Markus Lüngen

Financial incentives in the German statutory health insurance: new findings, new questions

OBJECTIVES This paper presents findings of a mandatory three-year evaluation of a prevention bonus scheme offered in the German Statutory Health Insurance (SHI). Its objective is to describe the rationale behind the programs, analyze their financial impact and discuss their implications on potentially conflicting goals on solidarity and competition. METHODS The analysis included 70,429 insured enrolled in a prevention bonus program in a cohort study. The intervention group and their matched controls were followed for a three-year period. Matching was performed as nearest neighbor matching. The economic analysis comprised all costs relevant for Sickness Funds (SF) in the SHI and was carried out from a SHI perspective. Differences in cost trends between the intervention and the control group were examined applying the paired t-test. RESULTS Regarding mean costs there was a significant difference between the two groups of euro177.48 (90% CI [euro149.73; euro205.24]) in favor of the intervention group. If program costs were considered cost reductions of euro100.88 (90% CI [euro73.12; euro128.63]) were obtained. CONCLUSIONS The uptake of a prevention bonus program led to cost reductions in the intervention group compared to the control group even when program costs were considered. However, the results must be interpreted with caution as in addition to financial aspects, socio-economic and health-status, selection bias and the function and use of bonus programs as marketing tools, as well as their long-term sustainability should be considered in future assessments.

The reform of hospital financing in Germany: an international solution?

From 2003, each inpatients stay at a German hospital will be reimbursed according to diagnosis related groups. The former German hospital financing system, which consisted partly of per diem rates and partly of per-case rates, was abolished in an attempt to increase efficiency in hospitals. This can be seen as the governments attempt to act on the principles of evidence-based policy. Since there is no strict global budget for inpatient treatment, it is not certain that those diagnosis related groups will actually decrease overall expenditures on hospitals. Also, it is argued that the introduction of diagnosis related groups in Germany may not be the last step in rebuilding the German health care system. The manner, scope and timing of this reform suggests that it will not succeed. Reforms lead to yet more reforms.

Is prevention of atopic eczema with hydrolyzed formulas cost‐effective? A health economic evaluation from Germany

To cite this article: Mertens J, Stock S, Lüngen M, Berg AV, Krämer U, Filipiak‐Pittroff B, Heinrich J, Koletzko S, Grübl A, Wichmann H‐E, Bauer C‐P, Reinhardt D, Berdel D, Gerber A. Is Prevention of Atopic Eczema with Hydrolyzed Formulas Cost‐Effective? A Health Economic Evaluation from Germany. Pediatr Allergy Immunol 2012: 23: 597–604.

Preliminary analysis of short term financial implications of a prevention bonus program: First results from the German statutory health insurance

SummaryObjectives:With the implementation of the Health Care Modernization Act in 2004 sickness funds in Germany were given the opportunity to award bonuses to their insured for healthpromoting behavior. The aim of this study was to investigate the financial implications of a prevention bonus program from a sickness fund perspective.Method:The investigation was designed as a controlled cohort study (matched pair study) comprising 70,429 members in each group. Matching criteria were sex, postal code, insurance status, and cost categories for health care utilization. Insured opted into the program on a voluntary basis. The program consisted of interventions featuring primary prevention, modest exercise and immunization. Differences in cost trends between the two groups were examined using the paired t-test.Results:A reduction in mean costs of 241.11 € per active member for the year 2005 (90 % CI = 348.70, 133.52; p-value < 0.001) could be achieved in the intervention group compared to the control group. When costs for the implementation of the program and the bonus payments were taken into account, there was a saving of 97.14 € per active member for the year 2005.Conclusions:Preliminary results of a prevention bonus program in the German Statutory Health Insurance suggest a decrease in mean health care spending per enrollee. These effects may increase with time as long term effects of prevention become effective. However, further research is needed to understand how much of these short term cost reductions can be attributed to the program itself rather than to possible confounders or volunteer bias and how the short term savings may be accrued.

Using diagnosis-related groups

The system of diagnosis-related groups classifies inpatients into clinically meaningful homogeneous classes based on the expected costs of treatment. It is used in several health care systems in developed countries to encourage hospitals to treat patients efficiently and to distribute resources based upon the performance of hospitals. The use of DRGs presumes that costs should drive hospital revenues, whereas other methods of financing, such as global budgeting, are based more on revenues driving costs (i.e. costs always rise as does income).

Evidenz der Wirksamkeit internationaler Präventionsmaßnahmen und Auswirkungen auf ein deutsches Präventionsgesetz

ZusammenfassungHintergrund und Ziel:In Deutschland werden seit Jahren Anstrengungen unternommen, ein Präventionsgesetz abzufassen und zu verabschieden. Trotz wechselnder politischer Mehrheiten konnte bisher kein Konsens über eine konkrete Umsetzung der Prävention erzielt werden. Der Beitrag geht der Frage nach, ob ein Grund für das wiederholte Scheitern auch der Mangel an Nachweisen des Effekts von Interventionen in Prävention und Gesundheitsförderung sein kann.Methodik:Im Anschluss an eine systematische Literatursuche wurden Effektivität und Qualität von Studien zu Interventionen in Prävention und Gesundheitsförderung bewertet. Untersucht wurden exemplarisch Interventionen der Jahre 1990–2006 aus den Bereichen Depression bei Kindern und Jugendlichen, Bewegung im betrieblichen Setting, Ernährung bei Kindern und Jugendlichen im schulischen Setting und Rauchentwöhnung bei Schwangeren. Die Studien wurden in jeweils einem von 13 Ländern durchgeführt, die einen mit Deutschland vergleichbaren sozioökonomischen Status haben.Ergebnisse:Für den Bereich Depression wurden 18, für Bewegung 26, für Ernährung 23 und für Rauchen 34 Studien bewertet. Von 26 Interventionen im Bereich Bewegung waren sechs effektiv (23,1%), von 18 Interventionen im Bereich Depression war eine effektiv (5,6%), von 23 gesichteten Interventionen im Bereich Ernährung waren sieben effektiv (30,4%), und im Bereich Rauchen schlossen neun Interventionen (26,5%) mit einem positiven Effekt ab. Nimmt man die Qualität des Studiendesigns wie der Durchführung der Interventionen als weiteres Kriterium dazu, bleiben von den effektiven Studien nur noch eine im Bereich Bewegung im Betrieb, zwei im Bereich Ernährung, drei im Bereich Rauchen und keine im Bereich Depression übrig.Schlussfolgerung:In vier exemplarisch ausgewählten Feldern konnten nur sechs von insgesamt 101 (5,9%) untersuchten internationalen Studien auch bei entsprechender Qualität des Studiendesigns und der Interventionsdurchführung einen Effekt zeigen. Angesichts dieses Ergebnisses könnte derzeit eine Verteilung von Ressourcen in der Prävention kaum auf einer verlässlichen Grundlage erfolgen, was die Verabschiedung eines Präventionsgesetzes möglicherweise erschwert. Ein zukünftiges Präventionsgesetz sollte daher wesentlichen Wert auf die Evaluation des Effekts wie der Qualität von Maßnahmen legen, um Fehlallokationen zu vermeiden.AbstractBackground and Purpose:Efforts have been undertaken to devise and pass an Act of Prevention in Germany. To date, no consensus could be reached with changing political majorities in parliament. Hence, the authors ask the question whether the lack of evidence in prevention and health promotion could also be contributing to this delay.Methods:After a systematic search of the literature on prevention and health promotion in nutrition, exercise, depression, and smoking, all retrieved studies were evaluated in terms of their effect as well as the quality of study design like prior power calculation and intervention like documentation of process or participation of intended group. For inclusion, studies had to be undertaken in one of 13 countries that have a socioeconomic standard of living comparable to Germany. The authors of this article exemplarily included studies from the following focus areas into the systematic review: prevention of depression among children and adolescents, exercise in the work environment, nutrition for children and adolescents, and smoking cessation programs among pregnant women, all from 1990 to 2006.Results:The authors retrieved 18 studies on prevention of depression among children and adolescents, 26 on exercise in the work environment, 23 on nutrition for children and adolescents, and 34 on smoking cessation programs among pregnant women. Six out of 26 on exercise had a positive effect (23.1%), one out of 18 on depression (5.6%), seven out of 23 in the field of nutrition (30.4%), and nine out of 34 smoking cessation programs (26.5%). If one takes into account the quality of study design and intervention as a marker for the reliability and validity of results, one intervention on exercise, two on nutrition, three on smoking and none on depression would remain with a positive effect.Conclusion:In four exemplarily selected fields only six out of a total of 101 international studies (5.9%) had an effect, if one also ties in quality of study design and intervention. With regard to this result, allocation of resources for prevention and health promotion would be highly ambiguous without sufficient evidence. This condition might contribute to the deferment of an Act of Prevention in the German legislation. For the future, the authors strongly urge that the Act of Prevention takes into account the evaluation both of effects and quality of any intervention in order to prevent false allocation of resources.BACKGROUND AND PURPOSE Efforts have been undertaken to devise and pass an Act of Prevention in Germany. To date, no consensus could be reached with changing political majorities in parliament. Hence, the authors ask the question whether the lack of evidence in prevention and health promotion could also be contributing to this delay. METHODS After a systematic search of the literature on prevention and health promotion in nutrition, exercise, depression, and smoking, all retrieved studies were evaluated in terms of their effect as well as the quality of study design like prior power calculation and intervention like documentation of process or participation of intended group. For inclusion, studies had to be undertaken in one of 13 countries that have a socioeconomic standard of living comparable to Germany. The authors of this article exemplarily included studies from the following focus areas into the systematic review: prevention of depression among children and adolescents, exercise in the work environment, nutrition for children and adolescents, and smoking cessation programs among pregnant women, all from 1990 to 2006. RESULTS The authors retrieved 18 studies on prevention of depression among children and adolescents, 26 on exercise in the work environment, 23 on nutrition for children and adolescents, and 34 on smoking cessation programs among pregnant women. Six out of 26 on exercise had a positive effect (23.1%), one out of 18 on depression (5.6%), seven out of 23 in the field of nutrition (30.4%), and nine out of 34 smoking cessation programs (26.5%). If one takes into account the quality of study design and intervention as a marker for the reliability and validity of results, one intervention on exercise, two on nutrition, three on smoking and none on depression would remain with a positive effect. CONCLUSION In four exemplarily selected fields only six out of a total of 101 international studies (5.9%) had an effect, if one also ties in quality of study design and intervention. With regard to this result, allocation of resources for prevention and health promotion would be highly ambiguous without sufficient evidence. This condition might contribute to the deferment of an Act of Prevention in the German legislation. For the future, the authors strongly urge that the Act of Prevention takes into account the evaluation both of effects and quality of any intervention in order to prevent false allocation of resources.

Direct non-medical and indirect costs for families with children with congenital cardiac defects in Germany: a survey from a university centre.

INTRODUCTION Parents of children with congenital cardiac disease suffer from psychological stress and financial burdens. These costs have not yet been quantified. MATERIALS AND METHODS In cooperation with paediatricians, social workers, and parents, a questionnaire was devised to calculate direct non-medical and indirect costs. Direct non-medical costs include all costs not directly related to medical services such as transportation. Indirect costs include lost productivity measured in lost income from wages. Parents were retrospectively queried on costs and refunds incurred during the childs first and sixth year of life. The questionnaire was sent out to 198 families with children born between 1980 and 2000. Costs were adjusted for inflation to the year 2006. Children were stratified into five groups according to the severity of their current health status. RESULTS Fifty-four families responded and could be included into the analysis (27.7%). Depending on severity, total direct non-medical and indirect costs in the first year of life ranged between an average of euro1654 in children with no or mild (remaining) cardiac defects and an average euro2881 in children with clinically significant (residual/remaining) findings. Mean expenses in the sixth year of life were as low as euro562 (no or mild (remaining) cardiac defects) and as high as euro5213 (potentially life-threatening findings). At both points in time, the highest costs were lost income and transportation; and day care/ babysitting for siblings was third. DISCUSSION Families of children with congenital cardiac disease and major sequelae face direct non-medical and indirect costs adding up to euro3000 per year on average. We should consider compensating families from low socioeconomic backgrounds to minimise under-use of non-medical services of assistance for their children.

Direct, indirect, and intangible costs after severe trauma up to occupational reintegration - an empirical analysis of 113 seriously injured patients.

Aim: Although seriously injured patients account for a high medical as well as socioeconomic burden of disease in the German health care system, there are only very few data describing the costs that arise between the days of accident and occupational reintegration. With this study, a comprehensive cost model is developed that describes the direct, indirect and intangible costs of an accident and their relationship with socioeconomic background of the patients. Methods: This study included 113 patients who each had at least two injuries and a total Abbreviated Injury Scale (AIS) greater than or equal to five. We calculated the direct, indirect and intangible costs that arose between the day of the accident and occupational reintegration. Direct costs were the treatment costs at hospitals and rehabilitation centers. Indirect costs were calculated using the human capital approach on the basis of the work days lost due to injury, including sickness allowance benefits. Intangible costs were assessed using the Short Form Survey (SF-36) and represented in non-monetary form. Following univariate analysis, a bivariate analysis of the above costs and the patients’ sociodemographic and socioeconomic characteristics was performed. Results: At an average Injury Severity Score (ISS) of 19.2, the average direct cost per patient were €35,661. An average of 185.2 work days were lost, resulting in indirect costs of €17,205. The resulting total costs per patient were €50,431. A bivariate analysis showed that the costs for hospital treatment were 58% higher in patients who graduated from lower secondary school [Hauptschule] (ISS 19.5) than in patients with qualification for university admission [Abitur] (ISS 19.4). Conclusions: The direct costs of treating trauma patients at the hospital appear to be lower in patients with a higher level of education than in the comparison group with a lower educational level. Because of missing data, the calculated indirect costs can merely represent a general trend, so that the bivariate analysis can only be seen as a starting point for further studies.

Evaluation of multi-dose repackaging for individual patients in long-term care institutions: savings from the perspective of statutory health insurance in Germany

Aims and objectives Elderly people often have difficulty adhering to multi‐drug medication regimens. The current study aimed to evaluate whether multi‐dose repackaging for individual patients reduces medication expenses from the perspective of statutory health insurance in Germany.

Die Messung der Fallschwere unter einem DRG-basierten Vergütungssystem

ZusammenfassungHintergrund: Die Einführung der Australian Refined Diagnosis-Related Groups (AR-DRG) in Deutschland ist beschlossen. Methode und Aussagekraft der Fallschweremessungen unter diesem System bekommen wachsende Bedeutung. Methode: Die wichtigsten Systeme zur Fallschweremessung werden vorgestellt und anhand von Kriterien zur Anwendbarkeit und technischen Ausgestaltung den australischen AR-DRG gegenübergestellt. Ergebnisse: Die derzeitigen Fallschweremessungen sind entweder gut geeignet, um ein Vergütungssystem zu unterstützen, oder aber gut geeignet, um Qualitätssicherung zu unterstützen. Keines der Systeme kann beiden Anforderungen in optimaler Weise gerecht werden. AR-DRG leiten die ökonomische Fallschwere (Fallkosten) sehr differenziert ab, ohne den Einstieg in die Messung der medizinischen Fallschwere (Behandlungskomplexität) zu leisten. Schlussfolgerung: Die Basierung der deutschen G-DRG auf einem weniger komplexen System hätte vergleichbare Effizienzanreize gesetzt und weniger Aufwand verursacht. Wird der differenzierten Messung der Fallkosten jedoch hohe Bedeutung zugeschrieben, so wäre der gleichzeitige Einstieg in die Messung der medizinischen Fallschwere eine sinnvolle Kopplung gewesen. Die Festlegung auf die australischen AR-DRG scheint damit nicht optimal.AbstractBackground: The Australian Refined Diagnosis-Related Groups (AR-DRGs) will be the model for the German DRGs (G-DRGs). Their system to measure severity of illness will be a major point of interest. Method: The most common systems for measuring severity of illness are presented and compared with the AR-DRGs based on criteria regarding applicability. Results: None of the systems for measuring severity of illness fits all the criteria. They can be used for reimbursement of inpatient care or for quality assurance, but not for both at the same time. The designated areas for the use of the systems should not be exceeded. Conclusion: AR-DRGs are very complex in measuring the costs per case (severity of illness in terms of efficiency). They are not able to support quality assessment by risk adjustment (severity of illness in terms of medical complexity). A less complex system would have been easier to transfer to Germany with the same incentives for providing effective care.