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.

     

Medical insurance and the use of health care services by the elderly

The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance.     

Unwinding the State subsidisation of private health insurance in Ireland

Ireland's private health insurance market provides primarily supplementary health insurance for hospital services, operating alongside a public hospital system to which residents have universal access entitlements, subject to some copayments for those without a medical card. The State subsidises the purchase of private health insurance through measures including tax relief on premiums and not charging the full economic cost for private beds in public hospitals. Furthermore, privately insured patients occupying public beds in public hospitals did not, until 2014, incur charges for such accommodation, apart from modest statutory charges. In the Budget in October 2013, a number of measures were announced that began to unwind these subsidies. Although it was initially feared that these measures would add to premium inflation, leading in turn to further discontinuation of health insurance, the evidence suggests that premium inflation has eased and take-up has stabilised, although some of this may have been due to the introduction of lifetime community rating in May 2015. Nevertheless, it would appear that the restriction on the subsidisation of private health insurance has not had a significant adverse effect on the market, while it has reduced an inequitable cross-subsidy.     

Who Opts out of the Statutory Health Insurance? A Discrete Time Hazard Model for Germany

The coexistence of social health insurance and private health insurance in Germany is subject to intense public debate. As only few have the opportunity to choose between the two systems, they are often regarded as privileged by the health insurance system. Applying a hazard model in discrete time, this paper examines the role of incentives set by the regulatory framework and the influence of individual personality characteristics on the decision to opt out of the statutory system. To address potential endogeneity of one of the key explanatory variables, an instrumental variable approach is also applied. The estimation results yield robust evidence on the choice of health insurance type that is consistent with pragmatic decision making, with both incentives set by regulation and personality traits as relevant determinants. Copyright © 2014 John Wiley & Sons, Ltd.     

Wie „repräsentativ“ sind GKV-Daten?

Using data obtained from a statutory health insurance (AOK) in the federal state of Lower Saxony, this study examined whether there were differences between the insured population compared with that of Lower Saxony (Niedersachsen) and of Germany with respect to social structural characteristics. Data for the comparisons were provided by the statistical office of Germany, and all datasets were coded according to the same criteria. The differences in gender distribution and age distribution between the AOK, Lower Saxony, and Germany were small. The share of employed individuals among the insured compared with those of Lower Saxony and Germany did not differ for males, but it was lower in women. In the insured population a higher proportion of individuals had lower qualification levels than in Lower Saxony or in Germany; the number of individuals with higher qualifications was, however, sufficient to permit statistical analyses. There were differences in the distributions of social structural characteristics between the health insurance population on the one hand and the populations of Lower Saxony and of Germany on the other. Due to the high number of cases, it is nevertheless possible to analyze associations between social structural variables, health impairments, and patterns of health care utilization.     

Sozialstruktur und Krankheit

Data from statutory health insurance companies are rarely used for studies in social epidemiology. Nevertheless it has been shown that health insurance data are suitable for studying social inequalities in health, social inequalities in health care utilization and for considering the healthrelated effects of unemployment. If analyses are confined to diseases that are well-documented and that are routinely treated in hospital settings, biases can be kept within acceptable boundaries. This applies particularly to malignant and cardiovascular diseases, diabetes, and accidents. Since the most frequently used indicators of social differentiation (income, education, and occupational position) are routinely recorded, social inequalities in health care can be examined, and unemployment periods of up to 24 months are well documented. The analyses have revealed considerable health inequalities. These may even be underestimated since the higher income groups are usually privately insured. Inpatient treatment in an unemployed compared to an employed insured is lower. Myocardial infarction is an exception since risks increase with increasing length of unemployment.     

Mut zur Lücke? Die Neuorientierung in der zahnmedizinischen Versorgung und ihre Alternativen

The new orientation of dental care through the so-called third step of health care reform in Germany does neither impro e the dental health of the population nor the structure of the statutory health insurance system. The continuity of the pre enti e deficit will be more or less preser ed while solidarity is damaged through the selecti e exclusion of co er age for certain groups of insured. Equally new is the de-facto suspension of the corporatist structures through the con ersion of prosthetic dental treatment from a ser ice deli ered under the regulations of statutory health insurance to pri ate treatment with a fixed subsidy from the sickness funds. Howe er, a re-orientation facing the problems is possible. Pro grammatically, this would mean to use defined and e aluable outcome-oriented health targets. Politically, this would mean to use the endogenous learning and reforming potential of the health care system. Starting points will be indicated.     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.     

Teilnahme an verhaltenspräventiven Maßnahmen

Health behaviour change programmes to promote healthy behaviours are aimed at, among other things, counteracting the emergence of widespread non-communicable diseases. Which population groups use these programmes? This analysis is based on data from DEGS1, which was conducted from 2008–2011. People aged 18–79 years were asked about their participation in programmes in the last 12 months in the fields of nutrition, physical activity and relaxation (n?=?7,807). The analysis was stratified by sex, age, socioeconomic status (SES), and type of statutory health insurance fund. A total of 16.6?% of respondents participate in at least one programme for behaviour change, with women using these programmes significantly more frequently, indeed twice as often, as men (22.1?% versus 11?%). The older population participates more often than younger age groups. Women and men with low SES use the programmes significantly less frequently than those with middle or high SES. Women who are insured by the AOK health insurance group have a significantly lower rate of participation than women insured by any other statutory health insurance fund. Overall participation has almost doubled since the “German National Health Interview and Examination Survey 1998” (9.1?%). Further efforts are necessary to reach population groups with low participation rates. An English full-text version of this article is available at SpringerLink as supplemental.     

Continuous case management of a German statutory health insurance

To support insured patients, especially those with chronic illnesses or disabilities, the German statutory health insurance Techniker Krankenkasse (TK) offers continuous case management (CCM) under a rehabilitation advisory program serving more than 150,000 insurees each year Rehabilitation advisors provide individual counseling, generally by telephone. They inform patients about treatment and rehabilitation options, about health care providers, and about other TK services. In a key feature, the model coordinates care across different health care sectors. Through the CCM approach, TK not only assures the best possible care for its insurees, but also safeguards its long-term financial sustainability.     

Employment-contingent health insurance, illness, and labor supply of women: evidence from married women with breast cancer

We examine the effects of employment-contingent health insurance (ECHI) on married women's labor supply following a health shock. First, we develop a theoretical framework that examines the effects of ECHI on the labor supply response to a health shock, which suggests that women with ECHI are less likely to reduce their labor supply in response to a health shock, relative to women with health insurance through their spouse's employer. Second, we empirically examine this relationship based on labor supply responses to breast cancer. We find that health shocks decrease labor supply to a greater extent among women insured by their spouse's policy than among women with health insurance through their own employer, suggesting that ECHI creates incentives to remain working when faced with a serious illness.     

Switching sickness funds and risk compensation mechanisms in the statutory health insurance system in Germany--empirical results from the cooperative health research in the region of Augsburg (KORA)

Since 1996, all citizens of the Federal Republic of Germany who are insured in the statutory health insurance system are entitled to switch their sickness fund. The rationale of this regulation was to strengthen elements of competition in this system in order to stimulate the sickness funds to improve the efficiency of health care and to respond to consumers' preferences. Simultaneously, to avoid the implicit incentives for sickness funds to engage in risk selection, a risk compensation mechanism was introduced, including as morbidity-related risk adjusters age, sex and incapacity to work. Based on the KORA survey S4 (1999/2001) we take the case of switching behaviour in the region of Augsburg, and analyse whether this risk adjustment scheme was working effectively. The results show that persons changing their sickness fund were characterised by a comparatively smaller burden of chronic diseases and by a less frequent utilization of inpatient health care. Under these conditions, differences in the contribution rates do not accurately reflect differences in the performance and efficiency of sickness funds. Moreover, the migration of good risk to sickness funds with favourable contribution rates threatens the principle of financial solidarity. Therefore, the system of risk equalisation has to be developed towards measuring the risk volume borne by the sickness funds more precisely than hitherto.     

Regional distribution of physicians: the role of comprehensive private health insurance in Germany

Objective

In recent years, the co-existence in Germany of two parallel comprehensive insurance systems—statutory health insurance (SHI) and private health insurance (PHI)—has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.

Methods

The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.

Results

Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.

Conclusion

From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.

     

Effect of competition-oriented reform in the Netherlands health care system on the relationship between primary care physicians, insurance groups and insured patients

The German health care policy debate is affected by proposals demanding the introduction of competitive elements. Analysis of the effects of regulated competition in the Netherlands health care system shows that actual behavioural changes of the key actors of the system differ considerably from expected changes, although incentives within the system have been substantially changed. Sickness funds are not selectively linked with providers and insured patients do not change their insurance company very often. From the point of view of the original reform targets, this preliminary result is quite disappointing. It can be explained by the fact that the relations between sickness funds, general practitioners and insured persons or patients are within a broader framework of health care. Thus, competition does not seem attractive to either of them. If regulated competition became more dominant, several undesirable effects on the so far well-appreciated primary care may be expected.     

Quality Health Care and Willingness to Pay for Health Insurance Retention: A Randomized Experiment in Kolkata Slums

The low quality of health care in developing countries reduces the poor's incentives to use quality health services and their demand for health insurance. Using data from a field experiment in India, I show that randomly offering insurance policyholders a free preventive checkup with a qualified doctor has a twofold effect: receiving this additional benefit raises willingness to pay to renew health insurance by 53%, doubling the likelihood of hypothetical renewal; exposed individuals are 10 percentage points more likely to consult a qualified practitioner when ill after the checkup. Both effects are concentrated on poorer households. There is no effect on health knowledge and healthcare spending. This suggests that exposing insured households to quality preventive care can be a cost‐effective way of raising the demand for quality health care and retaining policyholders in the insurance scheme. Copyright © 2016 John Wiley & Sons, Ltd.     

The effect of the Affordable Care Act preexisting conditions provision on marriage

This paper investigates the effect of the Affordable Care Act preexisting conditions provision on marriage. The policy was implemented to prevent insurers from denying insurance coverage to individuals with preexisting health conditions. We test whether the implementation of the provision led to decreases in marriage among affected adults. We add to earlier work on how marital behavior is influenced by spousal health insurance and examine for the presence of “marriage lock,” a situation in which individuals remain married primarily for insurance. Using longitudinal data from the Panel Study of Income Dynamics from 2009 to 2017 and estimating difference‐in‐differences models, we find that male household heads with preexisting conditions are 7.12 percentage points (8.9 percent) less likely to be married after the policy. Using information on insurance status prior to the policy change, we find significant reductions in marriage among individuals with preexisting conditions who were previously insured by spousal health insurance plans. The findings suggest that the inability to attain individual coverage and reliance on spousal insurance provided incentives to remain married before 2014.     

McAllen And El Paso revisited: Medicare variations not always reflected in the under-sixty-five population

Medicare spending for the elderly is much higher in McAllen, Texas, than in El Paso, Texas, as reported in a 2009 New Yorker article by Atul Gawande. To investigate whether this disparity was present in the non-Medicare populations of those two cities, we obtained medical use and expense data for patients privately insured by Blue Cross and Blue Shield of Texas. In contrast to the Medicare population, the use of and spending per capita for medical services by privately insured populations in McAllen and El Paso was much less divergent, with some exceptions. For example, although spending per Medicare member per year was 86 percent higher in McAllen than in El Paso, total spending per member per year in McAllen was 7 percent lower than in El Paso for the population insured by Blue Cross and Blue Shield of Texas. We consider possible explanations but conclude that health care providers respond quite differently to incentives in Medicare compared to those in private insurance programs.     

Morbidität und Gesundheitsversorgung bei GKV- und PKV-Versicherten

Background

It has rarely been analyzed whether there are differences in Germany concerning morbidity and healthcare between insured by statutory health insurance (Gesetzliche Krankenversicherung, GKV) and insured by private health insurance (Private Krankenversicherung, PKV). In addition, the available studies are very scattered and no review has been published yet. The study presented here aims at closing this gap and at discussing recommendations for future analyses.

Methods

By searching for publications in the Medline and PubMed databanks, only a very few studies could be identified in this manner Thus, our search was extended to include a number of German institutes and organizations working in the field of public health and health systems research. In addition, we checked all references listed in the relevant publications.

Results

A total of 18 relevant publications could be identified; however, just four of them were found via Medline and PubMed. The empirical analyses show that the GKV insured are often less healthy than the PKV insured, and that they more often go to primary care physicians. A potential disadvantage of GKV insured concerning healthcare can be seen in regard to new, innovative drugs, organ transplantations, financial burden due to co-payments, waiting times, and communication between patient and physician.

Conclusion

Most studies show that there are large differences between GKV-insured and PKV-insured, concerning health status as well as healthcare. However, due to methodological weaknesses, some of these results are difficult to interpret. More studies focusing on specific age groups (e.g., children) are needed, and the methodological standard (e.g., statistical control for other factors such as income, distinction between different subgroups of insured) must also be raised. Finally, systematic differences between GKV and PKV should be considered in all analyses comparing these two schemes, such as differences in the availability of data concerning healthcare.     

Type of health insurance and the quality of primary care experience

OBJECTIVES: This study examined the association between type of health insurance coverage and quality of primary care as measured by its distinguishing attributes--first contact, longitudinality, comprehensiveness, and coordination. METHODS: The household component of the 1996 Medical Expenditure Panel Survey was used for this study. The analysis primarily focused on subjects aged younger than 65 years who identified a usual source of care. Logistic regressions were used to examine the independent effects of insurance status on primary care attributes while individual sociodemographic characteristics were controlled for. RESULTS: The experience of primary care varies according to insurance status. The insured are able to obtain better primary care than the uninsured, and the privately insured are able to obtain better primary care than the publicly insured. Those insured through fee-for-service coverage experience better longitudinal care and less of a barrier to access than those insured through health maintenance organizations (HMOs). CONCLUSIONS: While expanding insurance coverage is important for establishing access to care, efforts are needed to enhance the quality of primary health care, particularly for the publicly insured. Policymakers should closely monitor the quality of primary care provided by HMOs.     

医保政策对社区卫生服务筹资作用的潜力分析

目的探索医保政策在社区卫生服务筹资方面的作用及潜力。方法采用描述性统计分析的方法对医保在社区卫生服务利用和业务收入方面的作用及情况进行描述和比较。结果 3年间社区卫生服务利用者医疗费用支付方式的构成有显著性差异;参保居民优先选择医保定点机构的比例高于非参保居民;医保定点后社区卫生服务机构收入有所增长;启动医保补偿机构的医保收入占业务收入的比例总体呈上升趋势,但仍较低。结论参保居民就诊比例逐年上升;医保定点是影响参保居民选择就诊机构的重要因素;医保政策筹资效用显现,但仍有较大潜力。