Bernard Braun

Free choice of sickness funds in regulated competition: evidence from Germany and The Netherlands

Sickness funds became the focal point of health insurance reforms in the 1990s. Policy makers expected funds to become more consumer-oriented and more active in managing the provision of health care. This is especially true for two countries in the heart of Europe that, on first view, have many similar institutional characteristics. Both Germany and The Netherlands have introduced competition between sickness funds in the last decade. We present extensive quantitative, as well qualitative, data with regard to the behaviour of consumers after the introduction of free choice between sickness funds. National data was used with regard to contribution rates and member flows and survey data was used to investigate personal motives for actual change and perception of differences between sickness funds. In Germany, contribution rates between sickness funds differ significantly. Accordingly, these differences are the main reason for consumers to switch funds, which occurs on a considerable scale. However, survey data show that other reasons may be important too. In The Netherlands, premium differences are much lower. The same is true for the degree of change. Survey data show that consumers perceive very small differences between sickness funds and do not see much reason for change. Our findings support the claim that the degree of actual changing depends strongly on economic incentives, especially with regard to the extent of financial risk sickness funds have to bear and to the extent premiums or contribution rates can differ. However, the higher the financial risk of individual sickness funds actually is, the higher the incentives for risk selection.

Krankenhaus unter DRG-Bedingungen: Zwischen Ökonomisierung, Unwirtschaftlichkeit, Veränderungsresistenz und Desorganisation

Fur das „Eindringen okonomischer Kalkule in das patientenbezogene Denken und Handeln“ (Kuhn/Simon 2001: 61) in das Gesundheitssystem, d.h. die Okonomisierung und die sie begleitenden und fordernden Strukturveranderungen, sind die stationare Versorgung und die Krankenhauser aus vielen Grunden und wegen ihrer Scharnier-Stellung innerhalb von Gesamtversorgungsprozessen pradestinierte Bereiche. So pendelt die Anzahl der im Krankenhaus vollstationar behandelten Erkrankungsfalle seit Anfang der 1990er Jahre mit insgesamt steigender und erst in den letzten Jahren stagnierender oder abgeschwachter Tendenz unter- und oberhalb der 16-Millionen-Marke. Dahinter stecken aktuell mehr als 12 Millionen Personen. Da ein relativ groser Teil der im Krankenhaus behandelten Personen nicht geheilt entlassen wird, sondern weiter behandlungsbedurftig ist, „strahlen“ die Umstande und ein Teil ihrer Behandlungsleistungen weit in andere Versorgungssektoren aus. Konkret wirkt sich etwa die Versorgungsqualitat im Krankenhaus mittelbar oder im Falle der stationar verordneten Medikamente auch direkt auf die Art und die Kosten der ambulanten Weiterversorgung aus.

Decision aids against overuse of orthodontic services

Development and evaluation of a patient decision aid for young people and parents considering fixed orthodontic appliances by Marshmann et al. (2016). J Orthod. 43:276-287. The development of the first fixed appliance decision aid (FADA) may be an enormous advancement in improving the quality of orthodontic care (Marshmann et al. 2016). The importance of the work arises especially from the fact that decision aids may facilitate the shared decision-making process by means of providing up-todate scientific evidence on benefits and harms if presented in an appropriate format and at a right time point during the patient-physician communication. That is to say, through better information and better understanding, FADA may strengthen patient autonomy which is the fundament of bioethics and professional ethics. As we read through the study however, we have certain doubts that authors conclusion that the FADA provides patient-relevant information, a hallmark of decision aids, probably cannot be drawn from this study. According to the criteria of the International Patients Decision Aids Standards (IPDAS), relevant treatment options presented in the decision aids have to include also the ‘comprehensive, critically appraised, and up-to-date syntheses of the scientific evidence’ (IPDAS 2012). However, according to the section Methods of the study, the authors did not conduct any systematic review and critical appraisal of the available evidence to inform the content of FADA. For example the FADA’s content on root resorption, white spot lesions and patient experience were supported by only few selected single studies without clear selection criteria (Marshmann et al. 2016). Yet if the FADA fails to include some up-to-date and critically appraised evidence it may misinform patients (ethical dimension), cause unnecessary treatments (quality of care dimension) and thus resulting in more harm than good (Montori et al. 2013). We are aware of the difficulties associated with providing up-to-date scientific evidence for available treatment options, often limited funding, time consuming appraisal of literature, or low quality of available systematic reviews, just to mention a few. However, those limitations should be explicitly mentioned in the study so readers may be aware of them when drawing conclusion from the results. Also, strategies have been suggested to overcome the limitations of traditional decision aids and they could be useful in developing the FADA (Agoritsas et al. 2015). To conclude, the authors made a first and probably most important step toward strengthening patient autonomy, given that the content and the presentation of the FADA is truly evidence-based. In orthodontic care, where probably misinformation and subsequent excessive overtreatment are common (Ackermann 2010; Spassov et al. 2015), decision aids may be one valuable strategy to overcome those problems that may causes unnecessary harm and costs to patients and society.

Patientenorientierung ernst nehmen

Einleitung Die Orientierung an und auf die Bedarfe, Bedürfnisse und Präferenzen von Patienten gehört seit vielen Jahren zum Basisrepertoire der Gesundheitsrhetorik. Trotz einiger praktischer Schritte in diese Richtung, sieht der Alltag im deutschen Gesundheitswesen aber noch deutlich anders aus. Erst wenn Versorgungsforscher, gesundheitspolitisch Verantwortliche und Versorgungspraktiker Patientenorientierung zum archimedischen Punkt ihrer Sicht- und Handlungsweise machen, wird sich daran etwas ändern.