Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system.

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Economic Evaluation of Digital Therapeutic Care Apps for Unsupervised Treatment of Low Back Pain: Monte Carlo Simulation.

BACKGROUND: Digital therapeutic care (DTC) programs are unsupervised app-based treatments that provide video exercises and educational material to patients with nonspecific low back pain during episodes of pain and functional disability. German statutory health insurance can reimburse DTC programs since 2019, but evidence on efficacy and reasonable pricing remains scarce. This paper presents a probabilistic sensitivity analysis (PSA) to evaluate the efficacy and cost-utility of a DTC app against treatment as usual (TAU) in Germany. OBJECTIVE: The aim of this study was to perform a PSA in the form of a Monte Carlo simulation based on the deterministic base case analysis to account for model assumptions and parameter uncertainty. We also intend to explore to what extent the results in this probabilistic analysis differ from the results in the base case analysis and to what extent a shortage of outcome data concerning quality-of-life (QoL) metrics impacts the overall results. METHODS: The PSA builds upon a state-transition Markov chain with a 4-week cycle length over a model time horizon of 3 years from a recently published deterministic cost-utility analysis. A Monte Carlo simulation with 10,000 iterations and a cohort size of 10,000 was employed to evaluate the cost-utility from a societal perspective. Quality-adjusted life years (QALYs) were derived from Veterans RAND 6-Dimension (VR-6D) and Short-Form 6-Dimension (SF-6D) single utility scores. Finally, we also simulated reducing the price for a 3-month app prescription to analyze at which price threshold DTC would result in being the dominant strategy over TAU in Germany. RESULTS: The Monte Carlo simulation yielded on average a €135.97 (a currency exchange rate of EUR €1=US $1.069 is applicable) incremental cost and 0.004 incremental QALYs per person and year for the unsupervised DTC app strategy compared to in-person physiotherapy in Germany. The corresponding incremental cost-utility ratio (ICUR) amounts to an additional €34,315.19 per additional QALY. DTC yielded more QALYs in 54.96% of the iterations. DTC dominates TAU in 24.04% of the iterations for QALYs. Reducing the app price in the simulation from currently €239.96 to €164.61 for a 3-month prescription could yield a negative ICUR and thus make DTC the dominant strategy, even though the estimated probability of DTC being more effective than TAU is only 54.96%. CONCLUSIONS: Decision-makers should be cautious when considering the reimbursement of DTC apps since no significant treatment effect was found, and the probability of cost-effectiveness remains below 60% even for an infinite willingness-to-pay threshold. More app-based studies involving the utilization of QoL outcome parameters are urgently needed to account for the low and limited precision of the available QoL input parameters, which are crucial to making profound recommendations concerning the cost-utility of novel apps.

Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers: results from a cross-sectional survey in Berlin, Germany.

BACKGROUND: Despite a high burden of chronic and mental illness, asylum-seekers show low utilization of ambulatory specialist healthcare. Forgoing timely healthcare when facing access barriers may direct them toward emergency care. This paper examines interrelations of physical and mental health and utilization of ambulatory and emergency care, and explicitly addresses associations between the different types of care. METHODS: A structural equation model was applied to a sample of n = 136 asylum-seekers living in accommodation centers in Berlin, Germany. Utilization patterns of emergency care (outcome) and physical and mental ambulatory care (endogenous predictors) were estimated, while controlling for age, gender, chronic conditions, bodily pain, depression, anxiety, length of stay in Germany (exogenous predictors) and self-rated health (endogenous predictor). RESULTS: Associations were observed between ambulatory care utilization and poor self-rated health (0.207, CI: 0.05; 0.364), chronic illness (0.096, CI: 0.017; 0.175) and bodily pain (0.019, CI: 0.002; 0.036); between mental healthcare utilization and anxiety (0.202, CI: 0.051; 0.352); and between emergency care utilization and poor self-rated health (0.621, CI: 0.059; 1.183), chronic illness (0.287, CI: 0.012; 0.563), mental healthcare utilization (0.842, CI: 0.148; 1.535) and anxiety (0.790, CI: 0.141; 1.438) (values in parentheses show estimated regression coefficients and 95% confidence intervals). We found no associations between the utilization of ambulatory and emergency care. CONCLUSIONS: Our study generates mixed results concerning associations between healthcare needs and ambulatory and emergency care utilization among asylum-seekers. We found no evidence that low utilization of ambulatory care contributes to emergency care utilization; neither did we find evidence that ambulatory treatment obviates the need to seek emergency care. Our results indicate that higher physical healthcare needs and anxiety are associated with more utilization of both ambulatory and emergency care; whereas healthcare needs related to depression tend to remain unmet. Both the undirected and under-utilization of health services may reflect navigation and accessibility issues. To facilitate more needs-based and effective healthcare utilization and thus contribute to health equity, support services such as interpretation and care navigation as well as outreach are warranted.

The role of consumer choice in out-of-pocket spending on health.

BACKGROUND: Analyses of out-of-pocket healthcare spending often suffer from an inability to distinguish necessary from optional spending in the data without making further assumptions. We propose a two-dimensional rating of the spending categories often available in household budget survey data where we consider the requirement to pay for necessary healthcare as one dimension and the incentive to pay extra for additional services, higher quality options or more convenience as a second dimension to assess the distortionary potential of higher spending for additional healthcare or higher quality options. METHODS: We use three waves of a large German Household Budget Survey and decompose the Kakwani-index of total out-of-pocket healthcare spending into contributions of the eleven spending categories available in our data, across which user charge regulations vary considerably. We compute and decompose Kakwani-indexes for the different spending categories to compare the degrees of regressiveness across them. RESULTS: The results suggest that categories with higher incentives for additional spending exhibit smaller contributions to the overall regressive effect of total out-of-pocket spending than categories where spending is presumably mostly on necessary and effective care. CONCLUSIONS: Assessing the consumer choice potential of different spending categories is important because extra spending among the better-off may outweigh necessary spending in aggregate expenditure data, and may also hint at potential inequalities in the quality of provided healthcare.

It probably worked: a Bayesian approach to evaluating the introduction of activity-based hospital payment in Israel.

BACKGROUND: In 2013-2014, Israel accelerated adoption of activity-based payments to hospitals. While the effects of such payments on patient length of stay (LoS) have been examined in several countries, there have been few analyses of incentive effects in the Israeli context of capped reimbursements and stretched resources. METHODS: We examined administrative data from the Israel Ministry of Health for 14 procedures from 2005 to 2016 in all not-for-profit hospitals (97% of the acute care beds). Survival analyses using a Weibull distribution allowed us to examine the non-negative and right-skewed data. We opted for a Bayesian approach to estimate relative change in LoS. RESULTS: LoS declined in 7 of 14 procedures analyzed, notably, in 6 out of 7 urological procedures. In these procedures, reduction in LoS ranged between 11% and 20%. The estimation results for the control variables are mixed and do not indicate a clear pattern of association with LoS. CONCLUSIONS: The decrease in LoS freed resources to treat other patients, which may have resulted in reduced waiting times. It may have been more feasible to reduce LoS for urological procedures since these had relatively long LoS. Policymakers should pay attention to the effects of decreases in LoS on quality of care. Stretched hospital resources, capped reimbursements, retrospective subsidies and underpriced procedures may have limited hospitals' ability to reduce LoS for other procedures where no decrease occurred (e.g., general surgery).

Stroke units, certification, and outcomes in German hospitals: a longitudinal study of patient-based 30-day mortality for 2006-2014.

BACKGROUND: Treatment of stroke patients in stroke units has increased and studies have shown improved outcomes. However, a large share of patients in Germany is still treated in hospitals without stroke unit. The effects of stroke unit service line, and total hospital quality certification on outcomes remain unclear. METHODS: We employ annual hospital panel data for 1100-1300 German hospitals from 2006 to 2014, which includes structural data and 30-day standardized mortality. We estimate hospital- and time-fixed effects regressions with three main independent variables: (1) stroke unit care, (2) stroke unit certification, and (3) total hospital quality certification. RESULTS: Our results confirm the trend of decreasing stroke mortality ratios, although to a much lesser degree than previous studies. Descriptive analysis illustrates better stroke outcomes for non-certified and certified stroke units and hospitals with total hospital quality certification. In a fixed effects model, having a stroke unit has a significant quality-enhancing effect, lowering stroke mortality by 5.6%, while there is no significant improvement effect for stroke unit certification or total hospital quality certification. CONCLUSIONS: Patients and health systems may benefit substantially from stroke unit treatment expansion as installing a stroke unit appears more meaningful than getting it certified or obtaining a total hospital quality certification. Health systems should thus prioritize investment in stroke unit infrastructure and centralize stroke care in stroke units. They should also prioritize patient-based 30-day mortality data as it allows a more realistic representation of mortality than admission-based data.

Can people afford to pay for health care? New evidence on financial protection in Germany

The incidence of catastrophic health spending is quite low in Germany compared to many countries in Europe. This reflects high levels of public spending on health, and health coverage policy carefully designed to protect children and regular users of health care from co-payments. Catastrophic spending on health is concentrated among older people and people in households whose main source of income is social benefits. The drivers of financial hardship are dental care on average, and both dental care and outpatient medicines among the poorest households. The introduction of an income-related cap on co-payments in 2004 and the abolition of co-payments for outpatient visits in 2012 have been important protective measures. The results of this analysis suggest that more could be done to protect poor households, however, and to reduce the financial hardship associated with dental care. Options include exempting low-income households from co-payments and making the cap less bureaucratic. This review is part of a series of country-based studies generating new evidence on financial protection in European health systems.

Developing a composite index of spatial accessibility across different health care sectors: A German example.

The evolving lack of ambulatory care providers especially in rural areas increasingly challenges the strict separation between ambulatory and inpatient care in Germany. Some consider allowing hospitals to treat ambulatory patients to tackle potential shortages of ambulatory care in underserved areas. In this paper, we develop an integrated index of spatial accessibility covering multiple dimensions of health care. This index may contribute to the empirical evidence concerning potential risks and benefits of integrating the currently separated health care sectors. Accessibility is measured separately for each type of care based on official data at the district level. Applying an Improved Gravity Model allows us to factor in potential cross-border utilization. We combine the accessibilities for each type of care into a univariate index by adapting the concept of regional multiple deprivation measurement to allow for a limited substitutability between health care sectors. The results suggest that better health care accessibility in urban areas persists when taking a holistic view. We believe that this new index may provide an empirical basis for an inter-sectoral capacity planning.

Longitudinal analysis of income-related health inequalities: methods, challenges and applications.

Socioeconomic inequalities in health are an important research area in health economics and public health. The concentration index has become a well-established measure of income-related health inequalities, and a number of approaches to identify potential causes of health inequalities exist. With the increasing availability of suitable longitudinal data, more sophisticated approaches to monitor inequalities and to identify potential causal relationships between socioeconomic status and health evolved. We first review the concentration index and some more basic approaches to explain health inequalities. We then discuss advantages and potential shortcomings of "static" and "dynamic" health inequality measures. We review different concepts of health and socioeconomic mobility, as well as recent studies on the life course perspective and economic changes. Our aim is to provide an overview of the concepts and empirical methodologies in the current literature, and to guide interested researchers in their choice of an appropriate inequality measure.

Correlation of Incident Potentially Inappropriate Medication Prescriptions and Hospitalization: An Analysis Based on the PRISCUS List.

BACKGROUND: Multimorbidity and polypharmacy represent a major problem for elderly patients. Potentially inappropriate medication (PIM) use is highly prevalent among the elderly. PIMs are considered high-risk drugs and are suspected to be responsible for adverse drug events (ADEs) leading to hospitalization. OBJECTIVE: The objective of this study was to determine hospitalization rates related to selected ADEs in elderly patients with an incident prescription of a PIM as defined by the PRISCUS list. A second objective was to identify other factors independently associated with hospitalization. METHODS: We retrospectively analysed a full census of pharmaceutical claims, from one of the largest public sickness funds in Germany, for 647,073 patients aged ≥65 years in 2010, the year of publication of the PRISCUS list. Patients who received an incident PIM in 2010 were assigned to the intervention group. Propensity score matching was used to build a control group of patients at a comparable risk level who received an incident equivalent non-PIM. The risk of hospitalization due to PIM prescription was estimated via the odds ratio (OR). Risk factors were analysed via logistic regression models. RESULTS: The results showed significantly more ADEs in the PIM group. The OR for hospitalization was 1.54 [95 % confidence interval (CI) 1.23-1.93] for patients receiving any PIM compared with those who received a non-PIM. This trend remained stable [OR 1.46 (95 % CI 1.16-1.84)] after adjustment for relevant covariates in the logistic regression models showing ORs for each risk factor. Besides PIMs, common risk factors such as greater age, comorbidity and specific drug classes were significantly responsible for hospitalization. CONCLUSION: PIMs (as defined by the PRISCUS list) are associated with high rates of ADEs associated with hospitalization. Our study suggests that PIM reduction may result in a lower risk of hospitalization in the elderly.

Individual Income, Area Deprivation, and Health: Do Income-Related Health Inequalities Vary by Small Area Deprivation?

This paper aims to explore potential associations between health inequalities related to socioeconomic deprivation at the individual and the small area level. We use German cross-sectional survey data for the years 2002 and 2006, and measure small area deprivation via the German Index of Multiple Deprivation. We test the differences between concentration indices of income-related and small area deprivation related inequalities in obesity, hypertension, and diabetes. Our results suggest that small area deprivation and individual income both yield inequalities in health favoring the better-off, where individual income-related inequalities are significantly more pronounced than those related to small area deprivation. We then apply a semiparametric extension of Wagstaff's corrected concentration index to explore how individual-level health inequalities vary with the degree of regional deprivation. We find that the concentration of obesity, hypertension, and diabetes among lower income groups also exists at the small area level. The degree of deprivation-specific income-related inequalities in the three health outcomes exhibits only little variations across different levels of multiple deprivation for both sexes.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany.

BACKGROUND: The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES). METHODS: The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity. RESULTS: We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12-1.64) as well as for obesity (OR 1.14; 95% CI 1.02-1.26). Further analyses showed that these associations were relatively similar for both men and women. CONCLUSIONS: Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Risk factors for the prescription of potentially inappropriate medication (PIM) in the elderly : an analysis of sickness fund routine claims data from Germany.

Elderly people are especially prone to suffer adverse drug reactions (ADR). Main reasons for the higher vulnerability of the elderly to ADR are changes in metabolism as i.e. slower renal clearance and polypharmacie which often results from multimorbidity. To prevent ADR careful prescription with special consideration of these aspects is warranted. To help physicians avoid drugs which are especially likely to cause ADR lists have been developed following the consensus method process. For Germany this list is called the PRISCUS list. It was developed based on a literature review, review of international lists such as the American Beers list, and a consensus process based on a Delphi survey. It contains 83 drugs from 18 classes which are classified as potentially inapropriate medication (PIM). It also lists alternatives for each PIM. If a drug is registered with the PRISCUS list this does not mean automatically that it is contraindicated in the elderly but that special caution should be excercised in prescribing the drug, alternatives should be considered and the patient carefully monitored.Prescription rates for PIMs in Germany in the elderly is pretty much stable at around 23% with only a small decline in the past years. Also, more than 5% of all prescriptions in the elderly are PIM prescriptions. Physicians specially trained in geriatrics tend to prescribe less PIMs compared to other physicians.

Examining regional variation in the use of cancer screening in Germany.

The detection of cancer in its early latent stages can improve a patient's chances of recovery and thereby reduce the overall burden of the disease. Cancer screening services are, however, only used by a small part of the population and utilization rates vary widely amongst the 402 German districts. This study examines to which extent geographic variation in the use of cancer screening can be explained by accessibility of these services and by spillover effects between adjacent areas, while controlling for a wide range of covariates. District level data on cancer screening utilization rates were calculated for breast, cervical, prostate, skin, and colorectal cancers using German data provided by the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung - KBV) between 2008 and 2011. We estimated the impact of health service variables on cancer screening utilization using spatial and non-spatial regression models. Spatial autocorrelation in the residuals was estimated using Moran's I statistic. After controlling for socioeconomic and other regional covariates, screening rates for breast, prostate, skin, and colorectal cancers are significantly higher in areas with higher physician density. The utilization of Pap-tests, skin cancer screening and colonoscopies is inversely related with average travel time to physicians. The coefficients for the spatial lag are significant and positive in all models. The positive spatial lags indicate that screening utilization rates are determined by knowledge spillovers between neighboring districts. In terms of public policy, our study demonstrates the potential to increase the use of cancer screening services through improving knowledge regarding cancer screening and by ensuring patient access to cancer screening services.

From a conservative to a liberal welfare state: decomposing changes in income-related health inequalities in Germany, 1994-2011.

Individual socio-economic status and the respective socio-economic and political contexts are both important determinants of health. Welfare regimes may be linked with health and health inequalities through two potential pathways: first, they may influence the associations between socio-economic status and health. Second, they may influence the income-related distributions of socio-economic determinants of health within a society. Using the Socio-Economic Panel (SOEP) for the years 1994-2011, we analyze how income-related health inequalities evolved in the context of the transformation from a conservative to a liberal welfare system in Germany. We use the concentration index to measure health inequalities, and the annual concentration indices are decomposed to reveal how the contributions of the explanatory variables age, sex, income, education, and occupation changed over time. The changes in the contributions are further decomposed to distinguish whether changes in health inequalities stem from redistributions of the explanatory variables, from changes in their associations with health, or from changes in their means. Income-related health inequalities to the disadvantage of the economically deprived roughly doubled over time, which can largely be explained by changes in the contributions of individual characteristics representing weaker labor market positions, particularly income and unemployment. The social and labor market reforms coincide with the observed changes in the distributions of these characteristics and, to a lesser extent, with changes of their associations with health.

Semiparametric modeling of age-specific variations in income related health inequalities.

A Gini-type concentration index is combined with semiparametric estimation techniques to derive a varying inequality index that works without a priori sample stratification. The new approach is used to investigate the question how income inequalities and income-related gradients in the distribution of health vary across age groups. With health data from the 2005 survey of the German microcensus, it is demonstrated that significant inequalities to the detriment of the deprived evolve in early mid-life and reach their maximum around the age for retirement. Some leveling is found for the elderly.

Measuring age-specific variations in income-related inequalities in smoking behavior in Germany.

Although monitoring smoking behavior is considered as most important to tackle the smoking epidemic, empirical evidence concerning age-specific variations of its income-related inequalities still seems scarce. This paper uses a semiparametric extension of the concentration index to measure age-specific variations of income-related inequalities in smoking behavior. First, current smoking is used to describe peoples' actual smoking status. Second, ever-smoking is included to approximate how inequalities in smoking behavior changed with the evolution of the smoking epidemic. Finally, smoking cessation is considered to indicate an individual's ability to conquer the habit. Cross-sectional data from the 2009 survey of the German microcensus reveal that current smoking is most prevalent among adolescents and young adults, more common among the worse-off in younger age groups and concentrated among the better-off in older age groups. Concentration of ever-smoking among the economically deprived is only found for younger adults. Smoking cessation is more common among higher income ever-smokers in all age groups. One may deduce from these results that anti-smoking policies should particularly aim at younger individuals in lower-income households.

On age-specific variations in income-related inequalities in diabetes, hypertension and obesity.

OBJECTIVE: This article examines whether the social health gradients in diabetes, hypertension and obesity for men and women vary significantly across different age groups. METHODS: We use a pooled sample of German survey data from the years 2002 and 2006 with a total of 87,601 observations. We employ a varying Wagstaff index derived from the class of Gini-type concentration indices to estimate age-specific income-related health inequalities. RESULTS: We find significant health disadvantages among poor women in mid-age, but no significant age-specific income-related health inequalities among men. Some leveling of inequalities in diabetes is observed. CONCLUSIONS: The results suggest that variations in age-specific inequalities are unlikely to be a purely artificial result of health-related selection into retirement or mortality.

Scalar generalized nonlinear Schrödinger equation-quantified continuum generation in an all-normal dispersion photonic crystal fiber for broadband coherent optical sources.

We quantitatively predict the observed continuum-like spectral broadening in a 90-mm weakly birefringent all-normal dispersion-flattened photonic crystal fiber pumped by 1041-nm 229-fs 76-MHz pulses from a solid-state Yb:KYW laser. The well-characterized continuum pulses span a bandwidth of up to 300 nm around the laser wavelength, allowing high spectral power density pulse shaping useful for various coherent control applications. We also identify the nonlinear polarization effect that limits the bandwidth of these continuum pulses, and therefore report the path toward a series of attractive alternative broadband coherent optical sources.

Few-cycle oscillator pulse train with constant carrier-envelope- phase and 65 as jitter.

We report on an octave-spanning Ti:sapphire laser oscillator stabilized to carrier-envelope-offset frequency zero, generating a pulse train with constant field profile for every pulse. Stabilization is realized using an extended self-referenced locking scheme enabling to lock the carrier envelope-offset phase with less than 65 attosecond rms timing jitter. The stabilized system features a pulse repetition rate of 100 MHz with pulses as short as 4.5 fs and 220 mW average output power. With this laser system it was possible for the first time to demonstrate a spectral interference pattern of 1011 oscillator pulses in an out-of-loop f-to-2f-interferometer.