Heinz Rothgang

Five types of OECD healthcare systems: Empirical results of a deductive classification

This article classifies 30 OECD healthcare systems according to a deductively generated typology by Rothgang and Wendt [1]. This typology distinguishes three core dimensions of the healthcare system: regulation, financing, and service provision, and three types of actors: state, societal, and private actors. We argue that there is a hierarchical relationship between the three dimensions, led by regulation, followed by financing and finally service provision, where the superior dimension restricts the nature of the subordinate dimensions. This hierarchy rule limits the number of theoretically plausible types to ten. To test our argument, we classify 30 OECD healthcare systems, mainly using OECD Health Data and WHO country reports. The classification results in five system types: the National Health Service, the National Health Insurance, the Social Health Insurance, the Etatist Social Health Insurance, and the Private Health System. All five types belong to the group of healthcare system types considered theoretically plausible. Merely Slovenia does not comply with our assumption of a hierarchy among dimensions and typical actors due to its singular transformation history.

9 The changing role of the state in healthcare systems

This article focuses on two major questions concerning the changing role of the state in the healthcare systems of OECD countries. First, we ask whether major changes in the level of state involvement (in healthcare systems) have occurred in the past 30 years. Given the fact that three types of healthcare system, each of which is characterized by a distinct role of the state, evolved during the ‘Golden Age’, we discuss how this distinctiveness – or more technically, variance – has changed in the period under scrutiny. While many authors analysing health policy changes exclusively concentrate on finance and expenditure data, we simultaneously consider financing, service provision and regulation. As far as financing is concerned, we observe a small shift from the public to the private sphere, with a tendency towards convergence in this dimension. The few data available on service provision, in contrast, show neither signs of retreat of the state nor of convergence. In the regulatory dimension – which we analyse by focusing on major health system reforms in Germany, the United Kingdom and the United States – we see the introduction or strengthening of those coordination mechanisms (hierarchy, markets and self-regulation) which were traditionally weak in the respective type of healthcare system. Putting these findings together we find a tendency of convergence from distinct types towards mixed types of healthcare systems.

Modelling an entitlement to long-term care services for older people in Europe: projections for long-term care expenditure to 2050

As the numbers of older people rise in Europe, the importance of long-term care services in terms of numbers of users and expenditures can be expected to grow. This article examines the implications for expenditure in four countries of a national entitlement to long-tem care services for all older people, based on assessed dependency. It is based on a European Commission-funded cross-national study, which makes projections to 2050 of long-term care expenditure in Germany, Italy, Spain and the UK. The policy option investigated is based on the German long-term care insurance scheme, which embodies the principle of an entitlement on uniform national criteria to long-term care benefits. The research models this key principle of the German system in the other three participating countries, with respect to home care services. The study finds that, if all moderately/severely dependent older people receive an entitlement to formal (in-kind) home care, the impact on expenditure could be considerable, but would vary greatly between countries. The impact on long-term care expenditure is found to be the least in Germany, where there is already an entitlement to benefits; and the greatest in Spain, where reliance on informal care is widespread. This article discusses the policy implications of these results.

Verfahren und Kriterien zur Konkretisierung des Leistungskatalogs in der gesetzlichen Krankenversicherung

ZusammenfassungDie Konkretisierung des Leistungsanspruchs für die Versicherten der GKV erfolgt durch Gremien der gemeinsamen Selbstverwaltung. Die Legitimität der angewandten Verfahren und Kriterien wird sowohl aus Input- als auch aus Output-Perspektive bewertet. Aus der Input-Perspektive ist die Priorisierung der Beratungsthemen überhaupt nicht und die Veröffentlichung von Beratungsthemen nur für Fachleute transparent. Außerdem sind die zuständigen Gremien nicht ausreichend repräsentativ zusammengesetzt. Aus der Output-Perspektive werden Potenziale für die Optimierung der wirtschaftlichen Mittelverwendung nicht genutzt, weil Kosten-Nutzen-Relationen in der Entscheidungsfindung eine untergeordnete Bedeutung einnehmen. Gleichzeitig werden Rationierungen vermieden. Darüber hinaus sind die angewandten Verfahren nur eingeschränkt konsistent und insgesamt als wenig effektiv zu bewerten. AbstractThe content of the benefits package in German social health insurance is determined by intermediate bodies of healthcare providers and healthcare funds. Legitimacy of procedures and criteria are evaluated by looking at inputs as well as at outputs. From an input perspective, the prioritization of topics totally lacks transparency, while the publication of decisions is transparent only for experts. Moreover, the composition of the intermediate bodies of healthcare providers and healthcare funds is not representative. From an output perspective, opportunities for a more rational allocation of resources are lost, since cost-benefit ratios are not used for decisions. However, rationing does not take place. Procedures are often inconsistent and for the most part relatively ineffective.

The Long-Term Costs of Public Long-Term Care Insurance in Germany. Some Guesstimates

After almost twenty years of discussion [see e.g. Gotting/Hinrichs (1993); Haug/ Rothgang (1994) or Gotting et al. (1995) for an overview of the sequence of events in policy development and Schmahl (1992) for an analysis of the different proposals discussed] in 1994 a Federal Act was passed concerning the introduction of a new public statutory Long-Term Care Insurance (LTCI)1 effective April 1, 1995.2 While at least for the last decade the necessity to cover the risk of long-term care comprehensively has been widely acknowledged, the main obstacle against any solution has been the fear of a ‘cost explosion’ resulting automatically from any newly introduced system of coverage. Particularly, any attempt to include long-term care into the social insurance system was criticised for this reason, not least from business representatives [see e.g. Engels (1991); Felderer (1992); Dinkel (1993); Ruf (1992), or the declaration of the Federation of Employers reprinted in Soziale Selbstverwaltung (1992)]. Concerns pertaining to this still exist. The aim of this paper therefore is to check to what extent such developments are likely to occur and to identify the main determinants of future expenditure developments within the new insurance’s framework.

Lebenserwartung in und ohne Pflegebedürftigkeit. Ausmaß und Entwicklungstendenzen in Deutschland

This article addresses the question if the number of life years men and women can expect to live in good health is increasing and secondly if the life years in long-term care decline to a shorter period before death (compression of morbidity) during the periods 1999-2003 to 2004-2008. The analyses is based on data of a health insurance company (Gmünder Ersatzkasse, GEK), which are calculated, using the prevalence-rate method of Sullivan. The results show that men and women at age 60 can expect to live longer (21.21 years instead of 20.04 years for men and 25.1 years instead of 23.96 years for women) and also live longer free of long-term care (19.89 instead of 18.89 years for men and 22.37 instead of 21.55 years for women). In addition to the prolonged life years, also the number of years a person can expect to live in long-term-care has increased (from 1.15 years to 1.32 years for men and from 2.41 years to 2.73 years for women). Therefore the data suggest that there is no compression of morbidity.

Von der Risiko- zur Anbieterselektion

Zusammenfassung Seit den 1990er Jahren lässt sich in mehreren OECD-Gesundheitssystemen des Sozialversicherungstyps die Implementation wettbewerblicher Reformen beobachten. Ein Vergleich von Deutschland und den Niederlanden als zwei Vertretern dieses Typs zeigt, dass diese Reformen eine Eigendynamik entwickeln: Einmal in einem Teilsegment eingeführter Wettbewerb erfordert „mehr“ Wettbewerb und Re-Regulierung. Von der freien Kassenwahl gingen in beiden Staaten zunächst steigende Anreise zur Risikoselektion aus. Um dieser Fehlentwicklung Einhalt gebieten, verbesserte der Gesetzgeber die Risikoadjustierung und eröffnete Möglichkeiten zur Anbieterselektion. Als Konsequenz wird das korporatistische Steuerungsmodell sukzessive durch Marktwettbewerb und staatliche Hierarchie ergänzt oder sogar substituiert.

Soziale Einflüsse auf das Risiko der Pflegebedürftigkeit älterer Männer

Es gehort zu den vielfach bestatigten Befunden, dass Personen in unteren soziookonomischen Positionen weitaus hoheren gesundheitlichen Risiken ausgesetzt sind, als Personen in hoheren soziookonomischen Positionen. Dieser inverse Zusammenhang zwischen sozialer Ungleichheit und dem Gesundheitszustand konnte in vielen Studien sowohl fur das das Morbiditatsrisiko (Helmert 2003; Lampert et al. 2005; Mielck 2005; Hernandez-Quevedo 2006; Richter/Hurrelmann 2006), als auch fur das Mortalitatsrisiko (Klein 1993; Voges/Schmidt 1996; Klein/Unger 2001; Helmert/Voges 2002; Helmert et al. 2002) nachgewiesen werden. Dabei ist anzumerken, dass sich die uberwiegende Anzahl der in diesem Rahmen vorliegenden Studien auf Personen im erwerbsfahigen Alter bezieht. Altere Personen spielen dagegen in der wissenschaftlichen und gesundheitspolitischen Diskussion lediglich eine untergeordnete Rolle. Aus diesem Grund ist bis zum gegenwartigen Zeitpunkt nur relativ wenig uber die Wirkungsweise von sozialer Ungleichheit auf den Gesundheitsstatus von alteren Menschen bekannt.

The Changing Public-Private Mix in OECD Health-care Systems

The economic recession following the oil price shocks of the 1970s triggered a broad range of cost containment measures in social polices throughout the OECD world. Health care was no exception. Globalization, demographic change and advancements in medical technology have strengthened the need for reforms that assure both the quality and efficiency of health-care systems while at the same time guaranteeing equal access to services (OECD, 1994). The pertinent question to be dealt with in this contribution is how the role of the state and the market in attaining these challenging and somewhat contradictory objectives, has changed over time. Evidence suggests that although common challenges are experienced, the responses to various socio-economic pressures have differed considerably across healthcare systems (Tuohy, 1999; Rothgang et al., 2006). Starting in the 1990s, for example, we observe that in many predominately publicly financed health-care systems market-oriented health-care reforms have been implemented or proposed (van de Ven, 1996; Freeman and Schmid, forthcoming), whereas in countries with private insurance systems access to health care and the introduction of universal health insurance have gained political salience (Skocpol, 1994; Zweifel, 2000). This contribution focuses particularly on the ‘hybridization’ of health-care systems induced by the changing public–private mix. In order to capture these developments systematically, we differentiate between dimensions of health-care systems: financing, service provision and regulation.

Die Auswirkungen Des Pflege-Versicherungsgesetzes Auf Die Entwicklung Der Heimentgelte

ZusammenfassungMit der Einführung der 2. Stufe der Pflegeversicherung zum 1.7.1 996 wurde die Vergütung von Pflegeeinrichtungen neu geregelt, womit insbesondere ein Beitrag zum Stop der seit Anfang der 70er Jahre beklagten „Preiswalze“ geleistet werden sollte. Neben der Umstellung von einer retrospektiven Kostenerstattung auf prospektiv vereinbarte Heimentgelte, der Vorgabe von Höchststeigerungsraten und der Einführung von Wirtschaftlichkeitsprüfungen wurde auch eine Standardisierung der Heimentgelte angestrebt. Die theoretische Betrachtung zeigt, daβ eine Kostenbegrenzung nur gelingen kann, wenn die Vergütung nicht mehr nach den individuellen, sondern nach den Durchschnittskosten vergleichbarer Einrichtungen festgelegt wird und Preis- bzw. Kostenabsprachen der Einrichtungsträger verhindert werden können. Die Analyse von Daten aller rheinländischen Pflegeheime zeigt, daβ die Preissteigerungen zwischen 1995 und 1998 gegenüber früheren Zeiträumen geringer, jedoch immer noch beachtlich ausfielen und über dem gesetzlichen Rahmen lagen. Gleichzeitig hat aber eine Angleichung der Entgelte stattgefunden, die die Möglichkeit für zukünftige Kostenbegrenzungen verbessert.AbstractThe current articles examines whether the newly introduced long-term care insurance leads to more price control in nursing home care. On a theoretical level it is argued that only a shift from individual pricing to pricing on the basis of average costs can serve this purpose — given binding agreements among providers to keep cost high can be prevented. Based on data from all rhenish nursing homes the empirical analysis reveals between 1995 and 1998 a still considerable increase in and a decreasing deviation among nursing home rates. Though the former result is disappointing the latter bears potential for more successful future price control, since more equal prices are a prerequisite for pricing on an average cost basis.