Stefan Greß

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.

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.

Strengthening weak primary care systems: Steps towards stronger primary care in selected Western and Eastern European countries

European health care systems are facing diverse challenges. In health policy, strong primary care is seen as key to deal with these challenges. European countries differ in how strong their primary care systems are. Two groups of traditionally weak primary care systems are distinguished. First a number of social health insurance systems in Western Europe. In these systems we identified policies to strengthen primary care by small steps, characterized by weak incentives and a voluntary basis for primary care providers and patients. Secondly, transitional countries in Central and Eastern Europe (CCEE) that transformed their state-run, polyclinic based systems to general practice based systems to a varying extent. In this policy review article we describe the policies to strengthen primary care. For Western Europe, Germany, Belgium and France are described. The CCEE transformed their systems in a completely different context and urgency of problems. For this group, we describe the situation in Estonia and Lithuania, as former states of the Soviet Union that are now members of the EU, and Belarus which is not. We discuss the usefulness of voluntary approaches in the context of acceptability of such policies and in the context of (absence of) European policies.

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

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.

Health Care System Change and the Cross-Border Transfer of Ideas: Influence of the Dutch Model on the 2007 German Health Reform

To increase understanding of the cross-border transfer of ideas through a case study of the 2007 German health reform, this article draws on Kingdons approach of streams and follows two main objectives: first, to understand the extent to which the German health reform was actually influenced by the Dutch model and, second, in theoretical terms, to inform inductively on how ideas from abroad enter government agendas. The results show that the streams of problem recognition and policy proposals have not been predominantly influenced by the cross-border transfer of ideas from the Netherlands to Germany. The Dutch experience was taken into consideration only after a policy window opened by a shift in politics in the third, the political, stream: the change of government in 2005. In many respects, the way Germany learned from the Netherlands in this case sharply contrasts with an image of solving policy problems by either lesson drawing or transnational deliberation. Instead, the process was dominated by problem solving in the sphere of politics, that is, finding a way to prove the grand coalition was capable of acting.

General Practitioners’ Participation in a Large, Multicountry Combined General Practitioner-Patient Survey: Recruitment Procedures and Participation Rate

Background. The participation of general practitioners (GPs) is essential in research on the performance of primary care. This paper describes the implementation of a large, multicountry study in primary care that combines a survey among GPs and a linked survey among patients that visited their practice (the QUALICOPC study). The aim is to describe the recruitment procedure and explore differences between countries in the participation rate of the GPs. Methods. Descriptive analyses were used to document recruitment procedures and to assess hypotheses potentially explaining variation in participation rates between countries. Results. The survey was implemented in 31 European countries. GPs were mainly selected through random sampling. The actual implementation of the study differed between countries. The median participation rate was 30%. Both material (such as the payment system of GPs in a country) and immaterial influences (such as estimated survey pressure) are related to differences between countries. Conclusion. This study shows that the participation of GPs may indeed be influenced by the context of the country. The implementation of complex data collection is difficult to realize in a completely uniform way. Procedures have to be tuned to the context of the country.

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.

Prospects of gatekeeping in German social health insurance

From 2004, German social health insurers are bound by law to offer their insured a gatekeeping option. In return for renouncing direct access to specialist care, the insured can be granted bonus payments by their social health insurer. So far, experience with gatekeeping is very limited in Germany. In social health insurance, sickness funds are very reluctant to offer gatekeeping, although this was already legally possible before 2004. In the private health insurance sector, cost savings in gatekeeping tariffs are probably the result of self-selection of the insured rather than more cost-efficient provision of health care services. International experience does not prove that gatekeeping results in cost savings or a better patient–physician relationship. Although in countries with a strong primary care system there is a higher life expectancy, gatekeeping is not the only factor to bring about this effect. It is not to be expected that the new legislation will result in a major proliferation of gatekeeping options in German social health insurance. Either the gatekeeping options will not be attractive for the insured or sickness funds will use gatekeeping options as an instrument for risk selection.

The Social Transformation of American Medicine: A Comparative View from Germany

In The Social Transformation of American Medicine (1982), Paul Starr argues that physicians in the United States exercise authority over patients, fellow workers in health care, and even the public at large. This authority spills over its clinical boundaries into arenas of political action for which medical knowledge is only partly relevant. According to Starr, the medical profession has been able to turn its authority into social privilege, economic power, and political influence. Hardly anywhere have doctors been as successful as American physicians in resisting national insurance and maintaining a predominantly private and voluntary financing system. Physicians in the United States have not only escaped from corporate and bureaucratic control in their practices, they also have been able to channel the development of hospitals, health insurance, and other medical institutions into forms that did not intrude upon their autonomy (5– 6). The enactment of compulsory social health insurance legislation in other Western capitalist countries suggests there was no fundamental reason that the United States could not also have adopted social health insurance. However, Starr argues, the medical profession was one of the main opponents of compulsory social health insurance. No powerful coordinating authority was permitted to emerge, because it would have threatened professional autonomy and physician control of the market. Even though universal health insurance would have boosted the income of

Primary care practice composition in 34 countries

Health care needs in the population change through ageing and increasing multimorbidity. Primary health care might accommodate to this through the composition of practices in terms of the professionals working in them. The aim of this article is to describe the composition of primary care practices in 34 countries and to analyse its relationship to practice circumstances and the organization of the primary care system. The data were collected through a survey among samples of general practitioners (n=7183) in 34 countries. In some countries, primary care is mainly provided in single-handed practices. Other countries which have larger practices with multiple professional groups. There is no overall relationship between the professional groups in the practice and practice location. Practices that are located further from other primary care practices have more different professions. Practices with a more than average share of socially disadvantaged people and/or ethnic minorities have more different professions. In countries with a stronger pro-primary care workforce development and more comprehensive primary care delivery the number of different professions is higher. In conclusion, primary care practice composition varies strongly. The organizational scale of primary care is largely country dependent, but this is only partly explained by system characteristics.