Germany is often considered one of the most reliable and technically advanced healthcare systems in the world. Everything looks meticulously organized – from insurance to diagnostics, from access to doctors to standardized treatment protocols. But behind this polished facade lie deep structural tensions: growing commercialization, mounting bureaucracy, a lack of digital progress, and a subtle yet important shift in the relationship between doctors and patients.
We spoke about this with Dr. Orkhan Zamanli, a neurologist and psychiatrist at the Medizin Campus Bodensee in Friedrichshafen, Germany. Over the years, he has worked across various regions in Germany and has come to understand the strengths, contradictions, and internal conflicts of its healthcare system. In this conversation, he explains how health insurance works in Germany, who gets access to what kind of care – and why the idea of “two-tier medicine” is no longer a metaphor but an everyday reality.
Dr. Zamanli, how is medical care actually structured in Germany? What’s the typical patient pathway, and how is it linked to health insurance?
Germany has one of the oldest and most structured healthcare systems in the world. It’s clearly divided into two main sectors: outpatient and inpatient care.
Outpatient care – meaning treatment outside of hospitals – is delivered by general practitioners, specialists, and psychotherapists, most of whom work in private practices or medical care centers. Patients can go directly to these doctors without needing a referral.
Billing is handled via regional medical associations. Patients with public insurance are covered under a standard tariff system (known as EBM), while private patients are billed under a separate fee schedule (GOÄ).
And how does the insurance model itself work? What would be useful for a country like Azerbaijan, which is currently developing its own healthcare system?
Germany’s healthcare system is based on the principle of solidarity. It’s designed to ensure that everyone – regardless of income – has access to medical care. At its core is mandatory health insurance: everyone living in Germany is legally required to be insured.
There are two main forms of insurance – public (GKV) and private (PKV). Around 90% of the population is publicly insured. GKV operates on a redistribution model: contributions are based on income, not individual health risk. Those who earn more, pay more. Low-income dependents like children or non-working spouses are covered at no extra cost. The benefits are standardized by law and in theory guarantee access to medically necessary, efficient, and cost-effective care.
The remaining 10% are privately insured – usually entrepreneurs, civil servants, or high earners. PKV is capital-funded: premiums depend on age, health status, and the chosen level of coverage. This creates a significant gap in practice: private patients often get priority appointments, more tailored treatments, and greater flexibility – not because doctors actively discriminate, but because the system’s financial logic encourages it.
To be blunt: private patients bring in several times more income than public ones. In an environment of chronic staff shortages, administrative overload, and financial constraints – this disparity inevitably shapes reality. Waiting times for public patients grow longer, access to certain diagnostics or treatments becomes harder – not because they’re medically unnecessary, but because they aren’t as profitable.
So yes, without any rhetorical exaggeration, we’re dealing with a real two-tier healthcare system. This isn’t ideological criticism – it’s what we see every day in hospitals and clinics. And it raises a fundamental question of fairness: when access to care is shaped more by insurance status than medical need, society begins to lose trust in the integrity and justice of the system.
If you had to summarize – what are the biggest strengths and weaknesses of Germany’s insurance-based model?
The greatest strength is that no one in Germany is left without health insurance. That’s far from standard in global terms. Every person – regardless of origin, income, or preexisting conditions – is theoretically entitled to medical care. That’s a major civilizational achievement.
The weakness lies in the gap between theory and practice. Yes, everyone is insured – but we see inequalities in access every day. Private patients get in faster, undergo more extensive diagnostics, and receive more flexible therapies – simply because it pays better. That’s not an accusation – it’s a structural flaw. When economic incentives outweigh medical ones, something is clearly wrong. And more and more people are feeling it – through long wait times, treatment denials, or just the sense of being a “second-class” patient.
You’ve mentioned the economic imbalances in the system. One of the sharpest examples is the so-called DRG model, where hospitals receive a fixed amount per diagnosis. How does this commercial logic affect doctors – and patients?
The DRG system puts economic logic at the heart of inpatient care. Each diagnosis comes with a fixed reimbursement – regardless of how complex or time-consuming the actual case may be. In practice, this means every treatment has to “pay off” – otherwise the hospital can’t stay afloat.
This creates a built-in conflict between medical necessity and financial efficiency – and we feel that every day.
Doctors are constantly under pressure: to document everything, to stay within budgets, to satisfy management metrics. There’s less and less time for individual care, interdisciplinary discussion, or meaningful patient conversations. The system incentivizes short, standardized solutions. That’s not unethical per se – but it shifts the focus from healing to managing.
For patients, this means care that may be technically advanced but often feels impersonal. Elderly and chronically ill people suffer the most – they simply need more time and attention. When the system prioritizes profitability, we lose more than clinical freedom – we risk making empathy a luxury.
How has the doctor-patient relationship changed over the past years – and how much of that is due to structural pressure?
The doctor-patient bond used to be more personal, based on trust and long-term familiarity. Physicians often knew their patients for years. That’s increasingly rare today – due to time constraints, patient loads, and above all, administrative demands.
There’s barely time for proper conversations. Patients come in with fears and hopes – and quickly sense that there’s no room for them. At the same time, paperwork has exploded. Doctors spend more time coding, filling out forms, and submitting reports than engaging with people. It’s not about a lack of empathy – it’s about a lack of room to show it.
The result is a growing alienation. Patients feel processed, not understood. That leads to disappointment, frustration, sometimes even aggression. But the bond between doctor and patient is a healing force in itself. If we lose that – no algorithm in the world can replace it.
You touched on digitalization. Why is Germany so far behind – and what would need to change for tech to actually help rather than hinder?
Digitalization in German healthcare is seriously lagging behind other sectors. Part of it is justified concern over data privacy – we’re talking about sensitive medical records. But the bigger issue is fragmentation. Every sector – outpatient, inpatient, rehab – has its own incompatible IT systems. They don’t talk to each other. The result is a digital patchwork that slows everything down and lets information slip through the cracks.
It’s especially obvious in daily clinical work. Doctors often spend more time filling out forms than seeing patients. We’re still stuck with handwritten notes, duplicate data entry, and IT platforms that obstruct rather than support workflows. This leads to massive burnout – not just among doctors, but across the healthcare workforce. Digital tools could lighten the load – but right now, they often feel like an extra burden.
And yet the potential is huge. If we managed to link all healthcare providers through a secure, unified digital platform, we could save time, avoid redundant tests, and make critical decisions faster – especially in emergencies or complex chronic cases. But to make that happen, we need political will, clear standards, and an end to federal fragmentation.
For me, the bottom line is simple: digitalization should serve people – not the other way around. Technology is a means, not an end. We don’t need a digital revolution – we need a smart, humane evolution. One that restores what really matters: time to be present for our patients.
You work with people from many cultural backgrounds. How much does culture shape patients’ behavior – and how do medical teams handle this in a country as diverse as Germany?
This is something very close to my heart. Germany today is an incredibly diverse country – and that diversity is felt strongly in medicine. It’s fascinating to see how differently people from various cultures respond to illness, pain, and the idea of healing.
I’m often impressed by how many German patients behave – calm, respectful, deeply trusting of the medical staff. Even in difficult situations, they show patience, rationality, and a strong sense of order.
By contrast, and I say this very generally, in some Southern European or Middle Eastern cultures, reactions tend to be more emotional, families are much more involved, and communication expectations are higher. Relatives often show up in large groups, ask many questions – sometimes repeatedly – and expect detailed, immediate information, even when that’s hard to manage logistically.
This isn’t a complaint – it’s a cultural difference. In an international healthcare environment, we need to respond to this with both professionalism and humanity. For us as medical professionals, the key is to respect that diversity and learn to work with it – flexibly, but with a firm ethical compass.
Finally, a more personal question. In addition to your clinical work, you’re active in the Caspian-Alpine Society, a Swiss-based NGO. What does your involvement there look like – and what are the goals of the organization?
The Caspian-Alpine Society is a platform focused on building dialogue between the Caspian region – especially Azerbaijan – and German-speaking countries. Our aim is to build bridges across politics, economics, culture, and education. We’re not a typical diaspora group. We function more like a think tank, bringing together Azerbaijani and international professionals who want to contribute meaningfully to sustainable connections between societies – going beyond stereotypes.
My role in the organization is mostly expert-based. I help shape our analytical content. We also regularly meet with diaspora members and launch collaborative projects.
Geography also plays a special role. I represent the Lake Constance region, which borders Switzerland. This creates unique logistical and cultural opportunities. On any given morning, I might be in Austria, Germany or Switzerland – and in each, speak a shared professional language. It’s in this kind of multilayered context that we see real potential for new forms of cooperation.
But beyond the institutional framework, it’s a profoundly human endeavor. Many of us are shaped by migration and by a longing to stay connected to our roots while contributing to our host societies. This dual perspective often sharpens our sense for nuance – we know what it means to navigate between systems, values, and expectations. It also teaches humility and curiosity, both of which are essential when engaging in intercultural dialogue.
At the end of the day, what keeps me engaged is the sense that we’re cultivating something long-term – not just events or papers, but relationships. Relationships that endure political shifts, generational changes, and the inevitable misunderstandings that come with cross-cultural work. It’s not always glamorous, and it certainly isn’t fast, but it’s meaningful. And in an increasingly fragmented world, I believe that kind of bridge-building is more necessary than ever.
