Introduction

Health insurance is mandatory in Germany. Most people are covered by statutory health insurance (SHI), but 11% are covered by full “substitutive” private health insurance (PHI). This latter group comprises civil servants, the self-employed, and people with an income above a certain threshold (in 2021: 64 350 €/year) who choose to opt out from SHI. However, this specific population group is underrepresented in health services research in Germany. Therefore, experiences of people with PHI regarding healthcare (e.g. patient safety) in Germany according to their level of health literacy (HL) were subject to this research. The aim was to analyze if people with limited HL perceive patient safety concerns more often.

Methods

In 2018, a survey was conducted among 20,000 people with full PHI in Germany. Survey data were linked with health insurance claims data (e.g. diagnoses, hospital stays, use of pharmaceuticals). Survey items were based on the intermediate and final goals of the WHO Health Systems Framework, e.g. patient safety. HL was assessed with the German version of the HLS-EU-Q16 questionnaire. Descriptive statistics and Chi-square test were used to analyze the data and group differences.

Results

Overall, 3,109 people (15.5%) participated in the study (58.9 years ±14.5; 65% male, 80% with high education level). Limited HL was seen in 43.7% (8.0% inadequate & 35.7% problematic), whereas 56.3% did not report limited HL (44.1% sufficient & 12.2% excellent). Limited HL was higher among men, younger people, people with poorer health status, and people with higher healthcare costs. Among those with limited HL, 17.9% suspected medical errors in their treatment (vs. 10.8% with not limited HL) and 5.1% were unsure (vs. 2.2%). Wrong test results were reported by 5.2% (vs. 3.1%) and wrong medication by 7.9% with limited HL (vs. 4.8%). All results were statistically significant (p < 0.001).

Conclusions

Limited HL was found in 43.7% of the PHI-insured participants, which is in line with previous research among the general German population. Participants with limited HL perceived more often safety concerns in their healthcare interactions. This could be explained by limited communication skills with healthcare professionals and lack of critical questioning.