German Social Health Insurance Research Articles

Value-based pricing of cognitive behavioral therapy for depression in primary care: an economic evaluation

ObjectivesValue-based pricing (VBP) determines product prices based on their perceived benefits. In healthcare, VBP prices medical technologies considering health outcomes and other relevant factors. This study applies VBP using economic evaluation to provider-patient communication, taking cognitive behavioral therapy (CBT) for adult primary care patients with depressive disorders as a case study.MethodsA 12-week decision-tree model was developed from the German social health insurance system’s perspective, comparing CBT against the standard of care. The influence of an extended time horizon on VBP was assessed using a theoretical model and long-term data spanning 46 months.ResultsUsing a willingness-to-pay threshold of €88,000 per quality-adjusted life year gained, the base-case 50-minute compensation rate for CBT was €45. Assuming long-term effects of CBT significantly affected the value-based compensation, increasing it to €226.ConclusionsThis study showcases the potential of applying VBP to CBT. However, significant price variability is highlighted, contingent upon assumptions regarding CBT’s long-term impacts.

The price of curing cancer

BackgroundHealth care systems around the world struggle with high prices for new cancer drugs. The purpose of this study was to conduct a gedankenexperiment and calculate how much health expenditures would change if a cure for cancer through pharmaceutical treatment were made available. The cancer cure was conceived to eliminate both cancer deaths and the underlying morbidity burden of cancer. Furthermore, the cure was hypothesized to arrive in incremental steps but at infinitesimally small time intervals (resulting, effectively, in an immediate cure).MethodsThe analysis used secondary data and was conducted from the viewpoint of the German social health insurance. As its underlying method, it used a cause-elimination life-table approach. To account for the age distribution of the population, the study weighted age-specific increases in remaining life expectancy by age-specific population sizes. It considered drug acquisition costs as well as savings and life extension costs from eliminating cancer. All cancer drugs that underwent a mandatory early benefit assessment in Germany between 2011 and 2015/16 and were granted an added benefit were included. Data on age- and gender-specific probabilities of survival, population sizes, causes of death, and health expenditures, as well as data on cancer costs were taken from the German Federal Office of Statistics and the German Federal Social Insurance Office.ResultsBased on the cause-elimination life-table approach and accounting for the age structure of the German population, curing cancer in Germany yields an increase in average remaining life expectancy by 2.66 life years. Based on the current incremental cost-effectiveness ratio of new cancer drugs, which is on average €101,493 per life year gained (€39,751/0.39 life years), the German social health insurance would need to pay €280,497 per insuree to eliminate cancer. Dividing this figure by current average remaining lifetime health expenditures yields a ratio of 2.07, which represents a multiplier of current health expenditures.ConclusionsEliminating cancer at current price levels would more than triple total health expenditures in Germany. As the current price of a cure requires a drastic reduction of non-health consumption, it appears that current prices for cancer drugs already on the market (i.e., small steps towards a cure) need careful reconsideration.

Moral Hazard and Market Capacity: Evidence from a Natural Experiment in Germany

It is well known that health insurance coverage increases the demand for health services. However, evidence on the effects of this increased demand on the structure and capacity of the health services market is relatively scarce. We analyze the effects of a reform in the German social health insurance system which caused exogenous variation in coverage for services across different geographic regions. A formal model predicts that the reform led to an immediate decline in demand for services and that it decreased the market capacity in the long run. Our empirical analysis provides strong support for these predictions. We show that the reform was welfare improving under standard assumptions and discuss possible market frictions which could weaken or reverse these conclusions about welfare. Our study informs the ongoing policy debate about the effects of insurance coverage on the societal costs for health care.

Indicators for Measuring Intergenerational Fairness of Social Security Systems—The Case of the German Social Health Insurance

The issue of fiscal sustainability is often labelled as a synonym for intergenerational fairness; however, pay-as-you-go schemes such as the German Social Health Insurance (SHI) involve a “natural” amount of intergenerational redistribution from younger net payers to older net beneficiaries. We calculate intertemporal balance sheets of SHI and compare two generational accounting approaches (GAC and GAIB) with an alternative measure of intergenerational fairness, SM, which we derive from Settergren and Mikula (2005). Our results indicate that the SM concept leads to similar implications concerning the amount of intergenerational redistribution as classical measures of fiscal sustainability. For the SM approach, the balance sheet of SHI shows a rate of unfunded benefits of 25 percent. Closing this gap requires an increase of the contribution rate by 30 to 40 percent. This total effect can be separated into an effect due to the current population structure (10 p.p.), the increase in life expectancy (10 p.p.), and medical technical progress (about 10 to 20 p.p.).

Cost-effectiveness of FOLFIRI + cetuximab vs FOLFIRI + bevacizumab in the first-line treatment of RAS wild-type metastatic colorectal cancer in Germany: data from the FIRE-3 (AIO KRK-0306) study

Aims: This analysis evaluates the cost-effectiveness of first-line treatment with FOLFIRI + cetuximab vs FOLFIRI + bevacizumab for patients with RAS wild-type (wt) metastatic colorectal cancer (mCRC) in Germany based on the randomized phase 3 FIRE-3 trial. For patients with RAS wt mCRC, FOLFIRI + cetuximab yielded statistically significant median overall survival gains over FOLFIRI + bevacizumab.Materials and methods: A standard 3-state partitioned survival cost-utility model was developed to compare the health benefits and costs of treatment from a German social health insurance perspective using individual patient–level trial data. Health outcomes were reported in life-years (LYs) and quality-adjusted life-years (QALYs) gained. Survival was estimated based on Kaplan-Meier (KM) curves supplemented with best-fitting parametric survival model extrapolations. Subgroup analyses of patients with a left-sided primary tumor location or patients with metastases confined to the liver were performed.Results: In the modified intention-to-treat analysis, FOLFIRI + cetuximab, providing 0.68 additional LYs (0.53 QALYs), yielded incremental cost-effectiveness ratios (ICERs) of €36,360/LY and €47,250/QALY. In subgroup analyses, patients experienced improved survival gains without a corresponding increase in costs, resulting in lower ICERs. Our model was most sensitive to changes in treatment duration across all lines of therapy, utility of progressive disease, as well as patients’ weight and body surface area.Limitations: This cost-effectiveness analysis was based on patient-level data from the FIRE-3 trial. Trial outcomes may not adequately reflect those in the real-world setting. Additionally, resource use and costs were obtained from tariff lists, which do not account for differences in treatment practice. These considerations limit generalizability of outcomes to other countries, or within the German healthcare setting.Conclusions: Based on our analyses, FOLFIRI + cetuximab is cost-effective compared with FOLFIRI + bevacizumab in patients with RAS wt mCRC, with ICERs well below willingness-to-pay thresholds for diseases with a high burden.

Increased instruction time and stress-related health problems among school children

While several studies suggest that stress-related mental health problems among school children are related to specific elements of schooling, empirical evidence on this causal relationship is scarce. We examine a German schooling reform that increased weekly instruction time and study its effects on stress-related outpatient diagnoses from the universe of health claims data of the German Social Health Insurance. Exploiting the differential timing in the reform implementation across states, we show that the reform slightly increased stress-related health problems among school children. While increasing instruction time might increase student performance, it might have adverse effects in terms of additional stress.

Increased Instruction Time and Stress-Related Health Problems among School Children

While several studies suggest that stress-related mental health problems among school children are related to specific elements of schooling, empirical evidence on this causal relationship is scarce. We examine a German schooling reform that increased weekly instruction time and study its effects on stress-related outpatient diagnoses from the universe of health claims data of the German Social Health Insurance. Exploiting the differential timing in the reform implementation across states, we show that the reform slightly increased stress-related health problems among school children. While increasing instruction time might increase student performance, it might have adverse effects in terms of additional stress.

Increased Instruction Time and Stress-Related Health Problems Among School Children

While several studies suggest that stress-related mental health problems among school children are related to specific elements of schooling, empirical evidence on this causal relationship is scarce. We examine a German schooling reform that increased weekly instruction time and study its effects on stress-related outpatient diagnoses from the universe of health claims data of the German Social Health Insurance. Exploiting the differential timing in the reform implementation across states, we show that the reform slightly increased stress-related health problems among school children. While increasing instruction time might increase student performance, it might have adverse effects in terms of additional stress.

Adapting Pharmacoeconomics to Shape Efficient Health Systems en Route to UHC - Lessons from Two Continents.

Background: Pharmacoeconomics is receiving increasing attention globally as a set of tools ensuring efficient use of resources in health systems, albeit with different applications depending on the contextual, cultural and development stages of each country. The factors guiding design, implementation and optimisation of pharmacoeconomics as a steering tool under the universal health coverage paradigm are explored using case studies of Germany and South Africa.Findings: German social health insurance is subject to the efficiency precept. Pharmaco-regulatory tools reflect the respective framework conditions under which they developed at particular points in time. The institutionalization and integration of pharmacoeconomics into the remit of the Institute for Quality and Efficiency in Health Care occurred only rather recently. The road has not been smooth, requiring political discourse and complex processes of negotiation. Although enshrined in the National Drug Policy, South Africa has had a more fragmented approach to medicine selection and pricing with different policies in private and public sectors. The regulatory reform for use of pharmacoeconomic tools is ongoing and will be further shaped by the introduction of National Health Insurance.Conclusion: A clear vision or framework is essential as the regulatory introduction of pharmacoeconomics is not a single event but rather a growing momentum. The path will always be subject to influences of politics, economics and market forces beyond the healthcare system so delays and modifications to pharmacoeconomic tools are to be expected. Health systems are dynamic and pharmacoeconomic reforms need to be sufficiently flexible to evolve alongside.

Cost-effectiveness of timely versus delayed primary total hip replacement in Germany: A social health insurance perspective.

Without clinical guideline on the optimal timing for primary total hip replacement (THR), patients often receive the operation with delay. Delaying THR may negatively affect long-term health-related quality of life, but its economic effects are unclear. We evaluated the costs and health benefits of timely primary THR for functionally independent adult patients with end-stage osteoarthritis (OA) compared to non-surgical therapy followed by THR after progression to functional dependence (delayed THR), and non-surgical therapy alone (Medical Therapy), from a German Social Health Insurance (SHI) perspective. Data from hip arthroplasty registers and a systematic review of the published literature were used to populate a tunnel-state modified Markov lifetime model of OA treatment in Germany. A 5% annual discount rate was applied to costs (2013 prices) and health outcomes (Quality Adjusted Life Years, QALY). The expected future average cost of timely THR, delayed THR and medical therapy in women at age 55 were €27,474, €27,083 and €28,263, and QALYs were 20.7, 16.7, and 10.3, respectively. QALY differences were entirely due to health-related quality of life differences. The discounted cost per QALY gained by timely over delayed (median delay of 11 years) THR was €1270 and €1338 in women treated at age 55 and age 65, respectively, and slightly higher than this for men. Timely THR is cost-effective, generating large quality of life benefits for patients at low additional cost to the SHI. With declining healthcare budgets, research is needed to identify the characteristics of those able to benefit the most from timely THR.

Comparative Effectiveness of Adalimumab versus Secukinumab for the Treatment of Psoriatic Arthritis: A Matching-Adjusted Indirect Comparison.

IntroductionThe Phase III FUTURE I and II trials demonstrated the clinical efficacy of secukinumab in active psoriatic arthritis (PsA). In the absence of head-to-head trials, this study compared the clinical efficacy and cost effectiveness of adalimumab 40 mg versus secukinumab 150 and 300 mg for the treatment of active PsA.MethodsA matching-adjusted indirect comparison was conducted using individual patient data from the ADEPT trial of adalimumab and published data from FUTURE I and II. To adjust for the cross-trial differences, individual patients in ADEPT were re-weighted so that the mean baseline characteristics (including age, weight, gender, race, baseline methotrexate use, psoriasis ≥3% body surface area, baseline PASI score, presence of dactylitis and enthesitis, and HAQ-DI) matched those in the FUTURE trials. Response rates relative to placebo and incremental costs per responder (CPR) over 24 weeks for ACR 20/50/70 and PASI 75/90 were compared between adalimumab and secukinumab 150 and 300 mg from the German social health insurance (SHI) perspective.ResultsAfter matching, mean baseline characteristics were balanced across the ADEPT and the FUTURE I and II populations. The mean differences between adalimumab and secukinumab 150 mg in relative ACR 20/50/70 and PASI 75/90 response rates were 9.5, 3.0, 6.0, 13.1, and 6.7%, respectively (p > 0.05 for all comparisons). Post-match relative ACR 20/50/70 and PASI 75 to placebo were also higher with adalimumab compared to secukinumab 300 mg. Adalimumab had lower incremental costs per responder over 24 weeks for all outcomes compared with secukinumab 150 and 300 mg.ConclusionsIn the absence of direct comparisons between adalimumab and secukinumab, this study provides valuable and reliable evidence for physicians and payers. After adjusting for cross-trial differences in baseline characteristics, adalimumab was associated with higher relative ACR and PASI rates and lower incremental CPRs compared with secukinumab 150 mg or 300 mg at week 24 among patients with active PsA.FundingAbbVie.

An Econometric Model of Healthcare Demand With Nonlinear Pricing.

From 2004 to 2012, the German social health insurance levied a co-payment for the first doctor visit in a calendar quarter. We develop a new model for estimating the effect of such a co-payment on the individual number of visits per quarter. The model combines a one-time increase in the otherwise constant hazard rate determining the timing of doctor visits with a difference-in-differences strategy to identify the reform effect. An extended version of the model accounts for a mismatch between reporting period and calendar quarter. Using data from the German Socio-Economic Panel, we do not find an effect of the co-payment on demand for doctor visits. Copyright © 2016 John Wiley & Sons, Ltd.

An Econometric Model of Health Care Demand with Non-Linear Pricing

From 2004 to 2012, the German social health insurance levied a co-payment for the first doctor visit in a calendar quarter. We develop a new model for estimating the effect of such a co-payment on the individual number of visits per quarter. The model allows for a one time increase in the otherwise constant hazard rate determining the timing of doctor visits, and uses a difference-in-differences strategy to identify the reform effect. The model can be adapted to a situation where the reporting period and the calendar quarter differ. Using data from the German Socio-Economic Panel, we do not find an effect of the co-payment on demand for doctor visits.

An econometric model of health care demand with non-linear pricing

From 2004 to 2012, the German social health insurance levied a co-payment for the first doctor visit in a calendar quarter. We develop a new model for estimating the effect of such a co-payment on the individual number of visits per quarter. The model allows for a one time increase in the otherwise constant hazard rate determining the timing of doctor visits, and uses a difference-in-differences strategy to identify the reform effect. The model can be adapted to a situation where the reporting period and the calendar quarter differ. Using data from the German Socio-Economic Panel, we do not find an effect of the co-payment on demand for doctor visits.

The Price Sensitivity of Health Plan Choice among Retirees: Evidence from the German Social Health Institute

We investigate two determinants of the price sensitivity of health plan demand: the size of the choice set and the salience of premium differences. Using variation in both features in the German Social Health Insurance (SHI) and information on health plan switches of retirees in the German Socio Economic Panel, augmented with information on individuals’ choice sets we find that retirees react less to potential savings from switching when they have more plans to choose from and when differences between premiums are less salient. Simplifying choices could save consumers money and improve the functioning of the health insurance market.

Health care costs in the elderly in Germany: an analysis applying Andersen’s behavioral model of health care utilization

BackgroundTo analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen’s behavioral model of health care utilization, in the German elderly population.MethodsUsing a cross-sectional design, cost data of 3,124 participants aged 57–84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents’ homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models.ResultsMean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs.ConclusionsMultimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.

PCV36 Increasing Costs for German Social Health Insurance (SHI) Funds by Abandonment of Pentaerithrityltetranitrat (PETN) for Patients With Coronary Heart Disease (CHD)? – A Cost Analysis Based on Sick Fund Data

PCV36 Increasing Costs for German Social Health Insurance (SHI) Funds by Abandonment of Pentaerithrityltetranitrat (PETN) for Patients With Coronary Heart Disease (CHD)? – A Cost Analysis Based on Sick Fund Data

The Exit Behavior of Doctors Under Conditions of Increasing Regulation in England and Germany - A Comparative Case Study of Service Providers in Most Different Healthcare Systems

The present study examines how one of the main actors and key stakeholders in healthcare systems – doctors – have reacted to changing regulatory environments by engaging in exit behavior in two most different systems for comparison: the English National Health Service and the German Social Health Insurance system. Our period of observation covers the early 1990s up to 2011, which represents a period of major reform for both cases. The underlying assumption tested is that within an environment of increasing regulation in which reforms adversely affect the conditions for remuneration and professional autonomy of providers, doctors will be found to progressively exit the medical profe ssion and/or respective healthcare system. Our findings establish a strong role for regulation in conditioning the exit behavior of doctors. However, this role need not be a negative one, as we find that where regulation improves particularly the conditions for remuneration, exit decreases and supply increases. Results also point to the necessity in differentiating amongst the effects of reforms on specific doctor-groups; considering the role of gender; as well as distinguishing amongst specific forms of regulation and types of exit.

Morbiditätsorientierter Risikostrukturausgleich

Numerous health systems have introduced competition between health plans while banning risk-rated premiums. Risk adjustment for health plans is introduced to reduce incentives for risk selection and to create incentives for health plans to permanently invest in care for the chronically ill. According to the international health economics state of the art, risk adjustment in the German social health insurance system has used information on health status (measured by diagnoses and drug prescriptions) on top of demographic information since 2009. In non-competitive health care systems similar mechanisms are sometimes established, e.g. to achieve an equitable distribution of resources between regions. An evaluation of the first year of health-based risk adjustment demonstrates a superior performance in comparison to the old, demographic risk adjustment. The old risk adjustment formula (without ex post high-cost pooling) showed R(2) of 5.8%, CPM of 10.4% and MAPE of 2,226 €, in contrast to the new health status-based risk adjustment formula (without cash benefit for sick allowance) which reaches R(2) 20.2%, CPM 22.5% and MAPE 1,817 €. However, to make competition between health plans functional for improvement of quality and efficiency of health care, health plans must be granted additional instruments to act as prudent buyers of health care.

Medical care of type 2 diabetes in German Disease Management Programmes: a population‐based evaluation

Type 2 diabetes disease management programmes (DDMPs) are offered by German social health insurance to promote healthcare consistent with evidence-based medical guidelines. The aim of this study was to compare healthcare quality and medical endpoints between diabetes management programme participants and patients receiving usual care designated as controls. All patients with type 2 diabetes (age range: 36-81) in a cross-sectional survey of a cohort study, performed by the Cooperative Health Research in the Region of Augsburg, received a self-administered questionnaire regarding their diabetes care. Physical examination and laboratory tests were also performed. The analysis only included patients with social health insurance and whose participation status in a diabetes disease management program was validated by the primary physician (n = 166). Regression analyses, adjusting for age, sex, education, diabetes duration, baseline waist circumference and clustering regarding primary physician were conducted. Evaluation of healthcare processes showed that those in diabetes disease management programmes (n = 89) reported medical examination of eyes and feet and medical advice regarding diet [odds ratio (OR): 2.39] and physical activity (OR: 2.87) more frequently, received anti-diabetic medications (OR: 3.77) and diabetes education more often (OR: 2.66) than controls. Both groups had satisfactory HbA(1c) control but poor low-density lipoprotein cholesterol control. Blood pressure goals (<140/90 mmHg) were achieved more frequently by patients in diabetes disease management programmes (OR: 2.21). German diabetes disease management programmes are associated with improved healthcare processes and blood pressure control. Low-density lipoprotein cholesterol control must be improved for all patients with diabetes. Further research will be required to assess the long-term effects of this diabetes disease management programme.