Remuneration of medical specialists

Amsterdam, 4 October 2012
Commissioned by the Dutch Ministry of Health, Welfare and Sport

Remuneration of medical specialists
An international comparison
Lucy Kok
Marloes Lammers
Caren Tempelman

With the cooperation of:
Hans Bénard (Kema van den Berk praktijkadviseurs)
Seán Boyle (London School of Economics)
Isabelle Durand-Zaleski (Unité de Recherche Clinique de Économie de
la Santé d’ Ile-de-France: URC-ECO)
Paul Guillaume (Belgian Healthcare Knowledge Centre: KCE).
Mareike Heimeshoff (Hamburg Center for Health Economics)
Christian Jervelund (Copenhagen Economics)

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REMUNERATION OF MEDICAL SPECIALISTS

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REMUNERATION OF MEDICAL SPECIALISTS

Table of contents
Summary .............................................................................................................................. i
Samenvatting........................................................................................................................v
1

Introduction................................................................................................................. 1

2

Income differences between countries ....................................................................... 3
2.1
OECD definition................................................................................................................... 3
2.2
Payment systems.................................................................................................................... 3
2.3
Self-employed specialists: Dutch doctors earn the highest incomes ............................ 4
2.4
Salaried specialists: English doctors earn the most.......................................................... 7
2.5
All medical specialists: differences are less pronounced ............................................... 10

3

Income differences within countries ......................................................................... 11
3.1
Self-employed medical specialists earn more than salaried .......................................... 11
3.2
Income of self-employed specialists differs by specialism ........................................... 14
3.3
Income salaried specialist differs per function ............................................................... 15
3.4
Summary ............................................................................................................................... 15

4

Explanations for differences in income between countries ...................................... 17
4.1
Healthcare utilisation and waiting lists............................................................................. 17
4.2
Numbers and characteristics of medical specialists ....................................................... 18
4.3
Differences in payment systems ....................................................................................... 21
4.4
Production by physicians in training ................................................................................ 21
4.5
Differences in education .................................................................................................... 21
4.6
Differences in roles of GPs ............................................................................................... 22
4.7
Conclusions .......................................................................................................................... 22

References .......................................................................................................................... 25
Appendix A

Adjustment OECD figures ................................................................. 27

Appendix B

Sources ............................................................................................... 35

Appendix C

Taxes and premiums in the Netherlands ........................................... 41

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REMUNERATION OF MEDICAL SPECIALISTS

i

Summary
The Ministry of Health, Welfare and Sport in the Netherlands wants to know how the incomes
of medical specialists in the Netherlands compare with those of medical specialists in other
European countries. To answer this question, the incomes of Dutch medical specialists were
compared with those of their colleagues in five neighbouring countries that made recent OECD
figures on the remuneration of medical specialists available: Belgium, Denmark, France, Germany
and the United Kingdom (UK).
According to the OECD, the incomes of self-employed medical specialists in the Netherlands are
among the highest in the world. A comparison based on the OECD figures is not reliable,
however, as gross income measurements differ extensively by country. For this study, 2009
OECD figures were taken as a starting point and corrected for differences in measurement.
These corrections were based on information and additional data provided by experts of
renowned research institutes in the countries under investigation.
For the Netherlands, 2009 was a special year, because of the introduction of a new payment
system. Therefore, an additional estimation has been made of the income of Dutch doctors in
2012.

Differences between countries
Payment systems
In four of the six countries under investigation (i.e. Denmark, England, France and Germany), all
medical specialists working within hospitals are salaried. In Denmark and England, few medical
specialists are self-employed (6% and 4%, respectively). They have a private practice outside the
hospital. In Germany and France, a large number of medical specialists have a private practice
outside the hospital (41% and 51% respectively).
In the Netherlands and Belgium, a large number of medical specialists are self-employed, but, as
opposed to the other countries, they are self-employed while they are working within the
hospital. In Belgium, it is common to work as a self-employed medical specialist in the hospital.
In the Netherlands, there is a mix of self-employed and salaried doctors in the hospital. In both
countries, all medical specialists in academic hospitals are salaried. On the whole, 74% and 43%
of medical specialists in Belgium and the Netherlands, respectively, are self-employed.
The difference between salaried and self-employed doctors is not clear. In England, around 50%
of the salaried doctors also work in a private practice. In Belgium, 7% of medical specialists are
both salaried and self-employed; in the Netherlands, this is 19%. They are included in the figures
of salaried specialists. In France, self-employed doctors working outside the hospital also often
work one day a week (on a salary) in the hospital.

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ii

Self-employed specialists
The figures for self-employed specialists deviate in various ways from the OECD definition. The
French figure refers to net income, instead of gross income. In Belgium and France, income
from extra billing above the regulated fees is excluded. In France, some self-employed specialists
are also salaried; these salaries are not included in the income figures of the OECD. On the other
hand, OECD figures for Belgium still include practice costs, whereas these are excluded in all
other countries. Figure S.1 illustrates the OECD figures, as well as the figures corrected for the
mentioned deviations from the OECD definition. For England, there are no figures on the
income of the few doctors that only work in private hospitals.
Figure S.1

*2007

Gross income of self-employed specialists, per person per year, in 2009 Euros

**2008

Figure S.1 illustrates that in 2009, Dutch doctors earn more than their colleagues in Germany,
France, Denmark and Belgium. This is the case before and after the adjustment for deviations
from the OECD definition. The income of the French doctors is adjusted upwards, from net to
gross income, including extra billing and extra income from salaried work in hospitals. The
income of the Belgian specialists is adjusted downwards by excluding practice costs and upwards
by including extra billing.
For the Dutch, 2009 was a special year for self-employed doctors. Their income increased rapidly
in 2008 and 2009 because of a change in the payment system. The government decreased the
DRG-rates in 2010 and 2011 and introduced a revenue ceiling (a maximum budget) in 2012 to
contain costs. The income of medical specialists in 2012 is estimated at around €211,500. As
incomes in other countries will have risen from 2009 onwards, the income differences with the
other countries will have narrowed.

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SUMMARY

iii

Salaried specialists
For salaried specialists, the OECD figures for England and Germany include physicians in
training. Therefore, the figures for these countries are underestimated. France and Germany
include the salaries of GPs (General Practitioners) in their numbers. Moreover, the numbers for
French specialists are net income instead of gross, also resulting in an underestimation. On top of
this, England, Germany and the Netherlands do not include income from private practice. Figure
S.2 presents the OECD figures and the figures adjusted for the mentioned deviations from the
OECD definition. For Belgium, there is no figures about the gross income of salaried medical
specialists.
Figure S.2

Gross income salaried specialists, per full time equivalent per year, in 2009 Euros

*2006

Figure S.2 shows that the Danish and the Dutch salaried specialists earn much more than
specialists in Germany, France and England, according to the OECD figures. Excluding
specialists in training (England and Germany) and GPs (Germany), including taxes (France) and
extra income from private practice (England, Germany and the Netherlands), it was determined
that the English salaried specialists have the highest income. The reason for this is that they top
up their salaries with income from work in the private sector.
The income of Dutch doctors will decrease to around €140,000 in 2012, because salaried doctors
that also work in a private practice were confronted with a revenue ceiling for self-employed
doctors in 2012.
Strong correlation between gross income and the number of doctors
There is a strong correlation between gross income (averaged over self-employed and salaried
doctors) in countries and the number of doctors. More specifically, the more doctors there are,

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iv

the lower is their income. English and Dutch doctors earn more than the doctors in the other
countries in the study. In England, there are 0.91 medical specialists per 1,000 inhabitants; in the
Netherlands, it is 0.98. In Germany and Denmark, the countries with the lowest incomes for
medical specialists, there are 2.4 and 2.3 medical specialists, respectively, per 1,000 inhabitants.
Higher productivity explains part of the correlation. Doctors in the Netherlands work more
hours than their colleagues in Denmark and are also most likely to be more productive per hour,
because they are self-employed more often. German doctors work as many hours as Dutch
doctors. They are also just as productive per hour as the Dutch doctors; however, they earn
substantially less. Another explanation might be that a low number of doctors leads to a high
negotiation power, and therefore, higher prices and associated incomes.
Other factors, such as the composition of the workforce, the gate keeping role of GPs, if the
production of the physicians in training accrues to the hospital or the medical specialist, and
differences in education, do not seem to have a significant influence on the earnings of medical
specialists.

Differences within countries
Large differences in income exist between doctors within countries.
• Self-employed doctors earn more than salaried doctors. In the Netherlands, in 2009, selfemployed doctors earned, on average, 1.8 times the average gross income of a (primarily)
salaried doctor. If self-employed doctors pay more taxes and premiums than salaried doctors
the differences in net income are smaller. In the Netherlands, self-employed doctors pay more
premiums for disability insurance and old age pensions, but less taxes than salaried doctors.
On the whole, the burden of taxes and premiums is about the same for self-employed and
salaried doctors with the same gross income.
• Within the group of self-employed doctors, income differs with specialism. Radiologists and
anaesthesiologists are the highest earners in most countries, while psychiatrists and paediatrics
usually earn least. In France, a radiologist earns 3.5 times as much as a psychiatrist.
• Within the group of salaried doctors, income differs with the hierarchical level. Doctors on
the highest level in Germany earn 3.1 times the income of doctors on the lowest level. In
addition, large differences exist between salaried doctors that are also self-employed and those
that only have an income from salary. In England, a medical specialist that also works in
private practice earns 1.9 times the income of a doctor not working in the private sector.

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REMUNERATION OF MEDICAL SPECIALISTS

v

Samenvatting
Het Ministerie van Volksgezondheid. Welzijn en Sport (VWS) in Nederland wil weten hoe de
inkomens van Nederlandse medisch specialisten zich verhouden tot die van hun collega's in
andere Europese landen. Om hierin inzicht te krijgen heeft SEO Economisch Onderzoek de
inkomens van Nederlandse medisch specialisten vergeleken met die van hun collega's in vijf
buurlanden waarvoor recente OESO cijfers beschikbaar waren: België, Denemarken, Frankrijk,
Duitsland en het Verenigd Koninkrijk.
Volgens de OESO behoren de inkomens van Nederlandse vrijgevestigde medisch specialisten tot
de hoogste ter wereld. De vergelijking op basis van de OESO-cijfers is echter niet betrouwbaar
omdat de manier waarop het bruto-inkomen wordt gemeten in deze landen verschilt. Dit
onderzoek neemt de OESO-cijfers als uitgangspunt en corrigeert vervolgens voor verschillen in
de definities. De correcties zijn gemaakt op basis van informatie en aanvullende data geleverd
door experts van gerenommeerde onderzoeksinstituten in de onderzochte landen.
Voor Nederland was 2009 een bijzonder jaar. Daarom is voor Nederland ook een schatting
gemaakt van het inkomen van medisch specialisten in 2012.

Verschillen tussen landen
Bekostigingssystemen
In vier van de zes landen (Denemarken, Engeland, Frankrijk en Duitsland) zijn alle specialisten
die in een ziekenhuis werken in loondienst. In Denemarken en Engeland is slechts een klein deel
van de medisch specialisten vrijgevestigd (respectievelijk 6% en 4%). Zij hebben een eigen
praktijk buiten het ziekenhuis. In Duitsland en Frankrijk heeft een groot deel van de medisch
specialisten een eigen praktijk buiten het ziekenhuis (respectievelijk 41% en 51%). Ook in
Nederland en België is een groot deel van de medisch specialisten vrijgevestigd, maar, in
tegenstelling tot de andere landen, werken zij vaak in het ziekenhuis. In België is het gebruikelijk
om als vrijgevestigd medisch specialist in het ziekenhuis te werken. Nederland kent een mix van
vrijgevestigden en artsen in loondienst in het ziekenhuis. In beide landen zijn de medisch
specialisten in academische ziekenhuizen in loondienst. In totaal is 74% van de Belgische en 43%
van de Nederlandse artsen vrijgevestigd.
Er is vaak overlap tussen loondienst en vrije vestiging. Zo heeft in Engeland ongeveer 50% van
de artsen in loondienst ook een eigen praktijk. In België is 7% van de medisch specialisten zowel
in loondienst als vrijgevestigd en in Nederland gaat het hier om 19% van de medisch specialisten.
De inkomens van deze artsen zijn meegeteld bij de cijfers voor specialisten in loondienst. In
Frankrijk werken vrijgevestigde artsen ook vaak één dag per week (in loondienst) in het
ziekenhuis.

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vi

Medisch specialisten in vrije vestiging
De cijfers voor vrijgevestigde specialisten wijken op verschillende manieren af van de OESOdefinitie. Het Franse inkomen betreft netto- in plaats van bruto-inkomen en in België en
Frankrijk zijn de extra opbrengsten uit declaraties met tarieven boven de gereguleerde tarieven
niet meegenomen. Daarnaast is in Frankrijk een aantal vrijgevestigde specialisten ook in
loondienst. Deze salarissen zijn niet meegeteld in de inkomenscijfers van de OESO. Aan de
andere kant zitten de praktijkkosten nog in het OESO-cijfer voor België, terwijl deze in de andere
landen niet zijn meegenomen. Figuur S.1 geeft de bruto-inkomens van vrijgevestigde specialisten
zowel op basis van de oorspronkelijke OESO-cijfers als de cijfers gecorrigeerd voor
bovenstaande afwijkingen. Voor Engeland zijn er geen cijfers over de inkomsten van het kleine
aantal artsen dat alleen in private ziekenhuizen werkt.
Figuur S.1

*2007

Bruto inkomen vrijgevestigde specialisten, per persoon per jaar, in 2009 euro’s

**2008

Figuur S.1 laat zien dat, zowel voor als na correctie voor afwijkingen van de OESO-definitie, de
Nederlandse artsen in 2009 meer verdienden dan hun collega's in Duitsland, Frankrijk,
Denemarken en België. De inkomsten van de Franse artsen zijn naar boven bijgesteld, van nettonaar bruto-inkomen, inclusief aanvullende declaraties en extra inkomsten uit arbeid in loondienst.
Het inkomen van Belgische specialisten is naar beneden bijgesteld door aftrek van de
praktijkkosten en naar boven vanwege de aanvullende declaraties. Hun uiteindelijke aangepaste
inkomen is lager dan het OESO-cijfer.
Voor Nederlandse artsen was 2009 een bijzonder jaar. Hun inkomen steeg in de jaren 2008 en
2009 sterk als gevolg van een verandering in het bekostigingssysteem. In 2010 en 2011 zijn de
DBC-tarieven verlaagd en in 2012 is een omzetplafond ingesteld om de kosten te beheersen. Het
inkomen van medisch specialisten in 2012 is naar schatting ongeveer € 211.500. Omdat de

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SAMENVATTING

vii

inkomens in de andere landen vanaf 2009 waarschijnlijk zijn gestegen, zullen de
inkomensverschillen tussen Nederlandse en buitenlandse specialisten kleiner zijn geworden.
Medisch specialisten in loondienst
De OESO-cijfers voor Engelse en Duitse artsen in loondienst bevatten ook artsen in opleiding.
De inkomens van medisch specialisten in deze landen worden daarom onderschat. De cijfers
voor Frankrijk en Duitsland bevatten ook de inkomens van huisartsen, die vaak minder
verdienen dan medisch specialisten. De inkomens voor Franse specialisten zijn bovendien nettoin plaats van bruto-inkomen, wat ook een onderschatting geeft. Daarnaast zijn de inkomsten uit
private werkzaamheden in Engeland, Duitsland en Nederland niet meegenomen. Figuur S.2 toont
de oorspronkelijke OESO-cijfers en de cijfers gecorrigeerd voor bovenstaande afwijkingen van
de OESO-definitie. Voor België zijn er geen cijfers over het bruto-inkomen van medisch
specialisten in loondienst.
Figuur S.2

Bruto inkomen specialisten in loondienst, per fte per jaar, in 2009

*2006

Figuur S.2 laat zien dat op basis van de oorspronkelijke OESO-cijfers Deense en Nederlandse
specialisten in loondienst veel meer verdienen dan specialisten in Duitsland, Frankrijk en
Engeland. Als specialisten in opleiding (Engeland en Duitsland) en huisartsen (Duitsland) niet
meegenomen worden en belastingen (Frankrijk) en extra inkomsten uit de eigen praktijk
(Engeland, Duitsland en Nederland) wel, dan blijkt dat Engelse specialisten het hoogste inkomen
hebben. Dit komt omdat zij hun salarissen aanvullen met werk in de particuliere sector.
De Nederlandse specialisten in loondienst die deels als vrijgevestigde werken zijn in 2012 ook
geconfronteerd met het omzetplafond voor vrijgevestigde specialisten. Hun inkomen zal als
gevolg van deze maatregel zijn gedaald tot naar schatting € 140.000 .

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viii

Sterke samenhang tussen bruto-inkomen en het aantal artsen
Er is een sterke samenhang tussen de bruto-inkomsten (gemiddeld over vrijgevestigden en artsen
in loondienst) en het aantal artsen: hoe meer artsen, hoe lager het inkomen. De Engelse en
Nederlandse artsen verdienen meer dan de artsen in de andere onderzochte landen. In Engeland
zijn er 0,91 medisch specialisten per 1.000 inwoners, en in Nederland 0,98. In Duitsland en
Denemarken, de landen met de laagste inkomens, zijn er respectievelijk 2,4 en 2,3 medisch
specialisten per 1.000 inwoners. Een hogere productiviteit verklaart een deel van deze
samenhang. Artsen in Nederland werken meer uren dan hun collega's in Denemarken en zijn
waarschijnlijk ook productiever per uur omdat ze vaker vrijgevestigd zijn. De Duitse artsen
werken echter net zoveel uren en zijn vermoedelijk net zo productief per uur als de Nederlandse
artsen, maar verdienen veel minder. Een andere verklaring kan zijn dat artsen meer
onderhandelingsmacht hebben in landen waar relatief weinig artsen zijn. Dit leidt tot hogere
tarieven en hogere inkomens.
Andere factoren zoals de verdeling naar leeftijd en geslacht van specialisten, de poortwachterrol
van de huisarts en verschillen in de opleiding lijken weinig invloed te hebben op het inkomen van
medisch specialisten.

Verschillen binnen landen
Er zijn grote verschillen in inkomen tussen artsen binnen landen.
• Vrijgevestigde artsen verdienen meer dan artsen in loondienst. In Nederland was het bruto
inkomen van vrijgevestigden in 2009 gemiddeld 1,8 keer meer dan het bruto inkomen van een
arts die (voornamelijk) in loondienst was. Als vrijgevestigde specialisten meer belasting en
premies betalen dan specialisten in loondienst dan zijn de verschillen in netto inkomens
kleiner dan de verschillen in bruto inkomens. In Nederland is er weinig verschil in het brutonetto traject tussen vrijgevestigden en specialisten in loondienst: vrijgevestigde artsen betalen
meer premies maar minder belasting dan specialisten in loondienst.
• Binnen de groep vrijgevestigden verschilt het inkomen sterk tussen verschillende
specialismen. Radiologen en anesthesisten zijn in de meeste landen degenen met het hoogste
inkomen, terwijl kinderartsen en psychiaters juist het minst verdienen. In Frankrijk verdient
een radioloog gemiddeld 3,5 keer zoveel als een psychiater.
• Binnen de groep van artsen in loondienst verschilt het inkomen met het hiërarchische niveau.
In Duitsland verdienen artsen op het hoogste niveau gemiddeld 3,1 keer zoveel als artsen op
het laagste niveau. Daarnaast zijn er ook grote verschillen tussen artsen die alleen in
loondienst werken en artsen die ook deels als vrijgevestigde werken. In Engeland verdient een
medisch specialist die ook in een eigen praktijk werkt 1,9 keer zoveel als een arts die alleen in
loondienst werkt.

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REMUNERATION OF MEDICAL SPECIALISTS

1

1

Introduction

The Ministry of Health, Welfare and Sport in the Netherlands wants to know how the incomes
of medical specialists in the Netherlands compare to those of their colleagues in other European
countries. To answer this question, the incomes of Dutch medical specialists are compared with
those of their colleagues in five neighbouring countries: Belgium, Denmark, France, Germany
and the UK.
To compare the incomes of medical specialists, the figures the OECD publishes about the gross
income of medical specialists in 2009 are taken as a starting point. These figures, however, are
measured in different ways and do not always represent total gross income. In addition, for
salaried medical specialists, extra income from a private practice is not always included. For selfemployed medical specialists, the figures sometimes refer to revenue instead of income. To
correct for these differences, information has been gathered by national researchers in the
countries under study. Subsequently, the OECD figures are adjusted to make them comparable.
The next chapter compares the incomes of medical specialists between countries. It presents the
OECD figures and the adjusted figures. Information is also provided about working hours and
the difference between gross and net income, to place the income differences in perspective.
Chapter 3 describes the income differences within countries. Chapter 4 tries to explain the
differences in income of the medical specialists between countries.

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REMUNERATION OF MEDICAL SPECIALISTS

3

2

Income differences between countries

2.1

OECD definition

The OECD gathers data from OECD-countries on the remuneration of medical specialists.
Medical specialists are defined as physicians who have specialised and work in areas other than
general practice. Physicians in training should be excluded from the medical specialists category.
In addition, the figures on remuneration should refer to the average gross annual income.
The medical specialist income figures should include:
The value of any social contributions, (income) taxes etc., payable by the employee
• All gratuities, bonuses, overtime compensation and ‘thirteenth month payments’
• Any supplementary income
•

And should exclude:
• For salaried medical specialists: social contributions payable by the employer
• For self-employed medical specialists: practice expenses
• Any physicians who are still in training to become a specialist
• Physicians who have specialised in general practice (GP)
The actual figures provided by the various countries depend on availability. Therefore, they often
deviate from this OECD definition.
The next section describes the main features of the payment systems of medical specialists in the
six countries. Section 2.3 provides the OECD figures and the adjusted figures for self-employed
medical specialists and Section 2.4 does the same for salaried medical specialists. Section 2.5
summarises. Appendix A contains a detailed description of the adjustment procedure.
As the OECD figures for the UK refer only to England, all figures are only reported for
England.

2.2

Payment systems

In four of the six countries under investigation (i.e. Denmark, England, France and Germany), all
medical specialists working within hospitals are salaried. In Denmark and England, few medical
specialists are self-employed (6% and 4%, respectively). They have a private practice outside the
hospital. In Germany and France, a large number of medical specialists have a private practice
outside the hospital (41% and 51% respectively).
In the Netherlands and Belgium, a large number of medical specialists are self-employed, but, as
opposed to the other countries, they are self-employed while they are working within the
hospital. In Belgium, it is common to work as a self-employed medical specialist in the hospital.
In the Netherlands, there is a mix of self-employed and salaried doctors in the hospital. In both

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4

CHAPTER 2

countries, all medical specialists in academic hospitals are salaried. On the whole, 74% and 43%
of medical specialists in Belgium and the Netherlands, respectively, are self-employed.
Self-employed medical specialists are paid fee for service. The service can be a Diagnosis Related
Group (DRG), but can also be an activity (e.g. a visit or an operation).
The difference between salaried and self-employed doctors is not clear-cut. In England, around
50% of the salaried doctors also work in a private practice. In Belgium, 7% of medical specialists
are both salaried and self-employed; in the Netherlands, this is 19%. As they work more than half
time on a salary, they are included in the figures of salaried specialists. In France, self-employed
doctors working outside the hospital also often work one day a week (on a salary) in the hospital
to remain in contact with their colleagues.
Table 2.1

Payment systems and number of medical specialists in 2009
Primarily salaried

Primarily self-employed

Total number of medical
specialists

Netherlands

57%*

43%

16,210

Germany

59%

41%

187,825

France

49%

51%****

108,061*****

England

96%**

4%

47,008

Denmark

94%

6%

13,190

26%***

74%

18,852

Belgium
*
**
***
****
*****
Sources:

including 19% of doctors which have income from both salary and fee for service
including around 50%-60% of doctors which have income from both salary and fee for service
including 7% of doctors which have income from both salary and fee for service
including 11% of doctors which have income from both salary and fee for service
2011
See Appendix B

2.3

Self-employed specialists: Dutch doctors earn the
highest incomes

The figures for self-employed specialists deviate in various ways from the OECD definition. The
French figure, once again, refers to net income instead of gross. In Belgium and France, extra
billing is excluded. For Belgium, this means that supplemental income (e.g. for sleeping in a single
room instead of a shared room) are excluded. In France, medical specialists in the so called
“secteur 2” can set their own fees. 1 The part of the fee above the standard fee, which is not
reimbursed by health insurance, is not included in the income figure. On the other hand, OECD
figures for Belgium still include practice costs, whereas these are excluded in all other countries.
In France, some self-employed specialists are also salaried. These salaries are not included in the
income figures of the OECD. 2 Figure 2.1 shows the OECD figures as well as the figures
corrected for the mentioned deviations from the OECD definition. For England, there are no
figures on the income of the few doctors that only work in private hospitals.

1
2

Secteur 1 doctors apply the official rates negotiated with the social security system. Secteur 2 doctors,
have signed an agreement with the national health insurance system but are free to set their own rates
http://www.ecosante.fr/DEPAFRA/343.html

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INCOME DIFFERENCES BETWEEN COUNTRIES

Figure 2.1

*2007
Sources:

5

Gross income of self-employed medical specialists, per person per year, in 2009
Euros

**2008
OECD 2012, calculations SEO Economic Research. See Appendix A for details.

Figure 2.1 illustrates that, before and after the adjustment for deviations from the OECD
definition, Dutch doctors in 2009 earned more than their colleagues in Germany, France,
Denmark and Belgium. The income of the French doctors is adjusted upwards, from net to gross
income, including extra billing in ‘secteur 2’ and extra income from salaried work in hospitals.
The income of the Belgian specialists is adjusted downwards by excluding practice costs and
upwards by including extra billing.
For Dutch doctors, 2009 was a special year. Their income increased rapidly in 2008 and 2009,
because of a change in the payment system. In 2007, they received a lump sum payment,
independent of production. In 2008, performance pay was introduced; they received a payment
dependent on the production of DRGs (in fact, the Dutch equivalent: DBCs: Diagnose Behandel
Combinaties). Their income rose from €186,999 in 2006 and €205,059 in 2007 to €235,105 in
2008 and €259,131 in 2009. Errors in the DRG-rates, and more registered production, led to the
rise in income. The government decreased the DRG-rates in 2010 and 2011 and introduced a
revenue ceiling (a maximum budget) in 2012 to contain costs. The income of medical specialists
in 2012 is estimated at approximately €211,500 (See Box 2.1).

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CHAPTER 2

Box 2.1

Estimation income for self-employed medical specialists in the Netherlands in 2012

Total revenue for self-employed medical specialists working in hospitals in the Netherlands was €2,239 billion
in 2009. The revenue ceiling in 2012 is set on €1,939. This is a reduction of 13.4% 3. The decreased income is
86.6% (100-13.4%) of the income in 2009. As the number of self-employed specialists rises, the decrease in
total revenue is bigger: the smaller budget has to be divided by more doctors. The number of self employed
specialists rose on average with 2% in the period 2006-2010, see Table below. Not all self-employed specialists
fall under the revenue ceiling. It is assumed that the growth rate of the number of specialists under the revenue
ceiling is equal to the growth rate of specialist not under the revenue ceiling.

2006

2007

2008

2009

2010

Average
growth rate
2006-2010

number
Salaried

5,310

5,615

5,910

6,210

6,765

Self-employed

6,650

6,705

6,885

6,985

7,200

Both salaried and self-empl.

2,930

2,925

2,895

3,015

3,040

Total

14,890

15,245

15,690

16,210

17,005

Growth rate
Salaried

1.06

1.05

1.05

1.09

1.06

Self-employed

1.01

1.03

1.01

1.03

1.02

Both salaried and self-empl.

1.00

0.99

1.04

1.01

1.01

Total

1.02

1.03

1.03

1.05

1.03

Source: Statistics Netherlands
If the number of specialists increases by 2% per year in the period of 2009-2012, this will lead to 6.12% more
doctors in 2012 compared to 2009. The increase in doctors will lead to an extra decrease in income: 5.76%
(1/1,0612). An extra decrease of 5.76% of 86.6% of the income in 2009 leads to an income of 81.6% of the
original income. The total decrease is: 100%-81.6%=18.4%. It is assumed that practice costs are a fixed
percentage of revenue. A total decrease of 18.4% of the income of €259,131 leads to an estimated income in
2012 of €211,451.

As incomes in other countries will have risen from 2009 onwards, the income differences with
the other countries will have narrowed down. It is likely that the gross income of the Danish selfemployed doctor will come close to the gross income of the other Dutch doctors. However, this
is a very small group in Denmark. Moreover, the prices in Denmark are higher than in the
Netherlands.
Table 2.2 shows that, when corrected for purchasing power, Danish doctors earn less than the
doctors in other countries. However, Dutch doctors still have the highest income, even when
taking into account the decrease in income of the Dutch doctors in 2012. Dutch doctors in 2009
earned 6.5 times the average wage in the Netherlands. This is far more than in other countries.
Taking into account the decrease in income in 2012, the Dutch doctors (5.3 times the average
wage) and the French doctors (5.4 times the average wage) earn approximately the same.

3

Source: NZa 2011. The figure of €2,215 billion in this document (p.66) was based on figures from nearly
all hospitals (see p. 68). After receiving information from the missing hospitals this figure is adjusted to
€2,239 billion, according to the NZa (Dutch Healthcare Authority). The revenue ceiling is not equal to
the total budget for all medical specialists (BKZ), see NZa 2011 p.68 and the Appendix in the same
document, p. 46.

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INCOME DIFFERENCES BETWEEN COUNTRIES

Table 2.2

7

Dutch self-employed doctors earn the highest income in 2009
Gross income of self-employed specialists, Self-employed gross income times
per FTE per year, in PPP 2009 Euros
average wage, 2009

Netherlands

259,131 (211,500 in 2012)

6.5 (5.3 in 2012)

Germany

167,540

5.0

France

170,474

5.4

Denmark

159,280

4.0

Belgium

166,751

4.4

PPP=purchasing power parity. The Netherlands =100
Source:
figure 2.1 and stat.oecd.org

Do Dutch doctors work more hours for their higher income? The table below illustrates that this
is the case. Danish doctors, on the other hand, earn less and also work less hours a week.
German doctors work more than French doctors, but earn less. Thus, there is not a one to one
relationship between hours worked and income.
Table 2.3

Working hours of primarily self-employed medical specialists: Dutch doctors work the
most hours
Year

Netherlands

2001 4

55

Germany

2010

52

France

2012

50

Denmark

2008

43

Belgium

2009

48

Sources:

See Appendix B. Comparability is limited, due to differences in measurement.

2.4

Salaried specialists: English doctors earn the most

For salaried specialists, the OECD figures for England and Germany include physicians in
training (foundation/registrars and Ärzte, respectively). Therefore, the figures for these countries
are underestimated. France and Germany’s values include the salaries of GPs 5. Moreover, the
numbers for French specialists are net income figures instead of gross, also resulting in an
underestimation. On top of this, England, Germany and the Netherlands do not include income
from private practice. Figure 2.2 presents the OECD figures and the figures adjusted for the
mentioned deviations from the OECD definition. For Belgium, there are no figures about the
gross income of salaried medical specialists.

4
5

A survey in 2010 among doctors confirms the results from the survey in 2001. The median work hours in
small hospitals is 50; in large hospitals, it is over 50 (Lagendijk, 2010).
OECD documentation (OECD, 2012) reports that for salaried physicians in Denmark, there is no
distinction made between GP’s and salaried specialists. However, this remark is irrelevant, since Danish
GP’s are never salaried and are therefore not included in the Danish income figure for salaried specialists.

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8

Figure 2.2

*2006
Sources:

CHAPTER 2

Gross income salaried specialists, per full time equivalent per year, in 2009 Euros

OECD 2012, calculations SEO Economic Research. See Appendix A for details.

Figure 2.2 shows that, according to the OECD, the figures for the Danish and Dutch salaried
specialists earn much more than specialists in Germany, France and England. By excluding
specialists in training (England and Germany) and GPs (Germany) and including taxes (France)
and extra income from private practice (England, Germany and the Netherlands), however, the
English salaried specialists are found to have the highest income. This is because they top up
their salaries with income from work in the private sector.
In the Netherlands Salaried doctors also working in private practice were confronted in 2012
with the revenue ceiling for self-employed doctors. This will have led to a decrease in income,
with around €7,500 per year to €140,000 per year, averaged over all salaried doctors. In this
figure, the wage increases from 2009-2012 have not been taken into account.
Do English doctors work more hours for their higher income? The table below shows that
English doctors work more hours a week than the Dutch, French and Danish doctors. But the
German doctors work more hours than English doctors and earn substantially less. The English
doctors work 46 hours in the public NHS hospitals and 5 hours in private practice. However,
31% of their income comes from private practice.

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INCOME DIFFERENCES BETWEEN COUNTRIES

Table 2.4

9

Working hours of primarily salaried full time medical specialists: German doctors
work the most
Year

Contractual hours

Actual hours
worked

Netherlands

2001 6

40-48

47

Germany

2010

40-42

55

France

2012

35

40

England

2006

40

51

Denmark

2008

37

44

Sources:

See Appendix B. Comparability is limited due to differences in measurements.

Between countries, there are large differences in the standard of living. Denmark has, on average,
a higher price level and higher average wages. Corrected for the purchasing power per Euro in
the countries under study, Danish doctors earn less than the doctors in other countries (See
Table 2.5). The Danish doctors earn 2.7 times the average wage, which is also less than in other
countries. The English doctors earn the most, when salaries are corrected for purchasing power
parity and compared with the average wage in the country.
Table 2.5

English salaried doctors earn 5.2 times the average wage in England
Gross income salaried specialists, per FTE per Salaried gross income times
year, in PPP 2009 Euros
average wage, 2009

Netherlands

147,447

3.7

Germany

126,604

3.8

France

127,550

4.0

England

201,331

5.2

Denmark

108,659

2.7

PPP=purchasing power parity. The Netherlands =100
FTE=Full time equivalent
Source:
Figure 2.2 and stat.oecd.org

Large differences in the amount of taxes and premiums might cause differences in net income.
Taxes and premiums for social insurance (including unemployment, sickness and disability
insurance, but excluding pension contributions) together amount to about 37% in England, 4044% in Belgium, France, and the Netherlands and 52% in Denmark. However, high tax rates also
reflect more public facilities. If tax rates are high, this may reduce the need for private spending
on, for instance, pensions and healthcare. They might also reflect higher future income (e.g.
during unemployment periods) and a higher quality of life. Therefore, to compare the wealth of
medical specialists across countries, it is better to compare gross income.

6

A survey in 2010 among doctors indicates that in 2010, the working hours of salaried medical specialists
may be higher. The median work hours in non-academic hospitals is 45; in academic hospitals, it is more
than 50 (Lagendijk 2010). As more than half of the salaried doctors work in academic hospitals, the
average number of hours worked is probably higher than 47.

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10

2.5

CHAPTER 2

All medical specialists: differences are less
pronounced

To compare incomes between countries, the income averaged over self-employed and salaried
workers is calculated. The comparison of the incomes of primarily salaried doctors is hindered by
the fact that there are a lot of doctors which combine a salaried position with working in private
practice as self-employed. Therefore, salaried doctors are not quite comparable between
countries; the same holds for self-employed doctors.
Table 2.6 illustrates the results. For Belgium, there were no figures available for salaried doctors.
An estimated guess was that the difference between salaried and self-employed doctors in
Belgium would be more or less the same as, on average, in Denmark, Germany and France. The
Netherlands is excluded, because it is an outlier. This leads to an estimated gross income of
salaried doctors in Belgium of €123,691.
Table 2.6

Average income in Euros per year
Salaried

Self-employed

% salaried Average

Belgium

(123,691)*

170,427

26

158,276

Denmark

136,799

200,530

94

140,623

England

175,586

n.a.

96

175,586

France

131,716

176,042

49

154,322

Germany

121,097

160,253

59

137,151

Netherlands

147,447
( 139,849 in 2012)**

259,131
( 211,451 in 2012)**

57

195,471
( 170,638 in 2012)**

*

**
Source:

The average fraction of the salaried income divided by the self-employed income of medical
specialists in Denmark, France and Germany multiplied by the income of self-employed medical
specialists in Belgium.
Estimation
See Figures 2.1 and 2.2

Comparing the incomes of all doctors shows that differences in income are less pronounced than
when comparing only salaried or only self-employed doctors. The Dutch doctors are still the
ones with the highest income, due to the high incomes of the self-employed doctors. Taking into
account the decrease in income, with 18.4% from 2009, the average income of doctors in the
Netherlands will decrease to €170,000, which is a bit lower than the English doctors.
In all countries, self-employed medical specialists earn more than their salaried colleagues. Does
this mean that in countries where more doctors are self-employed the average income is higher?
The comparison illustrates that incomes are not systematically higher if a higher percentage of
doctors is self-employed. The English doctors even earn more than doctors in most other
countries, while the majority is salaried. However, a large part of the salaried doctors also work in
a private practice; thus, they are partly self-employed. The Danish doctors, on the other hand,
earn less than doctors in most other countries and are also almost all salaried. The proportion of
salaried doctors in Germany and the Netherlands is about the same, but the Dutch doctors earn
substantially more than the German doctors.

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REMUNERATION OF MEDICAL SPECIALISTS

11

3

Income differences within countries

3.1

Self-employed medical specialists earn more than
salaried

Comparing the gross incomes of salaried medical specialists with self-employed medical
specialists within countries reveals that in all countries under study self-employed doctors earn
more than salaried doctors (Figure 3.1).
Figure 3.1

Gross income of salaried and self-employed medical specialists, in 2009 Euros per
year

In Germany, France and Denmark, self-employed doctors earn around 30% to 40% more than
salaried doctors. In the Netherlands, self-employed doctors earned 76% more than their primarily
salaried colleagues. Taking into account the income decrease in 2012 of self-employed doctors,
and salaried doctors working also in a private practice, the income differences decrease to 50%
(€211,451/€139,849, see Table 2.6).
Differences in working hours
A difference in working hours explains some of the differences between self-employed and
salaried medical specialists. In France, self-employed doctors work around 20% more hours per
week than salaried doctors. This explains more than half of the differences in gross income. In
Germany and Denmark, self-employed medical specialists seem to work about the same number
of hours as their salaried colleagues.

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12

CHAPTER 3

Table3.1

Working hours per week
Year

Primarily salaried

Primarily self-employed

Netherlands

2001

47

55

Germany

2010

55

52

France

2012

40

50

England

2006

51

Denmark

2008

44

Belgium

2009

Source:

43
48

See Appendix B. Comparability is limited, due to differences in measurement. The figure for
primarily salaried doctors in the Netherlands is probably underestimated, see Footnote 6.

Self-employed medical specialists produce more services per hour
Self-employed medical specialists work on a fee for service basis. Hence, they have a strong
incentive to increase the number of services per hour (and decrease the time per service), whereas
salaried medical specialists do not have this incentive. In empirical research, it is systematically
found that doctors working on a fee for service basis are more productive than their salaried
colleagues (Barro & Beaulieu, 2003). The differences stem from two causes. Not only does a fee
for service payment system stimulate production, it also attracts more productive persons. So
doctors who think of themselves as highly efficient and productive want to be rewarded for their
higher production, and therefore, choose a fee for service position. Moreover, the fee for service
payment schedule in and of itself induces higher productivity. If the payment system of salaried
doctors is changed into a fee for service scheme, they become more productive (Barro &
Beaulieu, 2003). The other way around is also the case: if the payment schedule of the selfemployed is changed from fee for service to fixed payment (lump sum), then productivity
decreases. If a revenue ceiling is introduced, they will not produce fewer services per hour, but
will work fewer hours in order to increase their leisure time.
Differences in taxes and premiums: In the Netherlands on balance small differences
Differences between self-employed and salaried doctors may stem from differences in taxes and
premiums. For the Netherlands, a comparison is made between the taxes and premiums of selfemployed and salaried specialists with the same net income. On balance these differences appear
to be small. In the Netherlands, salaried doctors do not pay a contribution for unemployment
and disability insurance. Moreover, in non-academic hospitals, they pay only half of the premium
for their old age pension; in academic hospitals, they pay even less (30%). The other part is paid
by the hospital. Self-employed doctors have to pay themselves for disability insurance and old age
pensions, leading to substantially higher costs. They also have costs due to the goodwill they paid
for their practice. 7 On the other hand, self-employed doctors are entitled to tax benefits leading
to a lower tax burden than salaried doctors. On balance self-employed doctors pay a little more
taxes and premiums than salaried doctors with the same gross income. Table 3.2 illustrates this
for a salaried doctor in the highest pay scale and a self-employed doctor with the same net
income. 8

7
8

The goodwill is the sum self-employed medical specialists in the Netherlands pay to buy a private
practice.
The highest pay scale in non academic hospitals is € 10,565 gross per month. Including 15%,
inconvenience pay and 8% holiday pay this amounts to € 158,000

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INCOME DIFFERENCES WHITIN COUNTRIES

Table 3.2

13

Taxes and premiums for salaried and self-employed doctors in the Netherlands in
2012 are about the same (Euros per year)
Salaried

Self-employed

Gross revenue

193,400

Collective practice costs

–15,500

Individual practice costs

–12,000

Gross income

158,000

165,900

Pensions

–18,074

–34,300

Disability insurance

–10,500

Loss of interest goodwill

–2,625

Taxes an premiums

–66,125

–44,669

Net income

73,801

73,806

Source:

calculations Hans Bénard (Kema van den Berk praktijkadviseurs). See Appendix C for details.

Table 3.2 also shows that in order to earn a net income of €73,806, a self-employed doctor needs
a gross revenue of €193,400. Self-employed doctors pay collectively (the partnership of selfemployed doctors) around 8% of their gross revenue to the hospital (€15,500 per doctor) to
compensate the hospital for the practice costs of the partnership (such as the wage costs of the
secretary). Individually, doctors pay around €12,000 practice costs, such as costs for conferences,
professional literature, accounting and insurance. Thus, a gross revenue of €193,400 leads to a
gross income of €165,900 and a net income of €73,806. On the other hand, for salaried doctors,
the costs for the hospital are higher than the gross wage. The hospital pays several premiums on
top of the gross wage, such as a part of the pension premium (€18,074), employer premiums for
unemployment and disability (€4,500), the premium for health care insurance (€4.170) and other
expenses like the costs of conferences (€5,500). So, in total, the hospital pays €32,670 on top of
the gross wage. The total costs of a salaried doctor for the hospital amounts to €190,244
(€158,000+€32244). The total costs of a salaried doctor can be compared with the net revenue of
a self-employed doctor. The collective practice costs are paid by the self-employed doctors to the
hospital for costs like the secretary. Salaried doctors also use the services of the secretary. The
net revenue of a self-employed doctor is €177,900 (€193,400-€15,500). This is lower than the
total wage costs for salaried doctors with the same net income (€190,244).
The calculations in Table 3.2 are based on medical specialists with the same net income. As the
gross income of self-employed medical specialists is substantially higher than the income of
salaried doctors, their net income is also substantially higher. In Table 3.3, the net incomes of
self-employed and salaried doctors are calculated based on the estimated gross income for 2012.
For salaried doctors, the net income is calculated based on the income of doctors that do not
have any income from a private practice. In 2009, they earned a gross income of €118,000 per
year (See Figure 2.2). Including a wage indexation of 3% per year, this will amount to a gross
salary of €129,000 in 2012. The following table illustrates that a self-employed doctor earns a net
income of about 50% more than a salaried doctor without extra income from a private practice.

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CHAPTER 3

Table 3.3

Net income for salaried and self-employed doctors in the Netherlands in 2012 (Euros
per year)
Salaried*

Self-employed

Gross revenue

243,000

Collective practice costs

–19,500

Individual practice costs

–12,000

Gross income

129,000

211,500

Pensions

–14,507

–43,300

Disability insurance

–14,000

Loss of interest goodwill

–3,173

Taxes an premiums

–52,900

–59,597

Net income

61,594

91,430

*
Source:

Excluding salaried doctors that also work in a private practice
calculations Hans Bénard (Kema van den Berk praktijkadviseurs). See Appendix C for details.

3.2

Income of self-employed specialists differs by
specialism

The income of medical specialists differs between countries and between specialties. In general,
psychiatry and paediatrics are among the lowest earning specialties. Anaesthesiologists and
radiologists receive a much higher pay. Surgeons are usually also among the higher paid
specialists, and in Denmark, they even earn more than anaesthesiologists. High earning specialties
make about 2-3 times as much money as the lowest earning specialties in most countries. An
exception is France, where radiologists earn 3.5 times the salary of psychiatrists. In Belgium and
France, the difference between specialties with a lot of patient contact (psychiatry, paediatrics,
internal medicine) and technical specialties, such as radiology and surgery, is striking. One
explanation offered by van den Oever (2008) is that fees were never thoroughly revised. Since
technical developments decreased time spent on medical acts, the income of specialists that
perform a lot of technical procedures increased in comparison to other doctors.
Table 3.4

Self-employed radiologists are top earners. Gross income of self-employed medical
specialists in 2009.
Psychiatry

Paediatrics

General surgery

Anaesthesiology Radiology

Belgium

€172,943

€177,474

€233,224

€276,456

Denmark

€156,932

€177,977

€246,613

€210,788

n.a.

France*

€62,080

€71,060

€130,060

€187,300

€217,070

Germany

€122,486

€127,590

€142,900

n.a.

€233,744

Netherlands

€ 129,000

n.a.

n.a.

€353,000

€421,000

*

Sources:

€334,632

Net income
Income figures are stated in 2009 Euros using the growth rate of average wages per country
(stats.oecd.org).
Belgium: Swartenbroekx et al. (2012). Denmark: Danish Regions (2009). France: Bellamy (2011).
Germany: Statistische Bundesamt (2009) Netherlands; Statistics Netherlands (2012).

In the Netherlands, radiologists and anaesthesiologists earned incomes high above the average
income of medical specialists in 2009. In 2012, differences between specialists will have decreased
due to the new payment system. In the new system, the maximum budget is set per hospital.
Medical specialists themselves have to allocate the budget over the specialists. It seems that in a

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INCOME DIFFERENCES WHITIN COUNTRIES

15

lot of hospitals, medical specialists decided to base their allocation on productivity and disutility’s.
Traditional income differences that cannot be justified by high productivity or high disutility’s
disappeared in those hospitals.

3.3

Income salaried specialist differs per function

The difference in income between salaried medical specialists in the same country is not driven
by their specialty, but by their function profile. An example is England, where consultants earn an
average NHS (National Health Service) pay of €134,730 per year in 2009, whereas associate
specialists earn €97,926 and staff grade doctors only earn €76,227, on average (own calculations,
based on NHC IC 2009) 9. Since consultants can earn an extra income as self-employed specialists
outside the NHS, total earning differences are even larger. On average, consultants earned
€60,628 outside the NHS, on average, in 2009 (See Appendix A). Since only 50% of NHS
consultants have income from a private practice, this amounts to a €121,256 average extra
income for NHS consultants who have an income from a private practice. Associate specialists
and staff grade doctors are usually full specialists (meaning that they completed the full specialty
education), but may not have been able to obtain consultant-level posts. This primarily occurs
because the number of consultant-posts is limited. All non-consultant specialists are only allowed
to practice in the NHS under the supervision of a consultant; they are not on any formal training
programs.
Another country with a clear hierarchy of salaried specialists is Germany. Right after completing
training, a specialist can become a Facharzt in a hospital. After a few years, he/she can continue
as an Oberarzt. In this function, he/she is allowed to train young specialists and lead the other
doctors. On the top of the pyramid is the Chefarzt. These are usually professors who are
responsible for the coordination of work in an entire department of the hospital. The Chefarzt
earns a much higher income (€257,000, on average, in 2010) than an Oberarzt (€113,000) or a
Facharzt (€82,000) (Thurm, 2011).
In countries where the hierarchy is not so clear cut, there are differences in wages. For example,
in the Netherlands, the starting (basic) salary of a specialist working in an academic hospital is
€5,334 per month, whereas a professor in a leading function can earn as much as €12,307 (basic)
salary per month in 2012. This excludes extra pay for work at nights and on weekends (CAO
UMC 2011-2013).

3.4

Summary

Within countries, large differences in income exist between self-employed and salaried doctors.
In Germany, France and Denmark, self-employed doctors earn around 30% to 40% more than
salaried doctors. In the Netherlands, self-employed doctors earned 76% more than their salaried
colleagues. Taking into account the income decrease in 2012 of self-employed doctors in the
Netherlands and an income increase of salaried doctors, self-employed doctors in the
Netherlands will still earn 50% more than salaried doctors. Differences in income can be
9

Exchange rates used to express figures in pounds in Euros can be found at stats.oecd.org

SEO ECONOMIC RESEARCH

16

CHAPTER 3

explained partly by differences in working hours and productivity per hour. They may also be
explained by differences in taxes and contributions. For the Netherlands, however, taxes and
contributions do not differ much.
Within the groups of salaried and self-employed doctors, large differences in income exist. Within
the group of self-employed doctors, earnings differ by specialism, where psychiatrists earn from
€111,901 to €172,943 per year, which is relatively little, compared to radiologists, who earn up to
€334,632 per year. Within the group of salaried specialists, earnings differ with the hierarchical
level in the hospital. In Germany, a medical specialist of the highest level earns, on average,
€257,000; on the lowest level, they earn €82,000.

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REMUNERATION OF MEDICAL SPECIALISTS

4

17

Explanations for differences in income
between countries

Fujisawa & Lafortune (2008) attempted to explain the remuneration of medical specialists
according to differences in income between countries using the following factors:
• hours worked
• number of doctors per capita
• gate keeping role of GPs
• payment system (self-employed/mixed payment/fee for service payment)
All factors had the expected influence on the income of medical specialists. The more hours
specialists worked, the more they earned. The fewer specialists there are per capita, the more they
earned. A gate keeping role of general practitioners led to a lower income of medical specialists
and self employment. 10 Fees for service or mixed payments led to higher incomes than salaries.
None of Fujisawa & Lafortune’s (2008) conclusions were statistically significant. This was due to
the limited number of countries for which data were available (only eight). Consequently, the
authors stressed that remuneration of medical specialists may be influenced by other factors not
included in the analysis.
The numbers of hours worked has been examined in the previous chapters. The Dutch and the
English doctors work more hours than doctors in other countries (except Germany) and earn
more. The Danish doctors work less hours than doctors in other countries and earn less.
In this chapter, some other factors will be examined. Indicators for the demand for healthcare are
summarised in Section 4.1. Section 4.2 deals with the influence of the number of medical
specialists and the characteristics of medical specialists by gross income. Section 4.3 examines if
differences in payment systems can account for differences in gross income between countries;
Section 4.4 does the same for differences in medical education. Section 4.5 goes into the
influence of the role of the GP on the incomes of medical specialists. Section 4.6 concludes.

4.1

Healthcare utilisation and waiting lists

There are large differences in the use of healthcare between countries. Danish residents only visit
a doctor (GP and medical specialist) 4.6 times per year, while Germans visit a doctor more than 8
times per year.

10

In countries where GPs have a gate keeping role, patients do not have direct access to secondary care.
They need a referral from their (primary care) GP to get access to a hospital or a specialist.

SEO ECONOMIC RESEARCH

18

CHAPTER 4

Table 4.1

Doctors visits per year per person (GPs and specialists)
Doctor visits
2009

Belgium

7.6

Denmark

4.6

England

5.0

France

6.9

Germany

8.2

Netherlands

5.7

Source:

OECD, Health at a glance 2011

This difference in doctors’ visits might reflect differences in preferences, but might also reflect
restrictions on the supply side. Waiting lists are indications of the latter. In Belgium, France,
Germany and the Netherlands, there seems to be no supply side restrictions. In Belgium, there
are no waiting lists. In France, Germany and the Netherlands, waiting lists are short. In the past,
problems with waiting lists existed in the Netherlands, England and Denmark. In the
Netherlands and England, policy has successfully reduced waiting lists. In Denmark, since 2007,
the maximum waiting time from diagnosis to treatment is set at 1 month (2 months from 2002).
If the patient cannot be guaranteed treatment within one month, he or she may choose to be
treated at another hospital, including private hospitals and hospitals in other countries. However,
the health system has had difficulties fulfilling the waiting time guarantees. It is unclear what
percentage of patients is actually treated within one month (Olejaz et al. 2012). Thus, the low
number of doctors’ visits in Denmark might be due to supply side restrictions.

4.2

Numbers and characteristics of medical specialists

Table 4.2 illustrates that, in the Netherlands and England, the number of doctors per inhabitant
is low. In Denmark and Germany, there are more than twice as many doctors per inhabitant
when compared with the Netherlands and England. France and Belgium take an intermediate
position. The percentage of female doctors is around 30%, as is the percentage of doctors aged
55 years and older. Exceptions include Belgium, where more doctors are female (39%), England,
where doctors are younger (only 21% are aged 55 years and over), and Denmark, where doctors
are relatively old (49% are aged 55 years and older). Female doctors are younger than male
doctors. In Denmark, 33% of the female doctors were aged 55 years and older, as compared with
57% of male doctors being aged 55 years and older. Of the doctors aged 35-44, the majority
(53%) are female.

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EXPLANATIONS FOR DIFFERENCES IN INCOME BETWEEN COUNTRIES

Table 4.2

19

Number of medical specialists (excluding trainees)
Total number of
medical
specialists

% female

% 55 years and
older

Number of medical
specialist per 1,000
inhabitants

Netherlands

16,210

33

29

0.98

Germany

187,825

44**

34***

2.29

France

108,061*

30

41

1.71

England

47,008

29

21

0.91

Denmark

13,190

35

49

2.39

Belgium

18,852

39

40***

1.75

*
**
***
Sources:

2011
including GPs and medical specialists in training (Assistenzärzte)
% 50 years and older
See Appendix B

In general, female doctors work less hours and earn less. Older doctors earn more when they are
salaried. Age has no influence on the income of the self-employed. There is no clear relationship
between characteristics and income. The two highest earning countries (The Netherlands and
England) have a relatively young workforce. The English workforce is very young, because it is
growing fast due to government policy to increase the number of medical students. Of the
countries with the lowest incomes (Denmark and Germany), Denmark has a high proportion of
elderly, but also has a large percentage of female doctors.
There is a clear relationship between the number of doctors and income. In countries with few
doctors (the Netherlands and England), incomes are higher (See Figure 4.1). This is consistent
with the previous study of Fujisawa & Lafortune (2008). In the UK, waiting lists in the NHS have
led to an incentive for patients to buy healthcare in the private sector. As the private sector
attracts wealthy patients, and as volumes are not budgeted by the government, doctors can earn a
substantial extra income from private practice.
In the Netherlands, self-employed medical specialists received, until 2007, a lump sum payment.
The lump sum payment was introduced in 1995, because costs increased rapidly. Before 1995,
medical specialists worked on a fee for service, as they have since 2008. The result of the
introduction of the lump sum payment was waiting lists. Since 2002, the government has released
the budgets of hospitals and medical specialists in order to resolve the issue of waiting lists. As of
2008, the system is back to fee for service. The difference with the situation before 1995 was that,
since 2008, DRGs are reimbursed, while before 1995, services like visits and operations were
reimbursed. Because of the errors in the DRGs and an increase in registered production, the
incomes of medical specialists increased rapidly. In 2010, DRG tariffs have been adjusted
downwards; in 2012, a temporary budgeting system was introduced. History illustrates that as
soon as budgets are released, the production of a medical specialist increases and so does their
income.
In England, as in the Netherlands, cost containment strategies lead to waiting lists; resolving
waiting lists leads to high incomes.
In Denmark and Germany, on the other hand, there are a large number of medical specialists.
Even with the large number of doctors, Denmark had a problem with waiting lists. Danish

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20

CHAPTER 4

doctors work short weeks and are almost all salaried. Therefore, even in Denmark, the solution
for waiting lists had to come from the private sector. However, the private sector has stayed
small and incomes of specialists stayed relatively low, compared to other countries. In Germany,
doctors work long hours and a large part of them are self-employed, which stimulates their
productivity. Therefore, the pressure on the system is low. Correspondingly, incomes are
relatively low.
Figure 4.1

Fewer doctors: higher incomes

Nr of medical specialist per 1.000 inhabitants

3,00
2,50
2,00

Denmark
Germany
Belgium

France

1,50
1,00

Netherlands 2012

England

Netherlands

0,50
0,00
130.000

140.000

150.000

160.000

170.000

180.000

190.000

200.000

Average income

A low number of doctors are thus associated with a high income. Does this mean that income
differences can be explained by differences in productivity? It seems plausible that part of the
differences in income between countries is explained by differences in productivity. However,
there is no one-to-one relationship between income and the number of hours worked. Working
hours in the Netherlands and England are higher than in Denmark, but not higher than in
Germany. Productivity per hour might be lower in Denmark than in the Netherlands and
England because the Danish doctors are all salaried, but of the German doctors, there are also a
large number of them that are self-employed. 11 So there must be more to it than differences in
productivity.
Another explanation might be that a low number of doctors leads to high negotiation powers.
Therefore, there are higher prices and associated incomes are also higher.

11

If the German doctors are as productive as the Dutch doctors, the German population must receive
more than twice as much care from medical specialists than the Dutch population. After all, the number
of doctors per inhabitant is more than twice as high in Germany as it is in the Netherlands. This is
reflected in the number of hospital beds in Germany: 5.7 per 1,000 inhabitants, compared to 2.8 in the
Netherlands. In addition, the occupancy rate of hospital beds in Germany is higher (Heida & Otter,
2012). This might mean the German system is less efficient. However, this subject goes beyond the scope
of this report.

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EXPLANATIONS FOR DIFFERENCES IN INCOME BETWEEN COUNTRIES

4.3

21

Differences in payment systems

Self-employed doctors earn more than salaried doctors in all countries where both systems exist
side by side (See Chapter 3). However, English doctors earn, on average, more than doctors in
other countries (except the Netherlands) and are almost all salaried. The English doctors
responded on supply side restrictions by working in the private sector. As the private sector is
not budgeted, it functions as an escape valve for the budgeted NHS. In countries where part of
the workforce is self-employed, there is more flexibility in responding to higher demands by
increasing the number of hours worked. In theory, it is possible to increase the production of
salaried doctors by introducing pay for performance. However, in the countries in this
investigation, hardly any performance pay has been introduced. In countries with two systems,
this might not be necessary, because pressure on the system can be accommodated by selfemployed doctors. However, in England and Denmark, there are hardly any performance pay
measures for salaried workers. Therefore, waiting lists can occur and lead to a parallel private
market. In Denmark, the private market is quite small, due to the relatively large number of
salaried doctors. But in England, the number of doctors is low, leading to an increasing private
sector. Therefore, the English government is now releasing severe entrance restrictions for
medical education.
On the whole, the differences in payment systems do not seem to have a significant influence on
the earnings of doctors.

4.4

Production by physicians in training

Part of the production of the Dutch and the Belgian doctors is produced by physicians in
training. The Dutch and Belgian doctors work inside the hospital and are responsible for the
education of physicians in training. In all other countries, self-employed doctors work outside the
hospital, while physicians in training almost always are educated in the hospital. The revenues of
the physicians in training by the Dutch and Belgian self-employed doctors is added to their
revenue. This is a compensation for the time they invest in the training. However, the Belgian
doctors pay the wages of the physicians in training, while the Dutch doctors do not. The wages
are paid by a national fund. This might explain, to some extent, the higher incomes of the Dutch
self-employed doctors. However, the English doctors do not get extra revenue from physicians in
training and earn as much as the Dutch doctors.

4.5

Differences in education

The education of English doctors is 12 to 15 years in length and is longer than the education in
the other countries. This might explain, to some extent, the high incomes of the English doctors.
Since 2012, undergraduate students have paid a fee of a maximum £ 9,000 per year (on average £
8,300). Existing doctors will have paid lower fees. Up to 2006, the maximum fee was £ 1,225.
From 2006-2011, the maximum was £ 3,225 (Jongbloed & Dassen 2009).

SEO ECONOMIC RESEARCH

22

CHAPTER 4

The education of the Dutch doctors, on the other hand, is just as long as it is in France and
Germany. The costs they pay are not much higher than in other countries and the salary in post
graduate training is about the same as in most other countries.
In all countries, except Belgium, entrance to medical study is restricted by numerous clauses. In
the Netherlands and the UK, the restrictions are more severe.
Table 4.3

Aspects of medical education
France

UK

Germany

Belgium

Denmark

Netherlands

Years of education

10-12

12-15

10-12

11-13

11-12

10-12

-undergraduate

6

5

6

7

6

6

-graduate

4-5

7-10

4-6

4-6

5-6

4-6

Costs for undergraduate
students (per year)

€402

₤ 8,300

€600 to
€1000

€840

€0

€1,620

Yearly salary of students
during (post graduate)
training 2009

€18,000€24,000

₤22,400₤57,000

€55,000*

€50,000

n.a.

€42,000 €53,700

Restricted entrance

Yes

Yes

Yes

No

Yes

Yes

*
Sources:

2004
See Appendix B

4.6

Differences in roles of GPs

In the Netherlands, England and Denmark, the GP has a gate keeping role. In Belgium, France
and Germany, the GP has no role as a gatekeeper, but in practice, most patients have a family
doctor whom they generally consult first.
Fujisawa and Lafortune (2008) find that in countries where the GP is a gatekeeper, medical
specialists earn less. They expected this relationship because the GP constrains the demand for
medical specialists. But it might also be the other way around: if the GP is gatekeeper, the
medical specialists only treat the more complex patients. The less complex patients will be treated
by the GP and will not be referred to the medical specialists. This might partly explain the higher
income of the specialists in the Netherlands and the UK. However, in both the Netherlands and
the UK, the number of GPs is also relatively low. This is because of the restricted entrance to the
medical education. On the whole, the role of the GP cannot explain differences in income
between countries.

4.7

Conclusions

Income differences between countries are associated with differences in the number of doctors.
In countries with a low number of doctors, incomes are high, whereas in countries with a high
number of doctors, incomes are relatively low. The differences are partly explained by differences
in working hours. A lower number of doctors might also lead to a high negotiation power of
doctors, and therefore, higher prices and associated incomes.

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EXPLANATIONS FOR DIFFERENCES IN INCOME BETWEEN COUNTRIES

23

Other factors, such as the composition of the workforce, the gate keeping role of GPs,
differences in payment systems, whether the production of the physicians in training accrues to
the hospital or the medical specialist and differences in education do not seem to have a
significant influence on the earnings of medical specialists.

SEO ECONOMIC RESEARCH

REMUNERATION OF MEDICAL SPECIALISTS

25

References
Attal-Toubert, K., H. Fréchou, F. Guillaumat-Tailliet (2009). Le revenue global d’activité des
médecins ayant une activité libérale, Les revenus d’activité des indépendants, édition 2009,
Direction de la recherche, des études, de l’évaluation et des statistiques (DREES).
Barro, J. & N. Beaulieu (2003). Selection and improvement: physician responses to financial
incentives. NBER Working paper 10017.
Bellamy, V. (2011). Les honoraires des professionels de santé libéraux entre 2008 et 2010,
Direction de la recherche, des études, de l’évaluation et des statistiques (DREES).
CBS (Statistics Netherlands)(2012). Medisch geschoolden; arbeidspositie, positie in de werkkring,
naar beroep. Available from statline.cbs.nl.
Chevreul, K. I. Durand-Zaleski, S. Bahrami, C. Hernandez-Quevedo, P. Mladovsky (2010).
France: Health system review, Health Systems in Transition, URC Eco & European
Observatory on Health Systems and Policies.
Danish Regions (2009). Omkostnings- og indtjeningsundersøgelse af speciallægepraksis 2008.
Obtained via
http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/F_A_S/FAPS/FAPS%20i
%20tal/omkostningsunders%C3%B8gelsen%202008.pdf
Fujisawa, R. & Lafortune G. (2008) The remuneration of general practitioners and specialists in
14 OECD countries: what are the factors influencing variations across countries. Paris:
OECD. Health Working papers no. 41.
Hilten O. van, Aaldijk M., Smit J. (2011). Nieuwe Nederlandse cijfers voor OESO over beloning
artsen. Centraal Bureau voor de Statistiek. Den Haag/Heerlen.
Jongbloed B. & A. Dassen (2009). Collegegelden en studiefinanciering. De situatie in Australia,
Canada, Duitsland, het Verenigd Koninkrijk en de VS. Enschede: Center for Higher
Education Policy Studies (CHEPS).
Ketel, N, E. Leuven, H. Oosterbeek en B. van der Klaauw (2012), The returns to medical school
in a regulated labor market: evidence from admission lotteries, werkdocument,
Universiteit van Amsterdam/Vrije Universiteit Amsterdam.
Lagendijk, P. (2010). Vrijgevestigde specialisten versus specialisten in dienstverband. deel 1.
(Beschikbare Specialisten Uren).

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Morris S., Elliot B., Ma A., McConnachi A., Rice N., Skatun D., Sutton M. (2008). Analysis of
consultants’ NHS and private incomes in England in 2003/2004. J R Soc Med 2008:
101: 372-380.
NHS IC (2009). Information centre for health and social care 2009 NHS staff earnings estimates.
Downloadable
via:
http://www.ic.nhs.uk/statistics-and-datacollections/workforce/nhs-staff-earnings
NZa

(Dutch Healthcare Authority) (2011) Verantwoordingsdocument Invoering
prestatiebekostiging medisch specialistische zorg. Uitwerking van implementatie per
2012

OECD (2012). OECD health data 2012. Definitions, sources and methods. Remuneration of
Medical specialists.
Olejaz M., Juul Nielsen A., Rudkjøbing A., Okkels Birk H., Krasnik A., Hernández-Quevedo C.
(2012). Denmark: Health system review. Health Systems in Transition, 2012, 14(2):1 – 192.
Oever. R. van den (2008). De vergoeding van de arts in België. De nomenclatuur: van
prestatievergoeding naar budgetfinanciering?
Siciliani L. and Hurst J. (2003) Explaining waiting times variations for elective surgery across
OECD countries. Paris:OECD.
Siciliani L., Verzulli R. (2009). Waiting times and socioeconomic status among elderly Europeans:
evidence from SHARE. Health Economics, 18(11):1295 – 1306.
Statistics Netherlands (2012). Gezondheid en zorg in cijfers 2012. CBS: The Hague.
Statistische Bundesamt (2009). Kostenstruktur bei Arzt- und Zahnarztpraxen, Praxen von
psychologischen Psychotherapeuten sowie Tierarztpraxen. Pp36-37 (income from solo
practice). Obtained via www.destatis.de
Statistische Bundesamt (2012). Grunddaten der Krankenhäuser 2010.
Swartenbroekx N., Obyn C., Guillaume P., Lona M., Cleemput I. (2012). Manual for cost-based
pricing of hospital interventions. Health Technology Assessment (HTA). Brussels:
Belgian Healthcare Knowledge Centre (KCE). KCE Report 178C.
Thurm, T. (2011). Immer mehr Krankenhäuser vergüten variabel. In: Arzt und Krankenhaus
3/2011

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REMUNERATION OF MEDICAL SPECIALISTS

27

Appendix A Adjustment OECD figures
Deviations from the OECD definition
The OECD gathers data from OECD-countries on the remuneration of medical specialists.
Ideally, these figures should be the average gross annual income.
The figures should include:
• The value of any social contributions, (income) taxes, etc., payable by the employee
• All gratuities, bonuses, overtime compensation and ‘thirteenth month payments’
• Any supplementary income
And should exclude:
For salaried: social contributions payable by the employer
• For self-employed: practice expenses
• Any physicians who are still in training to become a specialist
• Physicians who have specialised in GPs
•

Earnings are given per FTE for salaried specialists and per specialist for the self-employed. The
actual figures provided by the various countries depend on availability, and therefore, often
deviate from this OECD definition. The deviations per country are provided in Table A.1
For salaried specialists, both England and Germany include physicians in training
(foundation/registrars and Ärzte respectively). The figures for these countries are therefore
underestimated. France and Germany include the salaries of GPs in their numbers 12. Moreover,
the numbers for French specialists are net income figures instead of gross, also resulting in an
underestimation. England and Germany do not include income from private practice. On the
other hand, France and the Netherlands only include those specialists that do not have any
income from private practices, thereby possibly selecting a group of specialists that earns less, on
average.
The figures for self-employed specialists also deviate in various ways from the OECD definition.
The French figure once again refers to net income instead of gross. In Belgium and France, extra
billing is excluded. For Belgium, this means that supplemental income (e.g. for sleeping in a single
room instead of a shared room) are excluded. In France, medical specialists in the so called
“secteur 2” can set their own fees. The part of the fee above the standard fee not reimbursed by
health insurance is not included in the income figure. On the other hand, OECD figures for
Belgium still include practice costs, whereas these are excluded in all other countries. In France,
some self-employed specialists are also salaried. These salaries are not included in the income
figures. 13

12

13

OECD documentation (OECD, 2012) reports that for Danish salaried physicians, there is no distinction
made between GP’s and salaried specialists. However, this remark is irrelevant, since Danish GP’s are
never salaried and are, therefore, not included in the Danish income figure for salaried specialists.
http://www.ecosante.fr/DEPAFRA/343.html

SEO ECONOMIC RESEARCH

28

APPENDIX A

Table A.1

OECD figures for incomes of medical specialists in 2009 Euros
Belgium

Gross income salaried

Denmark

England

France

Germany

Netherlands

€136,799

€89,319

€73,284

€75,700*

€118,431

Includes specialists in
training

X

X

Includes GP’s

X

Net income instead of gross

X

Excludes extra income as
self-employed

Gross income selfemployed

X

€239,763

€192,791***

Net income instead of gross
X

Includes practice costs

X

Excludes extra income from
salary
**2007

Only
salaried

X

Only
salaried

€118,000

€157,000**

€259,131

X

Excludes extra billing

*2006

X

X

X

***2008

Adjustments to the OECD figures
Belgium
The OECD only provides figures for the Belgian self-employed specialists. Figures are taken
from the Institut national d’assurance maladie-invalidité (INAMI). These already include any
patient contributions to the nationally set tariffs (20-25% of the tariff, on average). However,
supplemental income that specialists can charge to the patients (e.g. for using a single room
instead of a shared room) over and above the nationally set tariffs are excluded. On the other
hand, the practice costs of specialists are still included in the figures, leading to an overestimation
of income.
A study by the Belgian Healthcare Knowledge Centre (Swartenbroekx et al., 2012) provides more
information on the income of self-employed specialists working in hospitals. This study gathers
2010 income figures from specialists in 13 hospitals in Belgium. This report not only presents
income figures including practice costs and excluding supplemental income, but also lists income
including supplemental income and/or excluding practice costs. In the report, income figures are
separated by specialty. In order to determine the percentage of income that consists of
supplemental income, and the percentage of income that is spend on practice costs, the specialtyspecific income figures are combined with the number of specialists in each specialty according
to the ‘Federale Overheidsdienst Volksgezondheid’. From this, it is calculated that, on average,
the supplemental income add an extra 13.50% to income (ranging from 0% for specialists
working on intensive care to 35% for plastic surgeons). Extra earnings in terms of supplemental
income are €239,763 * 13.50% = €32,378, on average. The income of Belgian specialists,
including supplemental income is therefore €239,763 + €32,378 = €272,141.
In the same way, the percentage of income (including supplemental income) that the specialist
pays to the hospital in order to cover practice expenses is determined. On average, 37% of gross
wages (including supplemental income) are deducted as practice costs (ranging from 13% for
oncologists to 81% for clinical biologists). Deductions on earnings in terms of practice costs are

SEO ECONOMIC RESEARCH

ADJUSTMENT OECD FIGURES

29

€272,141 * 37% = €101,714, on average. Adjusted gross income (including supplemental income,
excluding practice costs) are therefore €239,763 + €32,378 - €101,714 = €170,427 per medical
specialist. 14 The final line of Table A.2 shows that the corrected gross wage is about 71% of the
original OECD figure (€170,427 / €239,763 = 71%).
Denmark
The Danish figures both for self-employed and salaried specialists are in accordance with OECD
definitions and therefore do not need to be adjusted. These are taken from the joint municipal
payroll data office (FLD) for salaried specialists, and from a survey of the Danish Association of
Practising Medical Specialists (FAPS) for self-employed specialists. For self-employed specialists,
the most recent OECD figure is from 2008. Assuming that the income of specialists increases at
the same rate as the average wage in Denmark between 2008 and 2009, the estimated income in
2009 is €200,530. 15
England
The figures for England (data do not include Scotland, Northern Ireland and Wales) are taken
from the NHS Information Centre for Health and Social Care (IC) Electronic Staff Record
(ESR) data (IC NHS, 2009). Since nearly all English specialists are salaried, income of selfemployed specialists is not available. Income figures are averages over all doctors, including those
who are still in training to become specialists (foundation and registrars). When those are
excluded, the average wage of a medical specialist becomes £ 112,111 or €125,720 in 2009
(exchange rates from stats.oecd.org are used throughout). This adds an extra €125,720 - €89,319
= €36,401 to the OECD figure. For the supplement income, we refer to research by Morris et al.
(2008). They use a unique, anonymized, non-disclosive dataset derived from tax returns for a
sample of 24,407 consultants (92.3% of the total) in England for the financial year 2003/4 and
report that the ratio of mean private to NHS income for consultants was 0.45. According to data
from the NHS Information Centre (IC NHS, 2009), consultants earn an average income of £
120,145 or €134,730. Supplementary income then amounts to 0.45 * €134,730 = €60,628. This
means consultants earn €195,358, of which 31% comes from private practices. Since consultants
account for around 82% of the total specialist FTE, the mean supplementary income added is
0.82 * €60,628 = €49,866, which makes the total gross wage income of English salaried specialists
equal to €125,720 + €49,866 = €175,586.
France
For France, the OECD figures for salaried specialists are based on administrative data from the
French Statistical Office (INSEE). The figures do not make a distinction between salaried GP’s
and salaried medical specialists working in the hospitals. However, the majority of salaried
doctors are medical specialists, and therefore, the figures provide a good indication of specialist
income. The OECD figures are net income instead of gross. Income taxes and social
14

15

The KCE report (KCE, 2012) calculates income figures per FTE. The OECD figures for self-employed
specialists are calculated per specialist. Using KCE income figures, the weighted (country-wide) average
income per FTE is €249.819 for self-employed specialists in hospitals. Since the 18.566 Belgian specialists
represent 12.429 FTE (Health Systems in Transition, 2012), the average number of FTEs per specialist is
0,67. The KCE figures therefore imply an average income of €249.819*0,67=€167.242 per specialist in
2010. This is only slightly different from the adjusted OECD figure of €170.427 per specialist in 2009.
Average income per year is obtained from stats.oecd.org

SEO ECONOMIC RESEARCH

30

APPENDIX A

contributions are about 44% for these income groups. 16 This means that, approximately, the
gross average income of salaried specialists is €131,716.
Figures on self-employed specialists are based on administrative data from the Système National
Inter-Régimes (SNIR) and provided by DREES. 17 These refer to the fees that are reimbursed by
the statutory health insurance. Again, the provided numbers refer to net income instead of gross
and exclude social security contributions. DREES has also calculated average gross incomes
based on the same data source, see Bellamy (2011). It is found that in 2009, self-employed
medical specialists received, on average, €178,530 in fees. This number is used to estimate the
average income.
The gross income of €178,530 still does not meet the OECD definition. First of all, practice costs
are included. Unfortunately, no source is available on the average practice costs, and therefore,
the difference between this figure and the OECD number is used: €60,530 (= €178,530 €118,000). This is an overestimation, as this amount also includes social security contributions.
Sources of supplementary income are currently excluded and need to be added. First of all,
French specialists in “secteur 2” can set their own fees. The part of their fee above the regular fee
(Sécu-tariff) is paid directly by the patient. In 2011, this extra billing (in French “dépassements”)
amounted to €2.1 billion.18 Divided by the approximately 50,000 self-employed specialists, this
results in around €40,000 additional gross income. Next to this, some self-employed specialists
also have a part-time job as a salaried medical specialist. They do this, among other reasons, to
maintain relationships with the hospital or to keep up their medical knowledge. About 21% of
self-employed specialists earn additional income through salaried work, referring to
approximately 10,000 specialists. 19 Attal-Toubert et al. (2009) from DREES calculated the total
revenue of medical specialists in 2005, taking into account the supplementary income earned
through salaried work (but excluding extra billing). They found that medical specialists that work
both as self-employed and as a salaried employee earn approximately the same as specialists that
are solely self-employed. Furthermore, approximately 37% of their net income comes from
salaried work. Based on this, we assume that the OECD figure of €118,000 contains the total
income of medical specialists that work solely as self-employed and 63% of the total income of
specialists that also work as salaried employees. The corrected average net income then becomes:
€127,941 (=€118,000 x 49,817 self-employed medical specialists / (39,355 solely self-employed +
10,462 both self-employed and salaried x 63%). The additional net income is therefore €9,941.
This means that the gross additional income is, on average, €17,867.
Adding extra income and excluding practice costs, the gross corrected income for French selfemployed medical specialists is estimated to be €176,042. This is still an underestimation, as social
contributions are excluded.

16
17
18

19

Source: interview and own calculations based on “charges sociales 2009” and “barême impôt 2009”.
DREES: Direction de la Recherche, des Etudes, de l’Evaluation et des Statistiques (du Ministère du
Travail, de l’Emploi et de la Santé)
See www.gourvernement.fr: “L’encadrement des dépassements d’honoraires et l’amélioration de l’accès
aux soins” or http://www.lequotidiendumedecin.fr/actualite/24-milliards-de-depassements-en-2011-ilest-temps-d-agir-pour-marisol-touraine
http://www.ecosante.fr/FRANFRA/343.html

SEO ECONOMIC RESEARCH

ADJUSTMENT OECD FIGURES

31

Germany
The OECD figures for salaried specialists in Germany come from a structure earnings survey of
the Federal Statistic Office (Statistisches Bundesamt). This survey provides a general overview of
income in various occupations, including doctors (Ärzte). Comparable to the English figures, no
distinction is made between specialists who completed their training (Chefärzte, Oberärzte and
Fachärzte) and specialists that are still in training (Ärzte). Unlike in England, separate figures for
the various hierarchical levels of salaried specialists in German hospitals are not available from
the Federal Statistic Office. We, therefore, use a different source to estimate the average income
of German salaried specialists.
Thurm (2011) reports on a survey among salaried medical specialists in German hospitals.
Reported income figures include any bonus and variable payments to the specialists, and also
include income from the so-called ‘Liquidationsrecht’ for leading specialists (Chefärzte), which
means they can treat private patients within the hospitals, and charge them directly for the
treatment. From this survey, average income of German Chefärzte, Oberärzte and Fachärzte in
2010 are €257,000, €113,000 and €82,000, respectively. According to data from the Statistische
Bundesamt (2012), there were 13,065 Chefärzte, 33,705 Oberärzte and 33,556 Fachärzte working
in German hospitals in 2010. Taken together, these figures imply an average income of €123,471
for German specialists. Adjusting wages for the average wage increase in Germany between 2009
and 2010 provides an estimated income of €121,097 in 2010. 20 When specialists in training are
included (68,370 trainees earning about €50,000 per year), earnings are only €89,689, on average,
in 2010.
The reported German income for the self-employed is in accordance with the OECD definition.
However, the figure refers to income earned in 2007, instead of 2009, and therefore, is corrected
for the average wage increase between 2007 and 2009, in order to make the figures comparable
between countries. This correction adds another €3,253 to the income of the self-employed for a
total income of €160,253 in 2009.
Netherlands
The data on the income of Dutch specialists is taken from Statistics Netherlands. Specialists are
identified by their registration in the BIG register as a medical specialists 21 and are working in the
healthcare sector (van Hilten et al., 2011).
The income for salaried specialists is only based on those specialists who do not have any income
from private practice. However, in the Netherlands, 57% of specialists are salaried: 38% only
have income from their salary, whereas 19% also have income from private practice. Those that
have income from private practice had an average wage of €81,599 in 2009 and an average
income from private practice of €123,881, for a total of €205,480 per specialist. 22 The average
wage of salaried specialists is therefore a weighted average of €118,431 and €205,480: (0.38 *
€118,431 + 0.19 * €205,480)/ (0.38+0.19) = €147,447.
20
21

22

Average income per year is obtained from stats.oecd.org
Medical specialists can only register in the BIG after completing their full education. The BIG-register
uses the registration of the Medical Specialists Registration Committee (MSRC) to identify a person as a
medical specialist.
Data acquired from Statistics Netherlands.

SEO ECONOMIC RESEARCH

32

APPENDIX A

The Dutch figures for self-employed specialists are in accordance with OECD definitions and
therefore do not need to be adjusted. For the self-employed, only those who obtain their full
income from profit are included. The income reported is gross profit excluding any practice
costs.
Table A.2

Calculated gross income medical specialists in 2009 Euros
Belgium

(Gross) income
salaried without
corrections

Denmark

€136,799

Excluding specialists in
training

England

France

€89,3193

€73,284

€36,401

Excluding GP’s

Germany

€89,6891****

Netherlands

€118,431

€33,782
not available

Income taxes and social
charges

€58,432

Extra income as selfemployed

€49,866

None

‘Inflation’ correction

€29,016

-€2,374

Gross income salaried
with corrections

€136,799

€175,586

€131,716

€121,097

€147,447

Income OECD figure

€136,799

€89,319

€73,284

€75,700*

€118,431

Correction in%*****

100%

197%

180%

-

100%

€178,5302

€157,000**

€259,131

Gross income selfemployed without
corrections

€239,763

€192,791***

Excluding GP’s
Including extra billing

€32,378

€40,175

Excluding practice costs

-€101,714

€60,530

Including extra income
as employee

€17,867 None

‘Inflation’ correction

€7,739

€3,253

Gross income selfemployed with
corrections

€170,427

€200,530

€176,042

€160,253

€259,131

Income OECD figure

€239,763

€192,791

€118,000

€157,000

€259,131

Correction in%*****

71%

100%

149%

100%

100%

*2006
**2007
***2008
****2010 ***** without inflation correction
Source: 1Thurm (2010) 2Bellamy (2011) 3NHS IC (2009). All other income figures from OECD Health Database.

Corrected OECD income figures from 2006-2009
Table A.3 provides an overview of the corrected OECD income figures from 2006-2009 (if
available). These corrected figures are calculated by multiplying the ratio between uncorrected
OECD figures and the corrected gross income figures for the year 2009 (given in Table A.2) with
the uncorrected OECD figures in all years. For the Netherlands, we know the average income of
those salaried specialists that have income from a private practice (data acquired from Statistics
Netherlands) and we know the proportion of salaried specialists that have income from a private
practice for all years 2006-2009. This implies that the use of a correction factor for the
Netherlands is unnecessary. The Dutch figures are therefore exact for all years.

SEO ECONOMIC RESEARCH

ADJUSTMENT OECD FIGURES

Table A.3

33

Corrected OECD income figures of medical specialists 2006-2009 in Euros
Belgium

Denmark

England

France

Germany Netherlands

Gross income salaried with corrections
€

€

DKK

€

£

2006

116,637

870,129

2007

120,968

2008
2009

€

€

128,303

128,072

901,286

215,272

147,251

135,996

133,507

129,154

964,502

192,484

153,374

140,214

137,924

136,799

1,018,783

175,586

156,578

131,716

121,097

€

147,447

Gross income self-employed with corrections
2006

147,237

165,748

2007

152,975

169,925

2008

161,122

192,791

1,439,738

174,252

2009

170,426

200,530

1,497,532

176,042

Source:

calculations SEO Economic Research

186,999
157,000

205,059
235,105

160,253

259,131

SEO ECONOMIC RESEARCH

REMUNERATION OF MEDICAL SPECIALISTS

35

Appendix B Sources
Sources total number of medical specialists:
Netherlands: CBS (2012). Medisch geschoolden; arbeidspositie, positie in de werkkring, naar
beroep. Available from statline.cbs.nl. Data over 2009
Germany: Bundesärztekammer (2009). Abbildung 3: Berufstätige Ärztinnen und Ärzte nach
Arztgruppen
zum
31.
12.
2009.
Available
from
http://www.bundesaerztekammer.de/downloads/Stat09Abb03.pdf. Data over 2009
France:
INSEE
(2011):
Médecins
suivant
le
statut
et
http://www.insee.fr/fr/themes/document.asp?reg_id=0&ref_id=T12F092

la

spécialité,

England: NHS IC (2010). NHS Staff 1999-2009 (Medical and Dental). Table 8: Hospital and
Community Health Services (HCHS): Medical and dental staff by grade and ageband. Available
from http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhsstaff-1999--2009-medical-and-dental Data over 2009.
Denmark: Sundhedsstyrelsen. Arbejdsstyrken af sundhesuddannede 2000-2009. Available from
http://www.sst.dk/Indberetning%20og%20statistik/Sundhedsdata/Arbejdsmarked/Arbejdsstyr
ken%20af%20sundhedsuddannede.aspx. Data over 2009
Belgium: FOD Volksgezondheid. Artsen specialisten praktijk 2009. Data over 2009
Sources percentage self employed/salaried:
Netherlands: CBS (2012). Medisch geschoolden; arbeidspositie, positie in de werkkring, naar beroep. Available
from statline.cbs.nl. Data over 2009
Germany: Bundesärztekammer (2009). Tabelle 7: Stationär tätige Ärztinnen/Ärzte nach
Gebietsbezeichnungen und Altersgruppen Stand: 31. 12. 2009. Available from
http://www.bundesaerztekammer.de/downloads/Stat09Tab07.pdf. Data over 2009.
France: Chevreul (2010)
England: Office for Fair Trading: Private market Healthcare market survey, December 2011.
http://www.oft.gov.uk/shared_oft/marketData
over
2011.
Available
from
studies/OFT1396_Private_healthcare.pdf
Denmark: Sundhedsstyrelsen. Arbejdsstyrken af sundhesuddannede 2000-2009. Available from
http://www.sst.dk/Indberetning%20og%20statistik/Sundhedsdata/Arbejdsmarked/Arbejdsstyrken%20af%2
0sundhedsuddannede.aspx. Data over 2009

SEO ECONOMIC RESEARCH

36

APPENDIX B

Danish Regions (2009). Omkostnings- og indtjeningsundersøgelse af speciallægepraksis 2008.
Available
from
http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/F_A_S/FAPS/FAPS%20i
%20tal/omkostningsunders%C3%B8gelsen%202008.pdf. Data over 2008
Belgium: FOD Volksgezondheid. Artsen specialisten. Data over 2009.
Sources working hours:
Netherlands: Weening, H. (2002). Artsen en de arbeidstijdenwet, eindrapport. Amsterdam:
Regioplan. Data over 2001.
Germany:
Salaried: Marburger Bund (2010). Marburger Bund Mitgliederbefragung 2010. Zur beruflichen
Situationen der angestellten und beamteten Ärztinnen und Ärzte. Data over 2010.
Self-employed: Stillfried D. Von, Leibner M., Erhart M. (2012). Wirtschaftliche Lage
niedergelassener Ärzte und Psychotherapeuten in Deutschland: Kritische Entwicklung in den
Available
from
Einzelpraxen?
http://www.zi.de/cms/fileadmin/images/content/PDFs_alle/G_S_Erste_Ergebnisse_des_ZiP
P_end.pdf . Data over 2008
France: Estimation from national expert (Isabelle Durand-Zaleski) and Breuil-Genier, P. & D.
Sicart (2005), La situation professionnele des conjoints de médecins, DREES: Études et
Résultats, no 430.
England: NAO (2007). Survey of NHS consultants – May 2006. National Audit Office. Available
from http://www.nao.org.uk/publications/0607/pay_modernisation_a_new_contr.aspx. Data
over 2006
Denmark:
Self-employed: Danish Regions (2009). Omkostnings- og indtjeningsundersøgelse af
speciallægepraksis
2008.
Obtained
via
http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/F_A_S/FAPS/FAPS%20i
%20tal/omkostningsunders%C3%B8gelsen%202008.pdf. Data over 2008
Salaried:
Overlægers
arbejdsvilkår.
Obtained
via
http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/F_A_S/Overl%C3%A6gef
oreningen/Rapporter/arbejdsvilkaer09.pdf. Data over 2008
Belgium: Claes A. And V. Milis (2009). Eindrapport bevraging beroepsgroep artsen-specialisten.
Rapport in opdracht van FOD Volksgezondheid. Data over 2009
Sources number of medical specialists per 1000 inhabitants
For sources on the number of medical specialists: see above
Source on the number of inhabitants: stat.oecd.org

SEO ECONOMIC RESEARCH

SOURCES

37

Sources % female
Netherlands: Medisch geschoolden; arbeidspositie, positie in de werkkring, naar beroep. Available from
statline.cbs.nl. Data over 2009
Germany: Bei den Ärztekammern registrierte Ärztinnen und Ärzte mit Gebiets- und
http://www.gbe-bund.de/oowa921Facharztbezeichnung.
Available
from:
install/servlet/oowa/aw92/WS0100/_XWD_FORMPROC?TARGET=&PAGE=_XWD_104
&OPINDEX=10&HANDLER=_XWD_CUBE.SETPGS&DATACUBE=_XWD_132&D.001
=1000001&D.002=1000002&D.003=43&D.928=11899&D.100=10101. Data over 2009
France: Féminisation. Pourcentage dans la “spécialité”. Available from www.irdes.fr. Data over
2007
England: NHS IC (2010). NHS Staff 1999-2009 (Medical and Dental). Table 1.1 and Table 1.2 :
Hospital and Community Health Services (HCHS): Medical and dental staff by specialty group
and grade. Available from http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhsstaff-numbers/nhs-staff-1999--2009-medical-and-dental Data over 2009.
Denmark: Danish Regions (2009). Omkostnings- og indtjeningsundersøgelse af
speciallægepraksis 2008. Available from
http://www.laeger.dk/portal/page/portal/LAEGERDK/Laegerdk/F_A_S/FAPS/FAPS%20i
%20tal/omkostningsunders%C3%B8gelsen%202008.pdf. Data over 2009
Belgium: FOD Volksgezondheid. Artsen specialisten praktijk 2009. Data over 2009
Sources % 55 years and older
Netherlands: Medisch geschoolden; arbeidspositie, positie in de werkkring, naar beroep. Available from
statline.cbs.nl. Data over 2009
Germany: Bundesärztekammer (2009). Tabelle 7: Stationär tätige Ärztinnen/Ärzte nach
Gebietsbezeichnunngen und Altersgruppen. Stand: 31. 12. 2009. Available from
http://www.aerztekammer-bw.de/40presse/05aerztestatistik/04c.pdf. Data over 2009
France: Vieillissement. % des médecins de 55 ans et plus. Available from www.irdes.fr
England: NHS Staff 1999-2009 (Medical and Dental). Table 8 : Hospital and Community Health
Services (HCHS): Medical and dental staff by grade and ageband. Available from
http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhs-staff-numbers/nhs-staff1999--2009-medical-and-dental Data over 2009.
Denmark: Sundhedsstyrelsen. Arbejdsstyrken af sundhesuddannede 2000-2009. Available from
http://www.sst.dk/Indberetning%20og%20statistik/Sundhedsdata/Arbejdsmarked/Arbejdsstyr
ken%20af%20sundhedsuddannede.aspx. Data over 2009

SEO ECONOMIC RESEARCH

38

APPENDIX B

Belgium: FOD Volksgezondheid. Artsen specialisten leeftijd. Data over 2009
Sources medical education (Data over 2009 unless otherwise specified)
Netherlands:
Number of years of education:
Opleiding tot medisch specialist. Available from: http://knmg.artsennet.nl/Opleiding-enRegistratie/Opleiding/medisch-specialist-3.htm.
College fees:
Betalingswijzen
collegegeld.
Available
from:
http://www.wageningenuniversity.nl/NL/Informatie+voor/huidige_bsc_studenten/financi%C3
%ABn+en+verzekeringen/Betalingswijzen+Collegegeld/.
Salary of students during (postgraduate) training:
CAO
Universitair
Medische
Centra.
leden.nl/uploads/CAO%20UMC%2008-11[1].pdf.

Available

from:

http://www.nu91-

Germany:
Number of years of education:
Busse R., Riesberg A. (2004). Health Care Systems in Transition 2004. Germany. (Information
confirmed by national contact)
College fees:
Information from national contact.
Salary of students during (postgraduate) training:
Walger M., Köpf P. (2005). Einkommen von Krankenhausärzten –eine differenzierte
Betrachtung. Krankenhaus 12-2005. Data over 2004
France:
Number of years of education:
Chevreul, K., Durand-Zaleski, I., Bahrami, S., Hernandez-Quevedo, C., Mladovsky, P. (2010).
Health Systems in Transition, URCeco, Health System Review 2010. France (Confirmed by
national contact).
College fees:
Université publique : droits de scolarité pour la rentrée universitaire 2009-2010. Available from:
http://www.actualite-francaise.com/depeches/universite-publique-droits-scolarite-rentree-universitaire,5165.html
Salary of students during (postgraduate) training:
Medisch contact, 67e jaargang, nr 26, p 1653, 6 juli 2012 (In Dutch).
England:
Number of years of education:

SEO ECONOMIC RESEARCH

SOURCES

39

Boyle, S. (2011). Health Systems in Transition, Health System Review 2011. United Kingdom.
(LSE). (Information confirmed and extended by national contact)
College fees:
Information from Seán Boyle.
Salary of students during (postgraduate) training:
NHS IC (2009). Information Centre for Health and Social Care 2009 NHS Staff Earnings
http://www.ic.nhs.uk/statistics-and-dataEstimates.
Downloadable
via:
collections/workforce/nhs-staff-earnings.
Denmark:
Number of years of education:
Olejaz, M., Nielsen, A.J., Rudkjobing, A., Okkels Birk, H., Krasnik, A., Hernandez-Quevedo, C.
(2012). Health Systems in Transition, Health System Review 2012. Denmark (confirmed by
national contact).
College fees:
Information from national contact.
Belgium:
Number of years of education:
Gerkens, S., Merkur, M. (2010). Health System in Transition, Health System Review 2010.
Belgium. (KCE). (Confirmed and extended by national contact)
College fees:
Information from national contact.
Salary of students during (postgraduate) training:
Estimation national contact.

SEO ECONOMIC RESEARCH

REMUNERATION OF MEDICAL SPECIALISTS

41

Appendix C Taxes and premiums in the
Netherlands
Assumptions Table C.1
Salaried
• Wage: highest pay scale in AMS system (non academic wage scale) with an income of
€158.000, - euro (step 6 with 15% disutility and 8% holiday pay)
• Pension contribution is based on: accrual rate 1,95% per year, starting age of 35 years,
retirement age of 65, a franchise of over €10.000, -. This leads to a pension at retirement of
€85.000, excluding the state pension (AOW).
Self-employed
• Collective practice costs are costs which are made for the common practice. This could
include, wages and salaries secretary, doctors not in training (anions) and other support
personnel, depreciation of tangible assets, audit fees, liability insurance costs charged by the
hospital, collection and administration etc.. Costs are estimated at 8% of gross revenue.
• Individual practice costs are costs of an accountant €3.000, -, congress fees, literature,
subscriptions, telephone etc. approximately €7.000, - per year, insurance €2.000, - per year.
• Pension premium: to reach €85.000 retirement benefits a total pension premium of €34.300 is
needed.
• The premium disability insurance is calculated on an insured daily amount from €310, - which
gives a coverage of €110.000, - i.e. 70% of the salaried income. Details:
• minimum age 35 years
• until age of 65 years
• own risk period 1 month
• indexed benefits
• As a self-employed in most cases has had to pay a goodwill sum there has been a loss of
interest on the invested capital. It is assumed the goodwill sum is equal to the gross income
and a net return of 1.5% = gross yield of 2.7% minus 1.2% tax Box 3.

Additional assumptions Table C.2
Salaried
• Wage: Average wage of €118,000 of salaried medical specialists not working also in private
practice (see figure 2.2), indexed with 3% per year for the period 2009-2012.
Self-employed
• Revenue: derived from gross income: see Box 2.1
• The supplementary pension is calculated on the basis of what would be paid be built with an
equal amount of net income. A net income of employed €91.430, - means a gross salary of
€200.000, • The premium disability insurance, in addition to the note above assumptions, calculated on a
insured daily amount of €404, - which coverage of €148.000, - i.e. 70% of gross income.

SEO ECONOMIC RESEARCH

42

APPENDIX C

Table C.1 Taxes and premiums for salaried and self employed doctors with the same net income
Self employed
Gross revenu

€

193,400

€

177,900

Collective practice costs
Net revenue

Salary

15,500

Total wage costs

€

190,244

Contribution health insurance

€

4,170

Contribution social insurance

€

4,500

Pension contribution

€

18,074

Other expenses

€

5,500

Individual practice costs

€

12,000

Gross income

€

165,900

Employers costs

Gross wage

€
Fiscal

Gross income

€

165,900

€

165,900

Employers contribution health
insurance
Employees pension contribution
Pension contribution (SPMS)

€

Pension supplement
Totaal

158,000

Cashflow

Fiscal
€

158,000

€

158,000

€

4,170

€

4,170

€

162,170

€

162,170

€

18,074

€

18,074

€

144,096

€

144,096

28,300

€

€

6,000

€

6,000

€

34,300

€

34,300

Profit

€

131,600

Tax exemption MKB

€

15,792

Tax exemption self employed

€

7,280

Disability insurance

€

10,500

€

10,500

Taxable income

€

98,028

€

144,096

Tax

€

43,011

€

66,697

Tax credit

€

3,442

€

3,442

Total taxes

Cashflow

28,300

€

39,569

€

63,525

-Not income dependent

€

2,600

€

2,600

-Income dependent

€

2,500

€

4,170

Total charges

€

89,469

€

70,295

Interest loss goodwill

€

2,625

€

Net income

€

73,806

€

Contribution health insurance

Source: calculations Hans Bénard (Kema van den Berk praktijkadviseurs).

SEO ECONOMIC RESEARCH

73,801

TAXES AND PREMIUMS IN THE NETHERLANDS

Table C.2

43

Taxes and premiums for salaried and self employed based on the estimated gross
income in 2012
Self employed

Gross revenu

€

Collective practice costs
Net revenue

Salary

243,000
19,500

€

223,500

Individual practice costs

€

12,000

Gross income

€

211,500

Total wage costs

€

157,677

Contribution health insurance

€

4,170

Contribution social insurance

€

4,500

Pension contribution

€

14,507

Other expenses

€

5,500

Gross wage

€

129,000

Employers costs

Fiscal
Gross income

€

211,500

Cashflow
€

211,500

Employers contribution health
insurance
Employees pension contribution

Fiscal
129,000

€

129,000

€

4,170

€

4,170

€

133,170

€

133,170

€

14,507

€

14,507

€

118,663

€

118,663

Pension contribution (SPMS)

€

28,300

€

28,300

Pension supplement

€

15,000

€

15,000

Totaal

€

43,300

€

43,300

Profit

€

168,200

Tax exemption MKB

€

20,184

Tax exemption self employed

€

7,280

Disability insurancec

€

14,000

€

14,000

Taxable income

€

126,736

€

118,663

Tax

€

57,939

€

53,742

Tax credit

€

3,442

€

3,442

Total taxes

Cashflow

€

€

€

54,497

€

50,300

-Not income dependent

€

2,600

€

2,600

-Income dependent

€

2,500

€

4,170

Total charges

€

116,897

€

57,070

€

3,173

€

€

91,430

€

Contribution health insurance

Interest loss goodwill
Net income

€

61,594

Source: calculations Hans Bénard (Kema van den Berk praktijkadviseurs).

SEO ECONOMIC RESEARCH