Gerald Lux

High cost pool or high cost groups—How to handle high(est) cost cases in a risk adjustment mechanism?

Competitive social health insurance systems (at least) in Western Europe have implemented systems of morbidity based risk adjustment to set a level playing field for insurers. However, many high cost insured still are heavily underfunded despite risk adjustment, leaving incentives for risk selection. In most of these health care systems, there is an ongoing debate about how to deal with such underpaid high cost cases. This study develops four distinct concepts by adding variables to risk adjustment or by setting up a high cost pool for underpaid insured besides the risk adjustment system. Their features, incentives and distributional effects are discussed. With a data set of 6 million insured, performance is demonstrated for Germany. All models achieve a substantial improvement in model fit, measured in terms of R(2) as well as CPM. As the results of the various models are different in different dimensions, the trade-offs that have to be dealt with and should be addressed, when implementing a model to reduce underfunding of high cost cases.

Effect of guideline orientation on the outcomes of peripheral arterial disease in primary care.

Abstract Objective: Peripheral arterial disease (PAD), an established marker of premature death and cardiovascular risk in general, is highly prevalent. We analysed factors associated with poor outcomes in an observational cohort, with particular focus on the effect of guideline orientation in the management of these patients. Methods: PACE-PAD is a multicentre, prospective, observational study of PAD patients in primary care. PAD guideline orientation was stated, if patients received the following: exercise training, (if applicable) advice for smoking cessation and diet, therapy for diabetes mellitus, hypertension, hypercholesterolaemia, or antiplatelets/anticoagulants. Multivariate regression models were applied to assess factors associated with all cause death, cardiovascular/cerebrovascular death, or cardiovascular/cerebrovascular/peripheral vascular non-fatal events. Results: After an 18-month follow-up, of the 5099 PAD patients analysed (mean age 68.0 ± 9.0 years, 68.5% males), only 28.4% of patients met all applicable quality indicators for guideline-oriented treatment. However, most patients were to a large extent managed in line with guidelines. While exercise training was reported in 41.8%, rates were very high for smoking cessation (90.7%), therapy for hypertension (92.5%), diabetes mellitus (82.0%), hypercholesterolemia (83.3%) and antiplatelet therapy (86.7%). Regarding events, there were inhomogeneous results with a statistically significant higher rate of cardiovascular/cerebrovascular deaths and all-cause deaths, but a lower rate of non-fatal vascular events in patients treated according to guidelines compared to those who were not. Limitations of this study include the open, non-controlled design, possible patient selection bias and misclassification of events. Conclusion: Even if the guideline orientation for the various indicators was remarkably stable across the three follow-up visits, the rate of patients comprehensively treated according to the guidelines was relatively low, which calls for optimisation. There was a lack of differentiation between the guideline-oriented and non-guideline-oriented therapy in terms of outcomes, which may be due to patient-related or other factors, and warrants further research.

Morbiditätsorientierter Risikostrukturausgleich – Ausgestaltung und Perspektiven für die Versorgung

Seit der Gesetzgeber des Gesundheitsstrukturgesetzes von 1992 die Einführung der Kassenwahlfreiheit für die meisten Versicherten und zugleich die Einführung des Risikostrukturausgleiches (RSA) beschlossen hat, steht die Ausgestaltung der GKV-Wettbewerbsordnung in der Diskussion der Fachöffentlichkeit. Insbesondere um den Risikostrukturausgleich wurden heftige Auseinandersetzungen geführt, gilt er doch als der „technische Kern“ der neuen GKV-Wettbewerbsordnung (Wasem 1993). Mit dem Übergang zum morbiditätsbezogenen RSA zum 1.1.2009 infolge des GKV-Wettbewerbsstärkungsgesetzes (GKV-WSG) findet eine mehr als zehnjährige Reformdebatte ihre Umsetzung. Vor diesem Hintergrund soll im Folgenden zunächst noch einmal auf die Rationale für einen (morbiditätsbezogenen) RSA eingegangen werden. Anschließend sollen die Spezifika einer Einführung unter den Bedingungen des Gesundheitsfonds thematisiert werden. Schließlich wird die Frage nach dem damit erreichten Stand der GKV-Wettbewerbsordnung aufgegriffen. RSA oder risikoäquivalente Prämien

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

AimThis study aims to calculate the cost of illness concerning multiple sclerosis (MS) from the perspective of the German social insurance system.Subjects and methodsExpenditures 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.ResultsIn 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 €.ConclusionThis 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.

Konzepte zur nachhaltigen Stärkung von Anreizen für die gesetzlichen Krankenkassen zur Vermeidung von Pflegebedürftigkeit

Die gesetzliche Krankenversicherung (GKV) hat den gesetzlichen Auftrag, Pflegebedurftigkeit zu vermeiden oder zu vermindern. Die Krankenkassen haben jedoch nur ein geringes okonomisches Interesse daran, Masnahmen zu finanzieren. Denn finanzielle Erfolge durch verzogerte oder vermiedene Pflegebedurftigkeit fallen vornehmlich bei der gesetzlichen Pflegeversicherung (GPV) an. Daher besteht die Gefahr, dass die Krankenkassen effiziente Masnahmen wie zum Beispiel Rehabilitationsmasnahmen oder auch ein gezieltes Case