What Germany pays for waiting

On a Tuesday morning in March, in a GP's office on the outskirts of a mid-sized city in Lower Saxony, a 43-year-old machinist is told he has alcohol use disorder. (He is a composite, drawn from several clinicians' accounts; the details have been changed.) His GP is kind about it, and quick. She prints a referral to the nearest addiction clinic, hands him a leaflet, and tells him someone from the clinic will be in touch. He leaves the office at 9:20 in the morning. He is, for the first time in his adult life, officially a patient.

The clinic calls him three weeks later. The first available assessment is in May. If the assessment goes well, the first available treatment slot is at the end of August. He writes the dates on the back of the leaflet and puts it on the kitchen counter.

From that morning in March until the end of August, the German health system will do a great deal for him. It will pay for a visit to A&E in late April, when his hands will not stop shaking and his wife will not stop crying. It will pay for two nights of inpatient detoxification at the regional hospital in early May, and for the antihypertensives he is prescribed on discharge. It will pay for a sick note covering most of June, and then most of July, and then, eventually, for the eight weeks of statutory sick pay that his employer has stopped wanting to extend. It will pay for a second A&E visit in late July, after a fall. None of these are treatment for his alcohol use disorder. They are the downstream consequences of his alcohol use disorder colliding, unaccompanied, with the rest of his life.

What the system will not pay for, during those five months, is anything that looks like a programme. There is no structured course he can start while he waits. There is no prescribable content. There is no one whose job it is to keep him stable between the diagnosis and the treatment. The assessment clinic has an admissions coordinator who takes his confirmation calls, a receptionist who logs them in a spreadsheet, and a waiting list that moves when a bed opens. That is the extent of the contact.

This is not a Lower Saxony problem. The Deutsche Rentenversicherung — the body that funds most medical rehabilitation in Germany, including addiction rehabilitation — reports that in 2023, the average wait between the moment a rehabilitation course is approved and the day a patient is admitted stood at roughly eleven weeks, and that figure is not bending in the right direction (Finanztip citing DRV data, 2024). That wait, the one that begins after approval, is only the last segment of a longer journey that starts with the first GP visit. By the time a patient sits down for their first real session with an addiction therapist, they have typically been, in one form or another, a patient for half a year.

For policymakers, the interesting question is not how long the wait is. The interesting question is what it costs.

The most rigorously matched estimate we have is from a 2018 study by Judith Dams and colleagues at the University Medical Centre Hamburg-Eppendorf, published in BMJ Open. Over a six-month observation window, the excess healthcare and productivity costs of an alcohol-dependent patient in psychiatric care, compared to a demographically identical person who was not, came to €11,839: €4,349 in direct medical costs and €7,490 in absenteeism and unemployment (BMJ Open, 2018). The largest direct-cost line items were inpatient treatment and formal long-term care. None of them were addiction therapy. The largest indirect-cost line items were the ones that land on the employer and the long-term care insurance, which is to say, on parts of the system that have no mechanism for telling the original insurer where the bill came from.

That number — €11,839 in six months, for the particular cohort the study could observe — is not a figure anyone can legitimately annualise or generalise to the whole population. What it establishes, with unusual rigour, is the direction and rough magnitude of the excess: when a person with an alcohol use disorder collides with the German system, most of what it costs lands somewhere other than treatment. For opioid use disorder, where Germany has better claims data, the shape rhymes. A 2019 cohort study at the same institution found that patients in opioid agonist treatment cost around €7,800 a year, of which the maintenance medication was a small minority; the bulk was inpatient care, comorbid psychiatric admissions, and somatic complications (Subst Abuse Treat Prev Policy, 2019). Treatment is not what is expensive about addiction. The absence of treatment is.

The reason this excess stays off the books is not that the money is not being spent. It is that no single line item tells the story. A fall is a fall. A detox admission is a detox admission. A course of statutory sick pay is a labour-market statistic. Each of them, looked at on its own, reads as noise. It is only when someone connects them back to the patient who walked out of his GP's office in March with a referral in his pocket that they resolve into a single picture, and no committee at the GKV-Spitzenverband does that work — because the connection between the fall in July and the diagnosis in March is exactly the connection the current accounting is not designed to see.

It is tempting, at this point, to produce a large number: a billion here, half a billion there. The honest answer is that the number doesn't exist yet. No one has published a rigorous German estimate of the share of addiction-related GKV costs that is specifically attributable to the unsupported waiting period, as opposed to the disorder itself. The Deutsche Hauptstelle für Suchtfragen estimates the total annual societal cost of alcohol misuse in Germany at around €57 billion (DHS Jahrbuch Sucht 2025, via dpa), but that figure includes lost productivity, premature mortality, criminal justice, and costs borne by employers and the long-term care insurance — it is a societal total, not an insurer total, and cannot be compared directly to the GKV's own 2024 expenditure of €326.85 billion (BMG data via ABDA, 2025). The two ledgers are measuring different things. What they have in common is that neither contains a line called "the waiting period".

The only international work that has tried to isolate the waiting-period effect itself is a 2022 analysis by Jenny Williams and Anne Line Bretteville-Jensen, who used linked Norwegian administrative data to follow patients applying for outpatient substance use treatment across the wait. Each additional month of delay produced measurable increases in emergency healthcare use, lower employment, and more contact with the criminal justice system, with the largest effects concentrated in the first months after referral (IZA DP 15083, 2022). Norway is not Germany, and the cohort is not a one-to-one match for the German clinic queue. It is also, at present, the best evidence we have that the waiting period does independent work — that the cost is not simply the disorder unfolding at its own pace, but the disorder unfolding faster and more expensively because no one is alongside it.

A GKV analyst in 2026 who wanted to build a business case for any intervention aimed at the waiting period would run into the same wall the rest of this article has run into: the data to cost it properly has not been assembled. The fragments exist. The study that ties them together does not. Whoever publishes that study first — whether it is the DRV, the GKV-Spitzenverband, a university group, or IQWiG in the course of a DiGA assessment — will be the first person to put a number on a category of expenditure that, at the moment, belongs to no one.

Until then, the most accurate sentence one can write about the German addiction waiting list is also the simplest. It is a programme that no one designed, that is costing money no one is counting, to do something no one believes in. The man from the Tuesday morning in March is still sitting at his kitchen counter, looking at the dates on the back of a leaflet. The bill is being paid. It is just being paid somewhere else.