[Conflicting Rules and Incentives for Health Promotion and Prevention in the German Statutory Health Insurance (GKV)]. / Normen- und Anreizkonflikte für die gesetzlichen Krankenkassen in Gesundheitsförderung und Prävention.

OBJECTIVES: This study examines what role the German statutory health insurance (GKV) has in health promotion and prevention, if regulations and incentives are consistent, and if the politically-intended strengthening of prevention has been achieved. METHODS: We compiled the regulations and incentives of the German Sozialgesetzbuch V as the legal basis for health promotion and prevention of the GKV and studied their effects and interactions. Using annual financial reports of GKV we determined how the spending in prevention overall and in specific fields of prevention has -developed. RESULTS: The responsibilities of the GKV in health promotion and prevention lack a clear scientific foundation. Regulations have been incrementally added following changing ideas in prevention and health promotion policies. Currently, different norms and a variety of incentives lead to inconsistent and conflicting aims. Only 2% of all expenditures of the GKV are for health promotion and prevention, mainly spent for medical measures like preventive medical check-ups or vaccination. While spending of the GKV in general is rising, expenditures for prevention have decreased since 2009. CONCLUSIONS: There is a need to harmonise the different regulations in health promotion and prevention and to correct currently inconsistent incentives in the GKV. Given the similar evidence base there seems to be no reason why responsibilities for health promotion and primary, secondary or tertiary prevention should be regulated by different normative constructs. Incentives should account for the different aims of health insurers and their members. Financial incentives to increase spending in prevention may be particularly effective when there is no short-term -financial interest for the health insurer.

[Participant structure and economic benefit of prevention bonus programmes in company health insurance funds]. / Teilnehmerstruktur und ökonomischer Nutzen präventiver Bonusprogramme in der betrieblichen Krankenversicherung.

OBJECTIVE: This study investigates differences in sex, age, and educational level between participants and non-participants of prevention bonus programmes. The differences in the utilisation of drugs, hospital care, and sickness absence before the start of the programmes between these groups are also shown. Finally the economic benefit of the health insurance funds attributed to these programmes is estimated. METHODS: Data from some 5.2 million insured subjects of 74 company health insurance funds in Germany were linked to information on enrollment into a prevention bonus programme anonymously. In a descriptive analysis the differences in the sociodemographic patterns between both groups are shown as well as the differences in costs to the health insurances in the three sectors mentioned above. The benefit to the health insurance funds is estimated by means of an analysis of covariance. RESULTS: Prevention bonus programmes yields an annual benefit of at least 129 euro per participant. Men aged 40 and older and women aged 30 and older are more likely to opt into such a programme. The same is true for persons with a higher educational level. There are only few differences in health-care utilisation between the participants and non-participants of the programmes before enrollment. Only 1.4% of all insured persons participated in the programmes. CONCLUSION: There is at least a short-term gain to both involved parties: the insured and the health insurance funds. The programmes are not dominated by deadweight effects. Long-term effects and effectiveness of prevention bonus programmes still have to be investigated.

[Work and Health. Representative work-related health monitoring with sickness absence data of the company health insurance in Germany]. / Berufliche Tätigkeit und Arbeitsunfähigkeit. Repräsentative arbeitsweltbezogene Gesundheitsberichterstattung mit Daten der Betriebskrankenkassen.

The use of sickness absence data of the health insurance funds for health reporting and health research has a long tradition in Germany. The data are especially used for work-related health monitoring. Work-related health reporting describes sickness absenteeism with respect to selected occupational populations and exposures and thereby provides valuable information pointing to needs in worksite prevention and health promotion. However, despite the routine use, different standards for the keeping, selection and evaluation of data have become established. Furthermore, in Germany there are a great number of statutory health insurances which traditionally were open to certain occupations only. A nationwide work-related health reporting therefore requires methods to account for these differences and to adjust for selective memberships in health insurance institutions. The BKK health report has established a specific standardisation approach which allows analysis with respect to occupations adjusted for economic sectors and vice versa.

Water quality objectives for mixtures of toxic chemicals: problems and perspectives.

The need to develop water quality objectives not only for single substances but also for mixtures of chemicals seems evident. For that purpose, the conceptual basis could be the use of the two existing biometric models: concentration addition (CA) and independent action (IA), which is also called response addition. Both may allow calculation of the toxicity of mixtures of chemicals with similar modes of action (CA) or dissimilar modes of action (IA), respectively. The joint research project Prediction and Assessment of the Aquatic Toxicity of Mixtures of Chemicals (PREDICT) within the framework of the IVth Environment and Climate Programme of the European Commission, provided the opportunity to address (a) chemometric and QSAR criteria to classify substances as supposedly similarly or dissimilarly acting; (b) the predictive values of both models for the toxicity of mixtures at low, statistically nonsignificant effect concentrations of the individual components; and (c) the predictability of mixture toxicity at higher levels of biological complexity. In this article, the general outline, methodological approach, and some preliminary findings of PREDICT are presented. A procedure for classifying chemicals in relation to their structural and toxicological similarities has been developed. The predictive capabilities of CA and IA models have been demonstrated for single species and, to some extent, for multispecies testing. The role of very low effect concentrations in multiple mixtures has been evaluated. Problems and perspectives concerning the development of water quality objectives for mixtures are discussed.

[Routine documentation based on disability data of the legal health insurance]. / Routineberichterstattung auf der Basis von Arbeitsunfähigkeitsmeldungen der Gesetzlichen Krankenversicherung.

Data on sickness absence of employees are routinely used for health reporting and the analysis of work-related morbidity by institutions of the German health insurance. Since the insurance system comprises several different branches, these health reports differ in respect of objectives, data selection, methods of analysis, and presentation of results. A further lack of comparability is caused by the heterogeneous populations, since membership in a certain health insurance depends on social status and job requirements. Aim of this paper was to review the methods and characteristics of health reports as they are routinely published in Germany. By evaluating these reports recommendations should be derived to improve comparability. The review showed that at least four different kinds of health reports should be differentiated: company-based health reports, health reports for business branches, morbidity statistics, and reports from research projects. Such reports have different objectives and therefore require different methods of data analysis. However, group-specific and common standards could be set up and it is suggested that health insurance institutions should work out report guidelines based on the recommendations given in this review.

[Effect of occupationally related stress on diagnosis-specific work incapacity]. / Der Einfluss arbeitsbedingter Belastungen auf das diagnosenspezifische Arbeitsunfähigkeitsgeschehen.

Sickness absence data of approx. 50,000 employees were gathered from the health insurance funds of five companies from the metal processing and retail trade. According to the job characteristics the employees were grouped in 83 different job types. Each job type was accessed with respect to the occurrence of risk factors (70 items). Finally, adjusted relative risks for disease-specific sickness absence were calculated. With respect to all diseases studied "low job control" turned out to be the risk factor highest associated with sickness absence. E.g., for back disorders a relative risk of 4.7 was seen for employees whose jobs were highest characterised by "low job control" compared to employees without. In contrast, relative risks concerning "high job demands" were well below one. In general, associations between physical work bad (e.g. heavy work, vibrations) and sickness absence from various diseases were observed also, but those of psychosocial factors were more consistent and dominant.

[Linking survey data with routine health and accident insurance data]. / Individuenbezogene Zusammenführung von Erhebungsdaten mit Prozessdaten der Kranken- und Unfallversicherung.

Data of the social security institutions, although gathered for administrative purposes, provide important information on work-related morbidity. The validity of the data can be improved by linking several data sources and data from questionnaires or medical examinations. Hence, within the framework of the "Cooperative Programme Occupation and Health" (KOPAG) a specific procedure for data linkage was developed. Data linkage was effected via an anonymous social security number on the one hand, and on the other hand a constructed short number using informations on birthday, sex, and the first letter of the surname of the employees. By means of this short number an average 62% of the questionnaires could be linked to the health insurance sickness leave data. Data linkage was particularly successful (85%) under specific advantageous conditions. Data linkage failed in 25% of all cases because the information necessary to construct the short number was obviously wrong. In general, this procedure to link survey data to routine data of the social security proves suitable for use in routine health reporting.

Evaluation of the isobologram method for the assessment of mixtures of chemicals. Combination effect studies with pesticides in algal biotests.

The aim of this paper is an evaluation of isobolograms, a method proposed for the assessment of combined effects of chemicals. In order to examine potentials and shortcomings of this approach for ecotoxicological purposes, algal biotests with selected pesticidal compounds were performed. Additivity, as defined by the model, is demonstrated for the combination of atrazine and metribuzin for different combination ratios, response levels, and parameters. Subadditivity is shown for amitrole and glufosinate-ammonium. The results and inherent biometrical features are discussed in terms of criteria considered suitable for comparative evaluation of biometrical models for the assessment of mixtures of chemicals.