ORIGINAL ARTICLE Health technology assessment of utilization, practice and ethical issues of self-pay services in the German ambulatory health care setting Theresa Hunger • Petra Schnell-Inderst • Katharina Hintringer • Ruth Schwarzer • Vanadin Seifert-Klauss • Holger Gothe • Ju ¨ rgen Wasem • Uwe Siebert Received: 12 December 2012 / Revised: 20 June 2013 / Accepted: 3 July 2013 / Published online: 1 August 2013 Ó Swiss School of Public Health 2013 Abstract Objectives The provision of self-pay medical services is common across health care systems, but understudied. According to the German Medical Association, such ser- vices should be medically necessary, recommended or at least justifiable, and requested by the patient. We investi- gated the empirical evidence regarding frequency and practice of self-pay services as well as related ethical, social, and legal issues (ELSI). Methods A systematic literature search in electronic databases and a structured internet search on stakeholder websites with qualitative and quantitative information synthesis. Results Of 1,345 references, we included 64 articles. Between 19 and 53 % of insured persons received self-pay service offers from their physician; 16–19 % actively requested such services. Intraocular pressure measurement was the most common service, followed by ultrasound investigations. There is a major discussion about ELSI in the context of individual health services. Conclusions Self-pay services are common medical pro- cedures in Germany. However, the empirical evidence is limited in quality and extent, even for the most frequently provided services. Transparency of their provision should be increased and independent evidence-based patient information should be supplied. Keywords IGeL Á Individual health services Á Self-pay services Á German Statutory Health Insurance Á Health care quality, access, and evaluation Á Cost sharing Electronic supplementary material The online version of this article (doi:10.1007/s00038-013-0494-x) contains supplementary material, which is available to authorized users. T. Hunger (&) Á P. Schnell-Inderst Á K. Hintringer Á R. Schwarzer Á H. Gothe Á U. Siebert Department of Public Health and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer Center I, 6060 Hall i.T., Austria e-mail: t.hunger@umit.at T. Hunger Á P. Schnell-Inderst Á R. Schwarzer Á H. Gothe Á U. Siebert Oncotyrol, Center for Personalized Cancer Medicine, Innsbruck, Austria K. Hintringer Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria V. Seifert-Klauss Department of Obstetrics and Gynecology, Technical University Munich, Munich, Germany J. Wasem Institute for Health Care Management and Research, University Duisburg-Essen, Essen, Germany U. Siebert Department of Health Policy and Management, Center for Health Decision Science, Harvard School of Public Health, Boston, MA, USA U. Siebert Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Int J Public Health (2014) 59:175–187 DOI 10.1007/s00038-013-0494-x 123