Health Insurance Funds In Germany Research Articles

Quo Vadis, Techniker Krankenkasse?

In January, the Techniker Krankenkasse (TK, a statutory health insurance fund in Germany), in collaboration with the Verband der Ersatzkassen (association of substitute health insurance schemes) and the statutory health insurer for North-Rhine (Kassenarztliche Vereinigung Nordrhein, KV) issued a joint press statement regarding the high quality of the disease management programs (DMP) in North-Rhine and the ensuing benefits for patients. Now, an original research article appears, “The Benefit and Efficiency of the Disease Management Program for Type 2 Diabetes,” which was submitted to Deutsches Arzteblatt on 29 July 2010 and published in the issue of 11 March 2011. The article’s key message is that the study does not reveal any clear medical benefit from DMP participation. Closer reading of this original article reveals multiple inconsistencies that substantially limit the meaningfulness of the article. What would make sense is a prospective analysis over several years or even decades, and not a retrospective analysis over two years (2007/2008). The inclusion criterion of registering a patient for a further DMP also throws up questions. In addition to so called hard end points, data on newly occurring typical comorbidities were collected and treatment successes in terms of adhering to standard values were used for the assessment. With regard to this the observation period is insufficiently long and using adherence to normal values is a pointless reflection of surrogate parameters. Hard end points regarding mortality over a long observational period would be required in this setting. Although, as the authors themselves cite, the statistical tests (Chi square test and Mann-Whitney U test) are not valid in their application after the so called matching, they were still used to assess the results. The point and purpose of this publication remains speculative and does not seem to serve any medical benefit. If the TK were systematic in its approach, it would have to cancel its participation in the DMP for type 2 diabetes (T2DM), but it might lose face in the eyes of the insurance scheme members by cutting preventive healthcare services..

Diabetes prevalence based on health insurance claims: large differences between companies

We investigated if there are substantial differences in the prevalence of diabetes between members of different health insurance funds in Germany and, if so, which variables might explain these differences. Ten representative surveys (conducted between 2004 and 2008) of the Bertelsmann Healthcare Monitor, comprising 15 089 participants aged 18-79 years, were analysed. Our main independent variable was membership in one of eight health insurance funds. We first estimated the crude prevalence of diabetes stratified by these funds. We further fitted logistic regression models and stepwise adjusted for age and sex, further co-morbidities and anthropometric measures and factors influencing health awareness and lifestyle. The overall prevalence of diabetes was 6.9%. Stratified by health insurance funds, prevalences ranged between 3.9% within the Innungskrankenkassen to 11.4% within the Allgemeine Ortskrankenkassen. Adjusting for age and sex only led to minor changes. After controlling for all mentioned variables, these differences remained. Compared with those who were privately insured, persons within the Allgemeine Ortskrankenkassen (OR 1.73; 95% CI 1.30-2.29), the Betriebskrankenkassen (OR 1.54; 95% CI 1.15-2.07) and the Barmer (OR 1.39; 95% CI 1.01-1.91) had a higher prevalence. We found considerable differences in diabetes prevalence between German health insurance funds that remained after controlling for several relevant variables.

Unterschiede in der Versichertenstruktur von Krankenkassen und deren Auswirkungen für die Versorgungsforschung: Ergebnisse des Bertelsmann-Gesundheitsmonitors

Claims data of health insurance companies are an important database for health services research. We investigated if there are differences in baseline characteristics and prevalence of chronic diseases between members of several health insurance funds in Germany, and if so, whether adjusting for age and sex could explain these differences. 10 representative surveys (conducted between 2004 and 2008) of the 'Bertelsmann Health-Care Monitor' comprising 15 089 participants aged 18 to 79 years were analysed. Our main independent variable was membership in one of 8 health insurance funds. The prevalence of self-reported hypertension, diabetes, atopic diseases, coronary heart disease and heart failure was studied. We first estimated the crude prevalence of chronic diseases stratified by these funds. We further fitted logistic regression models and adjusted for age and sex as well as for further comorbidities and health related factors. Most respondents were insured in the BKK (Betriebskrankenkassen; 20.1%), the AOK (Allgemeinen Ortskrankenkassen; 19.2%) and private health insurances (15.3%). Substantial differences were found according to age, sex, educational level and prevalences of chronic diseases. Stratified by health insurance funds, prevalences ranged between 17.1-29.6% for hypertension, between 3.9-11.4% for diabetes, between 4.3-6.7% for atopic diseases, between 3.4-6.7% for coronary heart disease and between 2.6-5.7% for heart failure. When adjusting for sex and age, estimates for all 5 diseases were significant higher in AOK members compared to privately insured persons (3 diseases within the BAMER and the DAK, accordingly). In total, this was the case for 17 out of 35 comparisons. Even after adjusting for further comorbidities and health related factors 6 out of 35 comparisons showed significant increased estimates compared to privately insured persons. We found considerable differences in the prevalence of chronic diseases between German health insurance funds that remained after controlling for age and sex, and even after adjustment for further health-related variables. Further methodological studies are urgently needed to assess strengths and weaknesses of German claim data.

Cancer incidence in type 2 diabetes patients - first results from a feasibility study of the D2C cohort

BackgroundA large prospective study in patients with type 2 diabetes (T2D), the German D2C cohort, is presently being enumerated to investigate risk factors of incident cancer in diabetic patients.Study settingA disease management program was offered, on a voluntary basis, to all T2D patients who were members of a statutory health insurance fund in Germany. This first feasibility report uses data from 26.742 T2D patients, who were 40 to 79 years old, resided in the Muenster District, and who were enrolled between June 2003 and July 2008. Cancer cases were identified through the regional Cancer Registry.MethodsInvasive cancer cases were identified using probabilistic record linkage procedures and pseudonymised personal identifiers. Censoring date was December 31, 2008. We included only first cancers, leaving 12.650 male and 14.092 female T2D with a total of 88.778 person-years (py). We computed standardised incidence ratios (SIR) for external comparisons and we employed Cox regression models and hazard ratios (HR) within the cohort.ResultsWe identified 759 first cancers among male T2D patients (18.7 per 1,000 py) and 605 among females (12.7 per 1,000 py). The risk of any incident cancer in T2D was raised (SIR = 1.14; 95% confidence interval [1.10 - 1.21]), in particular for cancer of the liver (SIR = 1.94 [1.15 - 2.94]) and pancreas (SIR = 1.45 [1.07-1.92]). SIRs decreased markedly with time after T2D diagnosis. In Cox models, adjusting for diabetes duration, body mass index and sex, insulin therapy was related to higher cancer risk (HR = 1.25 [1.17 - 1.33]). No effect was seen for metformin.DiscussionOur study demonstrates feasibility of record linkage between DMP and cancer registries. These first cohort results confirm previous reports. It is envisaged to enhance this cohort by inclusion of further regions of the state, expansion of the follow-up times, and collection of a more detailed medication history.

Wie oft wird die Depersonalisations-Derealisationsstörung (ICD-10: F48.1) in der ambulanten Versorgung diagnostiziert?

The study determines how often Depersonalization-Derealization Disorder (ICD-10: F48.1) is diagnosed in the general population and analyzes the associations of other diseases with F48.1. The sample consists of 1.567 million insured persons of a statutory health insurance fund in Germany. We analyzed the prevalence of F48.1 and the associations of F48.1 with other diseases according to ICD-10. We found a 1-year prevalence of 0.007 % for the diagnosis of F48.1. After adjustment for age, sex, depression and anxiety, several somatic disease groups were found to be associated with an increased likelihood of F48.1, e.g., abnormalities of breathing (R06), cardiac arrhythmias (I47-I49), epilepsy (G40), dizziness (H81, H82, R42) and headache (G43, G44, R51). According to epidemiological studies, the prevalence of depersonalization-derealization disorder is 1-2 %. We therefore conclude that F48.1 is severely underdiagnosed. Increased awareness for the detection of F48.1 and further health care research are urgently warranted.

Teilnehmerstruktur und ökonomischer Nutzen präventiver Bonusprogramme in der betrieblichen Krankenversicherung

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. 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. 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. 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.

Going separate ways? The reform of health insurance funds in Germany, Japan and South Korea

Many aspects of Japanese and Korean national health insurance systems were modelled after the German system of social insurance where non-competitive sickness funds were based on a corporatist principle. Far from converging or remaining on a corporatist path, however, each country has followed a distinctive reform trajectory in an era of globalisation: Germany choosing to grant freedom of choice between different sickness funds, Japan maintaining a multiplicity of insurance societies, and Korea merging all health insurance societies into one. This article examines the reform process underpinning health insurance funds in these three countries where significant similarities as well as differences exist. It then argues that looking into the unique institutional opportunities of the time explains how and why these governments have adopted these paths to achieve dual objectives of cost containment and social solidarity.

Comparative cost analysis of outpatient and inpatient rehabilitation for musculoskeletal diseases in Germany

To examine the costs of inpatient and outpatient rehabilitation for musculoskeletal disorders from the perspective of a major statutory health insurance fund in Germany. A nation-wide database from a major health insurance fund in Germany was used to evaluate all rehabilitation cases in 2005. In addition, to all direct cost domains of the rehabilitation itself, costs incurred in the preceding and the following year for hospital treatment, drugs and physical therapy were analysed. A cost-cost analysis in different institutional settings was chosen for the cost comparison of inpatient and outpatient rehabilitation. To minimize the influence of possible confounders, a statistical control system was implemented. After a preceding hospital stay, inpatient and outpatient rehabilitation results in mean costs of euro2047 and euro1111, respectively. If the rehabilitation was not preceded by a directly related hospital treatment, mean costs for inpatient (outpatient) rehabilitation were euro2067 (euro1310). No systematic differences could be found between inpatient and outpatient rehabilitation evaluating costs for hospital treatment, drugs or physical therapy in the year preceding and the year directly following the rehabilitation. Assuming comparable medical outcomes, outpatient rehabilitation seems to be a superior alternative compared with inpatient rehabilitation from an economic perspective. Hence, from the perspective of the statutory health insurance, fostering a higher market share of outpatient rehabilitation may add to a better allocation of overall health care resources. For this, regional differences in rehabilitation infrastructure have to be taken into account.

Beitragssatz, Kassenwettbewerb und Gesundheitsreform / Premium Rates, Competition Among Health Insurance Funds and the Health Care Reform 2007

Summary The premium rates paid for statutory health insurance in Germany play a key role in the competition among health care funds. With the most recent health care reform (GKV-Wettbewerbsstärkungsgesetz GKV-WSG), a range of new products have been introduced that could erode the advantageous selling proposition of the premium rates. In addition to the pure monetary incentive to change health insurance provider, the new products include aspects that are becoming increasingly important to insured persons, such as the assessment of their own morbidity and the level and quality of health care provision. We find that current morbidity, experiences in morbidity, and expectations about morbidity will gain in importance when choosing health care provider. Using micro-data for the years 1999 to 2004 from the German Socio-Economic Panel study (SOEP), we investigate the willingness to change health provider in a multivariate setting. The SOEP data will be matched with register information about premium rates of all statutory health insurance funds in Germany. Applying a multinomial logit model, we show that there are two prototypes of insured people who change funds. The characteristics of those who changed funds can be used to evaluate the future developments in statutory health insurance in Germany, assuming that customer mobility will continue to increase.

Changes in Body Image and Health-Related Quality of Life Following Breast Reduction Surgery in German Macromastia Patients

Health insurance funds in Germany are increasingly reluctant to fund the cost for reduction mammaplasty. However, several studies have already demonstrated the beneficial effects of breast reduction on symptom relief and health-related quality of life. More specifically, the psychologic and social consequences of breast reduction surgery were also recently evaluated. Relating to the contemporary debate on financial restraint, the present article describes a follow-up study conducted in a sample of 40 patients undergoing reduction mammaplasty. The purpose of the investigation was to assess indicators of health-related quality of life following reduction mammaplasty. Furthermore, the study aimed to assess body image changes and to test a new assessment instrument, Digital-Body-Photo-Test (DBPT), in comparison with a well-validated body image measure (Color-a-Person Body Dissatisfaction Test, CAPT) (concurrent validity). As hypothesized, the findings indicate significant improvements in health-related quality-of-life measures and body-image characteristics. The substantial improvement of body-image satisfaction of all body areas suggests a generalized positive effect of reduction mammaplasty on overall body image. The strong association between the DBPT and the CAPT scores in this study indicates that DBPT is an efficient and valid new tool for measuring body-image changes relating to patients' evaluations of their average satisfaction of specific body parts or areas and their overall appearance acceptance.

The impact of occupation and family status on overall mortality in a cohort of male members of a health insurance fund in Germany

The aim of the study was to evaluate the impact of occupation, family status, and smoking on overall mortality in males in Germany. This study used data from a longitudinal register of the “Gmuender Ersatzkasse” (GEK), a German health insurance fund, for the time period between January 1989 and December 2000. Included in the analysis were male members of the GEK who were employed on 1 January 1989 and who were born between 1935 and 1950. Only those occupations were considered for which the frequency exceeded 1,000 cases. Thus, 17 occupations comprising 80,716 individuals were included. The statistical analysis was performed utilizing the software package “Transitional Data Analysis” (TDA) and employing the Kaplan-Meier life-table approach and a multivariate survival analysis applying the Cox regression method. Statistically increased relative risks for total mortality were observed for non-married persons, for the four main occupational groups with a lower status, for 13 occupations with medium or lower status, and for occupations yielding a smoking prevalence rate of 40% and more. Longitudinal data from health insurance funds in Germany provide a valuable resource for social epidemiological investigations. The findings suggest that the occupational setting has a strong impact on overall mortality experience in Germany.