Erstattungsf?higkeit neuartiger Arzneimitteltherapien

Medical progress poses a new financial challenge for the German statutory health insurance. In order to assure the stability of the German statutory health insurance all services have to be economical, but on the other hand the health care system allows access to new therapy in the ambulant and in-patient sector. This article describes in detail how new therapies are reimbursed.     

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.

     

HTA in den Entscheidungsprozessen des IQWiG und G-BA

The development of the German HTA system and the corresponding HTA law began in 2000 and was concluded for the time being with the coming into force of the law on the modernisation of statutory health insurance on 1 January 2004. This law has established the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG) as "new institutions" of statutory health insurance, restructured the procedures for the assessment of health services and formulated more precise assessment criteria than hitherto provided. There are other institutions in the health care system concerned with HTA which are not dealt with here.     

Unterschiede in den soziodemografischen Merkmalen,der Gesundheit und Inanspruchnahme bei Kindern und Jugendlichen nach ihrer Krankenkassenzugehörigkeit

Differences in the socioeconomic characteristics and morbidity between members of German private and statutory health insurance funds and also between several statutory health insurances have been shown for adults. We used data from the National Health Survey for Children and Adolescents (KiGGS) to study differences in sociodemographic characteristics, health risks, morbidity, and health service use in child and adolescent insurants of different types of health insurance funds (Ersatzkasse, Allgemeine Ortskrankenkasse, Betriebskrankenkasse , Innungskrankenkasse, other statutory health insurance funds, private health insurance). Differences in the proportion of respondents with a migration background, somatic diseases, psychopathological problems, and contact with a dentist between the different health insurance fund types were found. These results should be considered in studies on health inequalities, which often focus solely on differences between statutory and private health insurance. Our results are also of relevance for health services research using the claims data of health insurance funds.     

Quantifying delay in access to new medical treatment: an application of risk advancement period methodology

BACKGROUND: We present a novel application of the concept of risk or rate advancement to compute the extent of delay in adoption of an effective new drug in 2 German health insurance systems. METHODS: We identified individuals with migraines, age 18 to 65 years, in 371 primary care practices in Germany in 1994 (MediPlus, IMS Health database). These included 8173 persons covered under the statutory health insurance system and 503 persons covered by private health insurance. We derived risk and population risk advancement periods for sumatriptan compared with nonserotoninergic acute migraine therapy using multiplicative risk regression and generalized estimating equations, adjusted for patient, physician, and practice cofactors. RESULTS: For patients at the mean age of the cohort, 43 years of age, sumatriptan was prescribed 1.2 (95% confidence interval [CI] = 0.3-2.0) years later among those in the statutory health insurance system compared with those who had private insurance. The lag increased by 0.6 (-0.1 to 1.3) years for every 10 years of patient age. In the age-mix of our sample, access to the health benefits of sumatriptan therapy lagged nearly 1.5 years behind in the statutory health insurance system and for Germany as a whole. CONCLUSIONS: Migraine patients' access to sumatriptan therapy lagged substantially in the statutory health insurance system and in the country as a whole. Risk advancement periods provide a useful methodology for communicating major healthcare issues in a meaningful way to society and policymakers.     

Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

The European Journal of Health Economics - Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in...     

Optional deductibles in social health insurance systems

A fundamental aspect of the German health insurance system is the principle of solidarity. At the same time, it is possible for certain socio-economic groups to opt out of the otherwise compulsory system. To determine whether rates incorporating deductibles are compatible with the principles of solidarity and have the ability to heighten the appeal of statutory health insurance (SHI) funds compared with private health insurance companies, Germany's third largest SHI fund, Techniker Krankenkasse, implemented a pilot scheme involving the use of deductibles. Preliminary scientific evaluations of the pilot scheme indicate three main results for these deductibles: Firstly, they are compatible with the principles of solidarity in the statutory health insurance system; secondly, they provide an effective means of preventing defection to private health insurance companies and thirdly, they reduced the volume of insurance claims (moral hazard).     

Heterogeneous Effects of a Nonlinear Price Schedule for Outpatient Care

Nonlinear price schedules generally have heterogeneous effects on health‐care demand. We develop and apply a finite mixture bivariate probit model to analyze whether there are heterogeneous reactions to the introduction of a nonlinear price schedule in the German statutory health insurance system. In administrative insurance claims data from the largest German health insurance plan, we find that some individuals strongly react to the new price schedule while a second group of individuals does not react. Post‐estimation analyses reveal that the group of the individuals who do not react to the reform includes the relatively sick. These results are in line with forward‐looking behavior: Individuals who are already sick expect that they will hit the kink in the price schedule and thus are less sensitive to the co‐payment. Copyright © 2016 John Wiley & Sons, Ltd.     

Optimising the impact of COVID-19 vaccination on mortality and hospitalisations using an individual additive risk measuring approach based on a risk adjustment scheme

The European Journal of Health Economics - In this population-based cohort study, billing data from German statutory health insurance (BARMER, 10% of population) are used to develop a...     

Free choice of doctors in Germany in retrospect

Due to discussions on the cost and quality of health care and a new legislation on the German statutory sickness insurance system in 1999, the free choice of doctors has recently become topical. To assess its legitimation for the German health care system, its history and the groups of interest involved should be taken into consideration. Before the period of industrialization no homogeneous pattern of the medical profession existed. In case of illness individuals who lived within reach and were known for their competence in disease matters were approached. However, industrialization destroyed existing social networks, and establishment of new structures of health care in rural as well as metropolitan areas became necessary. The government approached this challenge by structuring medical education, passing regulations on the settlement of doctors and promoting the foundation of statutory sickness funds. The Health Insurance Law of 1883 established a mandatory insurance system for a broad array of industries. As it was the sickness funds' responsibility to provide sufficient resources for medical care, a sick member was tied to the physician under contract with his insurance. After a rapid increase in practising physicians at the end of the 19(th) century, doctors' organisations were eager to gain access to the new market segment of insurance members by calling for the free choice of physicians. The Leipzig association (Hartmannbund) was founded in 1900 to organize strikes of doctors in order to get their goals accepted. After 30 years of conflicts an appeasement was achieved by a presidential emergency law in 1931. It transferred the responsibility for the provision of sufficient health care resources from the sickness funds to the newly created body of the Association of Sickness Fund Physicians (Kassen?rztliche Vereinigung) and determined the patients' free choice among licensed sickness fund physicians.     

Organisationsreform der GKV Anspruch und Wirklichkeit

The new “Health-Structure Bill” (Gesundheits-Strukturgesetz/GSG), which is effective since January 1, 1993, provides some immediate steps, but it also assigns a long-term orientated organizational reform (Organisationsreform) of the German Statutory Health System (Gesetzliche Krankenversicherung/GKV). These measures are aimed to safeguard the financial basis of the GKV and to limit the contribution rates. Hence, the question remains: Is the application of the new methods generating more competition within the GKV or will it lead straight into a state-governed unity insurance fund? This question cannot be answered definitely: On the one hand, the legislator fulfills essential demands for a fundamental reform, e.g. the option of insurance funds, a system of risk compensation between the competing sickness funds (kassenartenübergreifender Risikostrukturausgleich) and modifications of the internal structure of the insurance funds. These reform measures can be valued as necessary requirements of an entry into a competitive statutory health system in Germany after 1996. On the other hand, the legislator has refrained from providing the insurance funds with sufficient competition parameters, has to some extent arranged the risk-compensation system inadequately, and is promoting the concentration process on the level of the sickness funds by means of inappropriate regulations of the market structure. These aspects let suspect that ultimately the GKV could be transformed into a unity insurance fund, de facto. Hence, the GSG leaves open both options. In the last analysis, the design of the German statutory health system to come will depend on the next legislative steps, which will be necessary in the future.     

Risk selection in the German public health insurance system

The German statutory health insurance market was exposed to competition in 1996. To limit direct risk selection the regulator required open enrollment. As the risk compensation scheme, introduced in 1994, is highly incomplete, substantial incentives for risk selection exist. Due to their low premiums, company-based sickness funds have been able to attract a lot of new members. We analyze, using data from the German Socio-Economic Panel, the determinants of switching behavior from 1995 to 2000. There is no evidence for selection by funds. The success of the company-based sickness funds originates in incomplete risk adjustment together with the negative correlation between health status and switching costs.     

Discrimination in waiting times by insurance type and financial soundness of German acute care hospitals

This paper shows that patients with private health insurance (PHI) are being offered significantly shorter waiting times than patients with statutory health insurance (SHI) in German acute hospital care. This behavior may be driven by the higher expected profitability of PHI relative to SHI holders. Further, we find that hospitals offering private insurees shorter waiting times when compared with SHI holders have a significantly better financial performance than those abstaining from or with less discrimination.     

Notes on the GKV-modernization law (GMG)--a dentist's trend analysis

Effective January 1st 2004 medical aid for patients receiving aid by means of the Federal German social welfare act has been transferred from the local social welfare offices to the statutory health insurances by decree regarding act modernisation of the statutory health insurance (GMG). The authors analyse the epidemiological and economical parameters concerning dental medical care for the city of Wuppertal on the basis of the experiences from 1994 to 2003 and attempt a well-founded forecast: the quality of medical standards will decline, whereas cost will rise.     

Schul- und Berufsausbildung, beruflicher Status und isch?mische Herzkrankheiten: eine prospektive Studie mit Daten einer gesetzlichen Krankenversicherung in Deutschland

Summary.¶Education and training, occupational position, and ischemic heart disease: a prospective study with data from a statutory German health insurance¶ Objectives: To study associations between education, occupational position, and incidence of ischemic heart disease (ICD-9 410-414).¶ Methods: A cohort of 151471 male and female members of a German statutory health insurance company aged between 25 and 65 years was investigated. The cohort comprised all members between 1987 and 1996. Information on ischemic heart disease was derived from clinical diagnosis. Education, training, and occupational position according to the British Registrar General defined the indicators of social status.¶ Results: After adjustment for age and length of observation period, education and training as well as occupational position were associated with the incidence of ischemic heart disease in both men and women. Whereas a gradient was observed in men regarding education and training (odds ratios (OR): 3.41-6.02) men with lower occupational position had higher risk estimates as compared to the highest occupational status group (OR: 1.73-3.05). Among women a gradient was observed concerning education and training (OR: 1.75-3.78). With regard to occupational status position female members of the highest group showed the lowest risk as compared to the lower status groups (OR: 1.58-2.19).¶ Conclusions: Social inequality in ischemic heart disease morbidity was observed among male and female members of a German statutory health insurance. Findings are of importance for health policy and call for preventive action.     

The German health care system and health care reform

This article presents a structured survey of the German health care and health insurance system, and analyzes major developments of current German health policy. The German statutory health insurance system has been known as a system that provides all citizens with ready access to comprehensive high quality medical care at a cost the country considered socially acceptable. However, an increasing concern for rapidly rising health care expenditure led to a number of cost-containment measures since 1977. The aim was to bring the growth of health care expenditure in line with the growth of wages and salaries of the sickness fund members. The recent health care reforms of 1989 and 1993 yielded only short-term reductions of health care expenditure, with increases in the subsequent years. 'Stability of the contribution rate' is the uppermost political objective of current health care reform initiatives. Options under discussion include reductions in the benefit package and increases of patients' co-payments. The article concludes with the possible consequences of the 1997 health care reform of which the major part became effective 1 July 1997.     

Current research perspectives of health system research and health economics in Germany

The German statutory health insurance scheme is confronted with a steadily rapid progress of medical sciences and increasing difficulties to mobilize the financial resources necessary for applying the new scientific knowledge in health care. Therefore it is absolutely imperative to intensify the efforts to improve the effectiveness and efficiency of health care. Health policies based on health targets, the development of patterns requiring integrated care, redefining the bunch of health insurance benefits, and a more regular use of methods of economic evaluation have been proposed as promising approaches towards optimizing resource allocation in health care. However, an analysis of these approaches demonstrates that a valid appraisal of their potential to improve the effectiveness and efficiency of health care requires further research. In addition, European integration may produce tendencies towards a convergence of the national health care systems; this makes it rather difficult to assess how the room for autonomous national health policies will develop in the future.     

Entwicklung arbeitsweltbezogener GKV-Präventionsziele

Background

The German statutory health insurance (Gesetzliche Krankenversicherung, GKV) plays an important role in health promotion in Germany, spending € 4 billion annually. In recent years, the GKV has emphasized the improvement of preventive practice by establishing quality criteria and documentation rules. At present, it is working on the development of goals for health promotion and prevention. Starting at the workplace – and soon to be followed in other settings – goals will already be used to focus preventive activities as early as 2007.

Methods

The development of goals in prevention is based on a method introduced by the Initiative Health and Work (Initiative Gesundheit und Arbeit, IGA), a common institution in two German health insurance groups and German accidence insurance.

Results

The GKV has selected the reduction of mental and behavioral disorders as its main goal in work-related prevention.     

Zum Stand der Qualitätssicherung in der Rehabilitation Zur Entwicklung der medizinischen Rehabilitation in den 90er-Jahren

Since the 1990ies, the field of Medical Rehabilitation in Germany, which is a largely independent part of the German health care system, has undergone a modification process oriented towards various objectives. An optimized orientation towards both user related attributes and result related aspects has been the object of endeavors, manifested in the introduction of quality assurance programs and intensified rehabilitation-scientific research. The quality assurance program created by the medical rehabilitation section of the federal statutory pension insurance providers (the so-called 5-point program) forms a central component of this new orientation. The conceptualization of appropriate initiatives for the medical rehabilitation sections of the health insurance organizations, for providers of child rehabilitation, and the field of ambulatory rehabilitation will take place within the immediate future.