Gesundheits?konomische Evaluation auf Grundlage von GKV-Routinedaten

Although the quality of administrative data of German health insurance is relatively good, administrative data are rarely used for the purpose of health economic evaluations in Germany. Health economic evaluations in Germany have so far mainly been performed based on primary data while in other countries the use of secondary data is quite common. The objective of the article is to give an introduction into the possibilities of performing health economic evaluations based on administrative data. First, we show that German health insurance have data sets that allow the follow-up of patients across all sectors of health care. Subsequently, characteristics of primary data and administrative data of health insurance for the purpose of health economic evaluations are compared. Finally we present an overview of recently performed health economic evaluations based on administrative data in Germany and conclude with lessons from other countries on the use of administrative data and implications for Germany.     

Measuring attitude toward social health insurance

In order to understand the health care system a country chooses to adopt or the health care reform a country decides to undertake, one must first be able to measure a country’s attitude toward social health insurance. Our primary goal was to develop a construct that allows us to measure this “attitude toward social health insurance”. Using a sample of 724 students from the People’s Republic of China, Germany, and the United States and an initial set of sixteen items, we extract a scale that measures the basic attitude toward social health insurance in the three countries. The scale is internally consistent in each of the three countries. A secondary factor labeled “government responsibility” is marginally consistent for the total sample and for the German sample. German respondents have the most favorable attitude toward social health insurance, followed by China, and then the United States. Chinese respondents have the most favorable attitude toward government responsibility in health insurance. The scale developed here can be used to further investigate and understand which health care system will succeed and which will fail in a given country, which is important from both a political and an economic perspective.     

Should administrative costs in health insurance be included in the risk-equalization? An analysis of five countries

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers.

     

Economic evaluation of communicable disease interventions in developing countries: a critical review of the published literature

Limited health care budgets have emphasized the need for providers to use resources efficiently. Accordingly, there has been a rapid increase in the number of economic evaluations of communicable disease health programmes in developing countries, as there is a need to implement evidence-based policy decisions. However, given the prohibitive cost of many economic evaluations in low-income countries, interest has also been generated in pooling data and results of previously published studies. Yet, our review demonstrated that very few published economic evaluations have been performed during 1984-1997 (n=107). Certain diseases and geographical areas have also been neglected. Of those studies published, appropriate analytic techniques have been inconsistently applied. In particular, there are four immediate concerns: the narrow perspective taken-dominance of the health care provider viewpoint and reliance on intermediate outcomes measures; bias-some costs were excluded from estimates; the lack of transparency-sources of data not identified; and the absence of a critical examination of findings-many papers failed to perform a sensitivity analysis. The usefulness of previously published economic evaluations to help make resource allocation choices on an individual basis and, therefore, for the purpose of international comparisons, pooling or meta-analysis, has to be questioned in light of the results from this study.     

Are Unit Costs the Same? A Case Study Comparing Different Valuation Methods for Unit Cost Calculation of General Practitioner Consultations

ObjectivesTo inform allocation decisions in any healthcare system, robust cost data are indispensable. Nevertheless, recommendations on the most appropriate valuation approaches vary or are nonexistent, and no internationally accepted gold standard exists. This costing analysis exercise aims to assess the impact and implications of different calculation methods and sources based on the unit cost of general practitioner (GP) consultations in Austria.MethodsSix costing methods for unit cost calculation were explored, following 3 Austrian methodological approaches (AT-1, AT-2, AT-3) and 3 approaches applied in 3 other European countries (Germany, The Netherlands, United Kingdom). Drawing on Austrian data, mean unit costs per GP consultation were calculated in euros for 2015.ResultsMean unit costs ranged from €15.6 to €42.6 based on the German top-down costing approach (DE) and the Austrian Physicians’ Chamber’s price recommendations (AT-3), respectively. The mean unit cost was estimated at €18.9 based on Austrian economic evaluations (AT-1) and €17.9 based on health insurance payment tariffs (AT-2). The Dutch top-down (NL) and the UK bottom-up approaches (UK) yielded higher estimates (NL: €25.3, UK: €29.8). Overall variation reached 173%.ConclusionsOur study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates. It shows large variations with potential impact on the conclusions in an economic evaluation. Although different methodological choices may be justified by the adopted study perspective, different costing approaches introduce variation in cross-study/cross-country cost estimates, leading to decreased confidence in data quality in economic evaluations.     

The influence of insurance status on waiting times in German acute care hospitals: an empirical analysis of new data

Background

There is an ongoing debate in Germany about the assumption that patients with private health insurance (PHI) benefit from better access to medical care, including shorter waiting times (Lüngen et al. 2008), compared to patients with statutory health insurance (SHI).

Problem

Existing analyses of the determinants for waiting times in Germany are a) based on patient self-reports and b) do not cover the inpatient sector. This paper aims to fill both gaps by (i) generating new primary data and (ii) analyzing waiting times in German hospitals.

Methods

We requested individual appointments from 485 hospitals within an experimental study design, allowing us to analyze the impact of PHI versus SHI on waiting times (Asplin et al. 2005).

Results

In German acute care hospitals patients with PHI have significantly shorter waiting times than patients with SHI.

Conclusion

Discrimination in waiting times by insurance status does occur in the German acute hospital sector. Since there is very little transparency in treatment quality in Germany, we do not know whether discrimination in waiting times leads to discrimination in the quality of treatment. This is an important issue for future research.     

Long-term care insurance in Germany: analyzing its progress from the perspective of economic indicators

Germany enabled public long-term care insurance (LTCI), a social insurance system, in 1995. This study focuses on the LTCI program in Germany, analyzes progress of LTCI in view of economic indicators in the inland 16 states (“Länder” in Germany), categorizes 16 states, and describes problems concerning the LTCI program. Statistical analysis was conducted using 24 variables of LTCI and the economic index. The 16 states were categorized in five clusters. The results revealed gaps in adoption rates of LTCI care services among 16 states, suggesting that each of the states developed its own service system of LTCI dependent on regional variables such as economic power and size of population. All former East German states tended to have lower economic resources of care. States with many requests for cash benefits tended to offer lower amounts of care services. The characteristics of these 16 states provide useful information for developing LTCI policies in Germany and offer an informative guide to other countries.     

Determinants of Regional Variation in Health Expenditures in Germany

Health care expenditure in Germany shows clear regional differences. Such geographic variations are often seen as an indicator for inefficiency. With its homogeneous health care system, low co‐payments and uniform prices, Germany is a particularly suited example to analyse regional variations. We use data for the year 2011 on expenditure, utilization of health services and state of health in Germany's statutory health insurance system. This data, which originate from a variety of administrative sources and cover about 90% of the population, are enriched with a wealth of socio‐economic variables, data on pollutants, prices and individual preferences. State of health and demography explains 55% of the differences as measured by the standard deviation while all control variables account for a total of 72% of the differences at county level. With other measures of variation, we can account for an even greater proportion. A higher proportion of variation than usually supposed can thus be explained. Whilst this study cannot quantify inefficiencies, our results contradict the thesis that regional variations reflect inefficiency. Copyright © 2015 John Wiley & Sons, Ltd.     

How relevant are district characteristics in explaining subjective health in Germany? – A multilevel analysis

This study was the first multilevel analysis to investigate the possible impact of macro-level factors on individual self-rated health over and above individual characteristics across Germany. This is especially interesting against the background of German history and the persistent disparity between Eastern and Western Germany. In this paper, the 439 German administrative districts, called Landkreise, provided the macro-level characteristics for this study. Altogether, 5516 individuals in 437 districts were included from data collected between 2005 and 2007. Our results show a significant association between the district unemployment rate and subjective health. The impact remains significant after adjusting for individual variables, including individual employment status. Furthermore, a significant association was found between subjective health and the degree of rurality, the proportion of elderly inhabitants and the proportion of foreigners. However, the variance of these was zero. In conclusion, our findings indicate an independent association between the unemployment rate of districts and individual self-rated health. Area mechanisms identified for other countries seem to exist in Germany, too, beyond the well-known differences between the Federal Republic of Germany and the German Democratic Republic that still influences individual health outcomes.     

Prospects of gatekeeping in German social health insurance

From 2004, German social health insurers are bound by law to offer their insured a gatekeeping option. In return for renouncing direct access to specialist care, the insured can be granted bonus payments by their social health insurer. So far, experience with gatekeeping is very limited in Germany. In social health insurance, sickness funds are very reluctant to offer gatekeeping, although this was already legally possible before 2004. In the private health insurance sector, cost savings in gatekeeping tariffs are probably the result of self-selection of the insured rather than more cost-efficient provision of health care services. International experience does not prove that gatekeeping results in cost savings or a better patient–physician relationship. Although in countries with a strong primary care system there is a higher life expectancy, gatekeeping is not the only factor to bring about this effect. It is not to be expected that the new legislation will result in a major proliferation of gatekeeping options in German social health insurance. Either the gatekeeping options will not be attractive for the insured or sickness funds will use gatekeeping options as an instrument for risk selection.     

National health system steps in Turkey: concerns of family physician residents in Turkey regarding the proposed national family physician system

Many countries are currently struggling with the public desire for improved health care and provision of basic services on the one hand, and the rising costs of health care on the other. Turkey is acutely experiencing this problem because of its relatively advanced level of economic development and its relatively low level of health status compared to Organization for Economic Cooperation and Development and European Union countries. Since 1990, there has been vigorous debate in the Turkish society regarding the best way to improve public health through improved primary health care. The current government is pursuing a proposal that has been mentioned before, but in a more serious effort than has been previously made. This is an approach to primary care based on systems such as those in the United Kingdom and in Germany, and the basic components are family physicians who have a particular list of patients whom they provide care for. Financing of the system is to be provided with a new general health insurance scheme. In this study, 38 family practice residents at the 3 major training hospitals for this specialty completed an investigator-designed questionnaire for the purpose of characterizing their concerns regarding this proposed system of primary health care delivery. The participants' responses indicated that the new system, which is known as the Family Physician System, will contribute importantly toward raising the overall level of health in Turkey. Specific expected benefits include closer patient-physician relationships, increased job satisfaction on the part of family physicians, and an overall increase in income for the physicians working in the system.     

Towards a social discount rate for the economic evaluation of health technologies in Germany: an exploratory analysis

Over the last decades, methods for the economic evaluation of health care technologies were increasingly used to inform reimbursement decisions. For a short time, the German Statutory Health Insurance makes use of these methods to support reimbursement decisions on patented drugs. In this context, the discounting procedure emerges as a critical component of these methods, as discount rates can strongly affect the resulting incremental cost-effectiveness ratios. The aim of this paper is to identify the appropriate value of a social discount rate to be used by the German Statutory Health Insurance for the economic evaluation of health technologies. On theoretical grounds, we build on the widespread view of contemporary economists that the social rate of time preference (SRTP) is the adequate social discount rate. For quantifying the SRTP, we first apply the market behaviour approach, which assumes that the SRTP is reflected in observable market interest rates. As a second approach, we derive the SRTP from optimal growth theory by using the Ramsey equation. A major part of the paper is devoted to specify the parameters of this equation. Depending on various assumptions, our empirical findings result in the range of 1.75–4.2% for the SRTP. A reasonable base case discount rate for Germany, thus, would be about 3%. Furthermore, we deal with the much debated question whether a common discount rate for costs and health benefits or a lower rate for health should be applied in health economic evaluations. In the German social health insurance system, no exogenously fixed budget constraint does exist. When evaluating a new health technology, the health care decision maker is obliged to conduct an economic evaluation in order to examine whether there is an economically appropriate relation between the value of the health gains and the additional costs which are given by the value of the consumption losses due to the additional health care expenditures. Therefore, a discount rate lower than the SRTP for consumption should be applied if an increase in the consumption value of health is expected. However, given the limited empirical evidence on the relationship between consumption and the value of health, it is hardly possible to make reliable forecasts of this value. Regarding the practice of the German evaluation authority, it is not recommended to use differential discounting in the base case. Instead, the issue of differential discounting should be addressed in sensitivity analyses. Reducing the discount rate for health compared to the rate for costs by a figure in the range between near 0% and 3% may be considered to be appropriate for Germany.     

Die Krankenhausversorgung im internationalen Vergleich

The article deals with data on expenditure, capacities and services of hospitals in comparative perspective and information on the structure of the health care systems and the hospital sector in OECD member states. International comparison shows that German hospitals by no means are particularly expensive. Therefore, the fact that Germany’s health care sector is very costly is explained by other factors, i.e. comparatively high costs of pharmaceuticals. In addition, the article shows that countries with social insurance-based health care systems usually favor the planning of hospital capacities by public authorities, not by the social health insurance funds. Like in Germany, in most other countries different systems for the financing of capital and running costs do exist. DRGs are getting more important everywhere, however, there is no example for a country using DRGs as a remuneration system for all hospital services.     

Sources of regional variation in healthcare utilization in Germany

We examine sources of regional variation in ambulatory care utilization in Germany. We exploit patient migration to examine which share of regional variation in ambulatory care utilization can be attributed to demand factors and to supply factors, respectively. Based on administrative claim-level data we find that regional variation can be overwhelmingly explained by patient characteristics. Our results contrast with previous results for other countries, and they suggest that institutional rules in Germany successfully constrain supply-side variation in ambulatory care use between German regions for most patients. Furthermore, we find that both demographics and other patient characteristics substantially contribute to regional variation and that causes of regional variation vary when comparing different regions within Germany.     

Evaluation of reprocessing medical devices in 14 German regional hospitals and at 27 medical practitioners‘ offices within the European context – consequences for European harmonization

Safe reprocessing of medical devices through cleaning, disinfection, and sterilization is essential for the prevention of health care associated infections (HAI) and to guarantee patient safety. Several studies detected residual contamination and even severe infections of patients, despite carrying out reprocessing. To develop appropriate solutions, the existing situation in Germany and selected European countries was analyzed. Additionally, in 27 medical practitioners’ offices and 14 hospitals, the true practice of reprocessing was analyzed using a questionnaire, a checklist, and inspection on site. A structured analysis of potential alternatives to the internal reprocessing was conducted within the German and European context. The results indicate that the conditions for the execution of the reprocessing process in the analyzed health facilities in southern Hesse (Germany) do not satisfy legal requirements. The detected deficiencies were consistent with other reports from Germany and Europe. The analysis gave insight into several reasons for the detected deficiencies. The three main reasons were the high costs for proper implementation, the subjective value assigned to the reprocessing unit in health care facilities, and deficits in monitoring by the health authority. Throughout the European Union, a similar regulatory framework for the performance of the reprocessing process exists, while the environment, structures of the health systems and administrative supervision vary significantly. The German states as well as selected European countries are currently discussing the challenges of increased quality-assured execution of the reprocessing process. For instance, the same supervisory system for hospitals and medical practitioners should be established at an equal standard. Alternatives such as the use of single-use medical devices, outsourcing the decontamination processes, or the cooperation of health facilities may be considered. This paper also discusses economic and ecological aspects. Finally, different options are recommended to ensure the exclusive use of reliable medical devices for surgical procedures that guarantee an adequate standard of patient safety within economic constraints.     

Health effects of a ban on late-night alcohol sales

This paper studies the impact of a ban on late-night off-premise alcohol sales between 10 p.m. and 5 a.m. in Germany. We use three large administrative data sets: (i) German diagnosis related groups-Statistik, (ii) data from a large social health insurance, and (iii) Road Traffic Accident Statistics. Applying difference-in-differences and synthetic-control-group methods, we find that the ban had no effects on alcohol-related road casualties, but significantly reduced alcohol-related hospitalizations (doctor visits) among young people by around 9 (18) percent. The decrease is driven by fewer hospitalizations due to acute alcohol intoxication during the night—when the ban is in place—but not during the day.     

Methodische Überlegungen für das Datenlinkage von Primär- und Sekundärdaten im Rahmen arbeitsepidemiologischer Studien

Within the scope of an aging population, the topic age, work and health becomes more and more important. So far, research in occupational epidemiology utilizes various primary or secondary data sources. However, data linkage has rarely been used as an instrument in this field. The study presented here combines two large databases within a so-called “age–work matrix”, stratified by sex, age group and occupational group. This matrix is based on the German classification of occupations and uses its occupation codes as a key variable. The first database is the representative BIBB/BAuA employment survey for employees of all occupations in Germany 2005/06. The second database consists in sickness absence data of the insurees of a German statutory health insurance fund. Using the matrix approach, the study investigates associations of reported subjectively perceived psychosocial work strains and health impairments provided by health insurance claims data. These claims data offer sickness absence data as an indicator for health impairments. Usability of sickness absence data for studies in occupational epidemiology, their methodological challenges and the solutions realized in this study are discussed.     

Economic burden of multiple sclerosis to the social insurance system in Germany

Aim

This study aims to calculate the cost of illness concerning multiple sclerosis (MS) from the perspective of the German social insurance system.

Subjects and methods

Expenditures for MS (ICD-10 GM: G35) were evaluated retrospectively for the year 2012 from the perspective of the social insurance system. Expenditures from the German statutory health insurance, the Federal statutory pension fund, and statutory long-term care insurances were calculated based on administrative claims of a large nationwide health insurance and statistics from the Federal statutory pension fund. Additionally, expenditures of the long-term care insurances were requested by standardized questionnaire. Costs were extrapolated for all health and statutory long-term care insurances.

Results

In the base case, extrapolated expenditures for German statutory health insurance amount to 1.062 billion €. German statutory pension funds expenses for MS were around 258.700 million € on medical rehabilitation and early retirement. Extrapolated for the whole population insured expenditures of the statutory long-term care insurances on persons with MS were approximately 372.200 million €.

Conclusion

This study delivered important information regarding the economic burden of MS for the social insurance system in Germany. The top-down process of data collection yielded population-based results on the cost of illness.

     

German health care system in transition

As is the case with all other health care systems, the German one is in constant transition. The reasons—such as costly medical innovations, aging population, and lack of overall economic growth—are well known, widely discussed, and not unique to Germany. Although the problems are not unique to Germany, there are some trends in each country which may be of interest to other countries. This contribution provides an update on the German health care system and reports current reform trends.