Abstract
BackgroundGermany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models.MethodsIn Germany’s largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex.ResultsSIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC.ConclusionThe results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.
Highlights
Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided
We chose the federal state of North Rhine-Westphalia (NRW), the largest federal state, for our empirical study as it is the only one with a mix of access models implemented within the same state legislation in a sufficiently large number of municipalities [22]
We have explored the difference in realized access to healthcare among refugees in six municipalities in Germany’s largest federal state of NRW, comparing two currently implemented local access models – electronic health card (eHC) and healthcare voucher (HcV)
Summary
Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Arrived refugees whose asylum claim is still being processed are initially excluded from the SHI Instead, their entitlements are restricted and parallel access models have been implemented. Arrived refugees whose asylum claim is still being processed – subsequently called “refugees” – are explicitly excluded from the SHI in Germany during the first months of their stay (at the time of our study usually 15 months). Instead, they fall under the federal asylum seekers' benefits act (ASBA) according to which their healthcare entitlements are restricted. The only exception is emergency treatment for which no HcV is needed
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