Juergen Wasem

German Recommendations on Health Economic Evaluation: Third and Updated Version of the Hanover Consensus

The second revision of the German Guidelines for Health Economic Evaluation provides a structured, broadly consented, scientific contri- bution to the ongoing methodological discus- sion in Germany. It provides the reader with guidance on different issues, i.e. study design, study perspective, study forms, selection of al- ternatives within a study, validity and data sources, cost assessment, assessment of out- comes, time horizon, discounting, sensitivity analyses, presentation and discussion of out- comes as well as publication of study results.

Consumer Price Sensitivity and Social Health Insurer Choice in Germany and the Netherlands

In this paper, we examine the effects of the introduction of free choice and price competition in social health insurance in Germany and the Netherlands. Using panel data at the sickness fund level we estimate the price elasticity of sickness fund choice in both countries. We find that the price elasticity in Germany is high and rapidly increasing. Consistent with findings of other studies on health plan choice, the price elasticity is much lower for elderly than for non-elderly. In the Netherlands, by contrast, the price elasticity of fund choice is negligible. Only when people were forced to choose a sickness fund, they were quite sensitive to premium differences. Key factors in explaining the observed differences in switching behavior between both countries are the degree of financial risk for sickness funds, the features of the risk-adjustment mechanism and the role of employers.

Economic Evaluation of Treatment Options in Patients with Alzheimer’s Disease

AbstractIntroduction: Alzheimer’s disease (AD) is common among the elderly; it is responsible for 60–80% of all dementia cases. AD is characterized by cognitive decline, behavioural and psychological symptoms, and reductions in functioning and independence. Because of its progressive neurodegenerative nature and unknown aetiology, the burden of AD becomes increasingly significant in an aging population. Estimates indicate that 35.6 million people worldwide suffered from AD in 2010. By 2030 and 2050, this figure is predicted to increase to 65.7 million and 115.4 million, respectively. Costs will also rise along with the increase in the number of people diagnosed with AD. In 2010, the world-wide costs associated with dementia were estimated to be

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

US604 billion. Objective: The objective of this study was to conduct a systematic review of current publications dealing with the pharmacoeconomic factors associated with AD medications and to describe the decision-analytic models used to evaluate long-term outcomes. Methods: A systematic literature search was performed to identify articles published between 1 January 2007 and 15 July 2010. The search was also based on a previous systematic review, which included literature up to 2007. Articles were included if they were complete and original economic evaluations of AD and if they were comparative in nature. A quality assessment of the included publications was conducted and relevant information was extracted into tables. Results: Seven out of 2067 identified articles were included in this systematic review. Four articles evaluated treatment with donepezil, one with galantamine and two with memantine. The studies were conducted in America, Europe and Asia.Five different groups of medications were compared. The incremental cost-effectiveness ratios (ICERs) for the group of patients treated with donepezil versus no drug treatment ranged from a dominant value to h281416.13 per quality-adjusted life-year (QALY). Patients treated with donepezil versus placebo showed ICERs with a range from a dominant value (not specified) up to h20 866.77 per QALY. Treatment with memantine in addition to donepezil versus treatment with donepezil alone showed an ICER range from a dominant value to €6818.33 per QALY. In comparison with the memantine treatment as an add-on therapy, the ICER of memantine monotherapy versus standard care (without cholinesterase inhibitors [CEIs]) ranged from a dominant value to €63 087.20 per QALY. Finally, the economic evaluation of galantamine in comparison with usual care without any AD drugs showed ICERs ranging from h1894.70 to h6953 per QALY. Conclusion: The seven identified publications included in this review indicate that treatment with CEIs or memantine seems to be reasonable in terms of clinical effects and costs for patients with AD. Depending on different hypotheses, assumptions and variables (e.g. time horizon, discount rates, initial number of patients in different states, etc.) in the sensitivity analyses, treatment with these drugs seems to be primarily a cost-effective strategy or even a cost-saving strategy. Nevertheless, the results generally are associated with a degree of uncertainty. The comparability of the results from the different economic evaluations is limited because of the different assumptions made.

Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland?

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.

Neonatal hearing screening: Modelling cost and effectiveness of hospital- and community-based screening

CONTEXT From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). METHODS We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. FINDINGS After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. CONCLUSIONS Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences.

Cost-effectiveness of primary HPV screening for cervical cancer in Germany--a decision analysis.

BackgroundChildren with congenital hearing impairment benefit from early detection and management of their hearing loss. These and related considerations led to the recommendation of universal newborn hearing screening. In 2001 the first phase of a national Newborn Hearing Screening Programme (NHSP) was implemented in England. Objective of this study was to assess costs and effectiveness for hospital and community-based newborn hearing screening systems in England based on data from this first phase with regard to the effects of alterations to parameter values.MethodsDesign: Clinical effectiveness analysis using a Markov Model. Outcome measure: quality weighted detected child months (QCM).ResultsBoth hospital and community programmes yielded 794 QCM at the age of 6 months with total costs of £3,690,000 per 100,000 screened children in hospital and £3,340,000 in community. Simulated costs would be lower in hospital in 48% of the trials. Any statistically significant difference between hospital and community in prevalence, test sensitivity, test specificity and costs would result in significant differences in cost-effectiveness between hospital and community.ConclusionThis modelling exercise informs decision makers by a quantitative projection of available data and the explicit and transparent statements about assumptions and the degree of uncertainty. Further evaluation of the cost-effectiveness should focus on the potential differences in test parameters and prevalence in these two settings.

Effects of the German reference drug program on ex‐factory prices of prescription drugs: a panel data approach

OBJECTIVES To systematically evaluate the long-term effectiveness and cost-effectiveness of HPV-based primary cervical cancer screening in the German health care context using a decision-analysis approach. METHODS A Markov-model for HPV-infection and cervical cancer was developed for the German health care context, and applied to evaluate various screening strategies that differ by screening interval and test algorithms, including HPV-testing alone or in combination with cytology. German clinical, epidemiological, and economic data, and test accuracy data from international meta-analyses were used. Outcomes predicted included the reduction in cervical cancer cases and deaths, life expectancy and discounted incremental cost-effectiveness ratios (ICER). The analysis was performed from the perspective of the healthcare system adopting a 3% annual discount rate for costs and outcomes. Extensive sensitivity analyses were performed. RESULTS HPV-based screening is more effective than cytology alone. It results in a 71-97% reduction in cervical cancer cases as compared to 53-93% for cytology alone. The ICER range from 2600 Euro/LYG (cytology, 5-year-interval) to 155,500 Euro/LYG (annual HPV-testing starting at age 30 years, cytology age 20-29 years). Annual cytology alone, the current recommended screening strategy in Germany, is dominated by HPV-strategies. Increasing the age at screening initiation from 20 to 25 years does not result in a relevant loss in effectiveness but results in lower costs. CONCLUSIONS Based on our analyses, HPV-based cervical cancer screening is more effective than cytology alone and could be cost-effective if performed at intervals of two years or longer. In the German context, an optimal screening strategy may be biennial HPV screening starting at age 30 years preceded by biennial cytology for women aged 25-29 years. Longer screening intervals may be considered in low-risk women with good screening adherence and in populations with low HPV-incidence.

Versteilerung der alters- und geschlechtsspezifischen Ausgabenprofile von Krankenversicherern

This paper examines effects of the German social health insurance systems reference drug program (RDP) for prescription drugs on ex-factory prices. Moreover, we analyze whether manufacturers adapt prices of their products that are not subject to reference pricing as a consequence of changes in reference prices of their products that are subject to reference pricing. We use econometric panel data methods based on a large panel data set of nearly all German prescription drugs on a monthly basis between October 1994 and July 2005. They provide information on ex-factory prices, reference prices, manufacturers, type of prescription drug, and market entries and exits. Our results show that there is no full price adjustment: A 1%-change in reference prices leads to a 0.3%-change in market prices. Price adjustment, however, is fast - it mostly happens in the first month. Furthermore, the first introduction of a reference price reduces market prices of the affected products by approximately 7%. Finally, we observe a significant time effect that is positive in the market without reference prices and negative in the market with reference prices.

The evidence for the use of growth factors and active skin substitutes for the treatment of non-infected diabetic foot ulcers (DFU): a health technology assessment (HTA).

ZusammenfassungDaß die durchschnittlichen Pro-Kopf-Gesundheitsausgaben bei älteren Menschen deutlich höher sind als bei Jüngeren, ist seit langem bekannt — man bezeichnet diesen Zusammenhang zwischen Höhe der durchschnittlichen Pro-Kopf-Ausgaben und Lebensalter als Ausgabenprofil. Versteuerung bezeichnet die These, daß die Ausgaben für ältere Versicherte schneller steigen als für jüngere Versicherte, daß also Ausgabenprofile im Laufe der Zeit „steiler werden“. Diese These wird anhand von Ausgabedaten verschiedener Bausteintarife eines deutschen privaten Krankenversicherers über einen Beobachtungszeitraum von 18 Jahren untersucht.Zur Untersuchung der Versteilerung von Krankenversicherungsprofilen liegen bislang keine Instrumente vor. Im Artikel werden drei unterschiedliche Instrumente zur Messung von Profilversteilerung vorgeschlagen und auf die zur Verfügung stehenden Daten angewendet. In der Mehrheit der untersuchten Tarife ist für den Beobachtungszeitraum eine Versteilerung des Ausgabenprofils zu beobachten. Obwohl alle drei vorgeschlagenen Instrumente durchaus kritisch gesehen werden sollten, zeigt der relativ einheitliche Trend der Daten, daß eine Versteilerung von Ausgabenprofilen vorliegt. Die Versteilerung ist bei den Männern deutlicher als bei den Frauen und in den stationären Tarifen deutlicher als in den ambulanten Tarifen.Eine Ursachenforschung kann aufgrund der gegebenen Datenstruktur nur außerhalb der Empirie erfolgen. Der Zusammenhang zwischen Restlebenszeit und Gesundheitsausgaben sowie die steigende Lebenserwartung tragen nicht zur Erklärung des Phänomens Versteilerung bei.AbstractIt is well-known for a long time, that health care expenditure of elder people are a lot higher than expenditure of younger people, we call this correlation of average per-capita-expenditure and age expenditure profiles. If health care expenditures for the elderly grow faster than for younger people, the expenditure profiles become „steeper“. Data of a German private health insurer are used to investigate the phenomenon growing steepness of profiles over a period of 18 years.In the article three instruments for measuring the phenomenon of growing steeper expenditure profiles are proposed. None of them is perfect, but the more or less common trend shows that the profiles of the investigated health insurance plans did grow steeper. The health plans of men do reflect this phenomenon clearer than those of women and the inpatient plans do show a stronger effect than the outpatient plans.Research of causes by data is not possible because of the given data structure. But neither the correlation between health expenditure and time til death nor the improving life expectancy can help to explain the phenomenon.