meaningful services"; is not dependent on an individual's health condition, but a percentage (currently 14.6%, 7.3% of which is covered by the employer) of salaried income under €64,350 per year (in 2021). additionally, each public health insurance provider charges an additional contribution rate, which is 1.3% on average (2021), but goes up to 2.7%; includes family members of any family members, or "registered member" (familienversicherung – i.e., husband/wife and children are free); is a "pay as you go" system – there is no saving for an individual's higher health costs with rising age or existing conditions. instead, the solidarity principle applies in which the current active generation pays forward for the costs of the current retired generation. private insurance in the private system, the premium is based on an individual agreement between the insurance company and the insured person defining the set of covered services and the percentage of coverage; depends on the amount of services chosen and the person's risk and age of entry into the private system; is used to build up savings for the rising health costs at higher age (as required by law). this is otherwise known as aging provisions (alterungsrückstellungen). for persons who have opted out of the public health insurance system to get private health insurance, it can prove difficult to subsequently go back to the public system, since this is only possible under certain circumstances, for example if they are not yet 55 years of age and their income drops below the level required for private selection. since private health insurance is usually more expensive than public health insurance, although not always, the higher premiums must then be paid out of a lower income. during the last twenty years private health insurance became more and more expensive and less efficient compared with the public insurance. in germany, all privately financed products and services for health are assigned as part of the 'second health market'. unlike the 'first health market' they are usually not paid by a public or private health insurance. patients with public health insurance paid privately about €1.5 billion in this market segment in 2011, while already 82% of physicians offered their patients in their practices individual services being not covered by the patient's insurances; the benefits of these services are controversial discussed. private investments in fitness, for wellness, assisted living, and health tourism are not included in this amount. the 'second health market' in germany is compared to the united states still relatively small, but is growing continuously. self-payment (international patients without any national insurance coverage) besides the primary governmental health insurance and the secondary private health insurance mentioned above, all governmental and private clinics generally work in an inpatient setting with a prepayment system, requiring a cost estimate that needs to be covered before the perspective therapy can be planned. several university hospitals in germany have therefore country-specific quotes for pre-payments that can differ from 100% to the estimated costs and the likelihood of unexpected additional costs, i.e. due to risks for medical complications. economics health economics in germany can be considered as a collective term for all activities that have anything to do with health in this country. this interpretation done by andreas goldschmidt in 2002 seems, however, very generous due to several overlaps with other economic sectors. a simple outline of the health sector in three areas provides an "onion model of health care economics" by elke dahlbeck and josef hilbert from the institut arbeit und technik (iat) at the university of applied sciences gelsenkirchen: core areas are the ambulatory and inpatient acute care and geriatric care, and health administration. around it is located wholesale and supplier sector with pharmaceutical industry, medical technology, healthcare, and wholesale trade of medical products. health-related margins are the fitness and spa facilities, assisted living, and health tourism. according to this basic idea, an almost totally regulated health care market like in the uk would not be very productive, but also a largely deregulated market as in the united states would not be optimal. both systems would suffer concerning sustainable and comprehensive patient care. only a hybrid of social well-balanced and competitive market conditions created a relevant optimum. nevertheless, forces of the healthcare market in germany are often regulated by a variety of amendments and health care reforms at the legislative level, especially by the social security code (sozialgesetzbuch- sgb) in the past 30 years. health care, including its industry and all services, is one of the largest sectors of the german economy. direct inpatient and outpatient care equivalent to just about a quarter of the entire 'market' – depending on the perspective. a total of 4.4 million people working in this, that means about one in ten employees in 2007 and 2008. the total expenditure in health economics was about €287.3 billion in germany in 2010, equivalent to 11.6 percent of gross domestic product (gdp) this year and about €3,510 per capita. drugs costs the pharmaceutical industry plays a major role in germany within and beyond direct health care. expenditure on pharmaceutical drugs is almost half of those for the entire hospital sector. pharmaceutical drug expenditure grew by an annual average of 4.1% between 2004 and 2010. such developments caused numerous health care reforms since the 1980s. an actual example of 2010 and 2011: first time since 2004 the drug expenditure fell from €30.2 billion in 2010 to €29.1 billion in 2011, i.e. a fall of €1.1 billion or 3.6%. that was caused by restructuring the social security code: manufacturer discount 16% instead of 6%, price moratorium, increasing discount contracts, increasing discount by wholesale trade and pharmacies. as of 2010, germany has used reference pricing and incorporates cost sharing to charge patients more when a drug is newer and more effective than generic drugs. however, as of 2013 total out-of-costs for medications are capped at 2% of income, and 1% of income for people with chronic diseases. statistics the reduction in infant mortality between 1960 and 2008 for germany (green) in comparison with australia, france, the netherlands, the united kingdom, and the united states in a sample of 13 developed countries germany was seventh in its population weighted usage of medication in 14 classes in 2009 and tenth in 2013. the drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. the study noted considerable difficulties in cross border comparison of medication use. it has the highest number of dentists in europe – 64,287 in 2015. major diagnoses in 2002, the top diagnosis for male patients released from the hospital was heart disease, followed by alcohol-related disorders and hernias. for women, a 2020 study lists the three most common diagnoses as heart disease, dementia and cardiovascular diseases. in 2016, an epidemiological study highlighted significant differences among the 16 federal states of germany in terms of prevalence and mortality for the major cardiovascular diseases (cvd). the prevalence of major cvd was negatively correlated with the number of cardiologists, whereas it did not show any correlation with the number of primary care providers, general practitioners or non-specialized internists. a more relevant positive relation was found between the prevalence or mortality of major cvd and the number of residents per chest pain unit. bremen, saarland and the former east german states had higher prevalence and mortality rates for major cvd and lower mean lifespan durations. hospitals types: there are three main types of hospital in the german healthcare system: public hospitals (öffentliche krankenhäuser). charitable hospitals (frei gemeinnützige krankenhäuser). private hospitals (privatkrankenhäuser). the charité university hospital in berlin the average length of hospital stay in germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the united states (5 to 6 days). drug costs have increased substantially, rising nearly 60% from 1991 through 2005. despite attempts to contain costs, overall health care expenditures rose to 10.7% of gdp in 2005, comparable to other western european nations, but substantially less than that spent in the u.s. (nearly 16% of gdp). in 2017 the bbc reported that compared with the united kingdom the caesarean rate, the use of mri for diagnosis and the length of hospital stay are all higher in germany. waiting times and capacity according to several sources from the past decade, waiting times in germany remain low for appointments and surgery, although a minority of elective surgery patients face longer waits. in 1992, a study by fleming et al. (cited in siciliani & hurst, 2003, p. 8), 19.4% of german respondents said they had waited more than 12 weeks for their surgery. in the commonwealth fund 2010 health policy survey in 11 countries, germany reported some of the lowest waiting times. germans had the highest percentage of patients reporting their last specialist appointment took less than 4 weeks (83%, vs. 80% for the u.s.), and the second-lowest reporting it took 2 months or more (7%, vs. 5% for switzerland and 9% for the u.s.). 70% of germans reported that they waited less than 1 month for elective surgery, the highest percentage, and the lowest percentage (0%) reporting it took 4 months or more. both social health insurance (shi) and privately insured patient experienced low waits, but privately insured patients' waits were even lower. according to the national association of statutory health insurance physicians (kbv, kassenärztliche bundesvereinigung), the body representing contract physicians and contract psychotherapists at federal level, 56% of social health insurance patients waited 1 week or less, while only 13% waited longer than 3 weeks for a doctor's appointment. 67% of privately insured patients waited 1 week or less, while 7% waited longer than 3 weeks. waits can also vary somewhat by region. waits were longer in eastern germany according to the kbv (kbv, 2010), as cited in "health at a glance 2011: oecd indicators". germany has a large hospital sector capacity measured in beds: it has the highest rate of intensive care beds among high income countries and the highest rate of overall hospital capacity in europe. high capacity on top of significant day surgery outside of hospitals (especially for ophthalmology and orthopaedic surgery) with doctors paid fee-for-service for activity performed are likely factors preventing long waits, despite hospital budget limitations. activity-based payment for hospitals also is linked to low waiting times (siciliani & hurst, 2003, 33–34, 70). germany introduced diagnosis-related group activity-based payment for hospitals (with a soft cap budget limit).