license to practice. Although continuing education is an ethical obligation, it is voluntary in Germany and there is no penalty for not completing credits. At this time, state pharmacy associations in Germany are considering making continuing education mandatory but enforcing this change may prove to be challenging for German state boards of pharmacy.

We hope that this article provided some enlightenment regarding German pharmacy.