Germany's Insurance Research Articles

My Germany in 2017: a resilient country that is taking responsibility

My Germany in 2017: a resilient country that is taking responsibility

Ilona Kickbusch: global health reformer

Ilona Kickbusch: global health reformer

Reinhard Busse: leader in Germany's health-system development

Reinhard Busse: leader in Germany's health-system development

From the Editor’s desk...: July 2017

From the Editor’s desk...: July 2017

Web search query data and prescription volumes of antidepressants

IntroductionPersons using the Internet generate large amounts of health-related data, which are increasingly used in modern health sciences.Objectives/aimsWe analysed the relation between annual prescription volumes (APV) of several antidepressants with marketing approval in Germany and corresponding web search query data generated in Google to test, if web search query volume may be a proxy for medical prescription practice.MethodsWe obtained APVs of several antidepressants related to corresponding prescriptions at the expense of the statutory health insurance in Germany from 2004–2013. Web search query data generated in Germany and related to defined search-terms (active substance or brand name) were obtained with Google Trends. We calculated correlations (Pearson's r) between the APVs of each substance and the respective annual “search share” values; coefficients of determination (R2) were computed to determine the amount of variability shared by the two variables.ResultsSignificant and strong correlations between substance-specific APVs and corresponding annual query volume were found for each substance during the observational interval: agomelatine (r = 0.968; R2 = 0.932; P = 0.01), bupropion (r = 0.962; R2 = 0.925; P = 0.01), citalopram (r = 0.970; R2 = 0.941; P = 0.01), escitalopram (r = 0.824; R2 = 0.682; P = 0.01), fluoxetine (r = 0.885; R2 = 0.783; P = 0.01), paroxetine (r = 0.801; R2 = 0.641; P = 0.01), and sertraline (r = 0.880; R2 = 0.689; P = 0.01).ConclusionsAlthough the used data did not allow to perform an analysis with a higher temporal resolution our results suggest that web search query volume may be a proxy for corresponding prescription behaviour. However, further studies analysing other pharmacologic agents and prescription data that facilitates an increased temporal resolution are needed to confirm this hypothesis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The emerging market for supplemental long term care insurance in Germany in the context of the 2013 Pflege-Bahr reform

The growing cost of long term care is burdening many countries’ health and social care systems, causing them to encourage individuals and families to protect themselves against the financial risk posed by long term care needs. Germany’s public long-term care insurance program, which mandates coverage for most Germans, is well-known, but fewer are aware of Germany’s growing voluntary, supplemental private long-term care insurance market. This paper discusses German policymakers’ 2013 effort to expand it by subsidizing the purchase of qualified policies. We provide data on market expansions and the extent to which policy goals are being achieved, finding that public subsidies for purchasing supplemental policies boosted the market, although the effect of this stimulus diminished over time. Meanwhile, sales growth in the unsubsidized market appears to have slowed, despite design features that create incentives for lower-risk individuals to seek better deals there. Thus, although subsidies for cheap, low-benefit policies seem to have achieved the goal of market expansion, the overall impact and long-term sustainability of these products is unclear; conclusions about its impact are further muddied by significant expansions to Germany’s core program. The German example reinforces the examples of the US and France private long term care insurance markets, to show how such products flourish best when supplementing a public program.

Real-world treatment for chronic hepatitis C infection in Germany: Analyses from drug prescription data, 2010–2015

Direct-acting antivirals (DAAs) for hepatitis C virus (HCV) have strongly improved treatment options since 2014, but it is unclear if treatment numbers have increased. We aimed to estimate the number of treatment regimens per month from 2010-2015 and the number of patients treated and cured with DAAs since 2014, as well as the associated costs. Drug prescription data of hepatitis C virus (HCV) antivirals for patients with statutory health insurance in Germany (∼85% of population) from January 2010-December 2015 were evaluated. Standard 28-day prescriptions of pegylated interferon (PegIFN) and 1st/2nd generation DAAs were combined according to treatment guidelines and analysed. Drug costs were calculated from pharmacy sales prices. Mean treatment durations/regimen from real-world data were used to calculate drug costs/regimen and numbers of DAA-treated persons in 2014/15. From January 2010-December 2015 PegIFN/ribavirin-treatments/month decreased from ∼6500 to ∼650. Monthly HCV-prescriptions rose with the approval of 1st generation DAAs (2011), and decreased at the end of 2013. With the approval of 2nd generation DAAs, prescriptions/month increased (peak: ∼6600; March 2015), and subsequently decreased (∼4000; December 2015). In 2014, ∼7000 patients were treated with DAAs, and ∼20,100 in 2015. Treatment costs/month were stable at 12 million EUR (2010-2011), increased to ∼38 million EUR (March 2012), and peaked to 150 million EUR (March 2015). DAA-drug costs/year added up to ∼664million EUR (2014) and ∼1.3billion EUR (2015). Despite an increase in DAA prescriptions, in December 2015 less persons/month were under treatment compared to January 2010, even though access to DAAs is not limited. However, yearly treatment numbers increased from 2014-2015. Under observed conditions, ∼18,000 patients/year can be cured, making substantial reduction of the estimated 160,000 diagnosed patients realizable. Political commitment to achieve further reduce DAA-prices and increase treatment numbers is recommended. New treatment options with all-oral second generation direct-acting antivirals (DAAs) have resulted in the potential to cure chronic hepatitis C infection, but at high costs. Analyses from HCV drug prescription data of patients with statutory health insurance in Germany from 2010-2015, showed that DAAs replaced treatments with pegylated interferon and ribavirin, but accompanied by a disproportionate rise in costs. Although the monthly number of patients under treatment did not increase over time, the total number of patients yearly treated with DAAs increased from ∼7000 patients in 2014 to ∼20,100 in 2015, with a trend to shorter treatment regimens. Under observed conditions ∼18,000 patients can be cured yearly, making a substantial reduction of the estimated 160,000 diagnosed patients in Germany achievable.

Demand and Selection Effects in Supplemental Health Insurance in Germany

This paper empirically assesses selection effects and determinants of the demand for supplemental health insurance that covers hospital and dental benefits in Germany. Our representative data set provides doctor-diagnosed indicators of the individual’s health status, risk attitude, demand for medical services and insurance purchases in other lines of insurance, as well as rich demographic and socio-economic information. Controlling for a wide range of individual preferences, we find evidence that individuals aged 65 and younger with hospital coverage are sicker than those without. In addition, insurance propensity and income are the most important drivers of the demand for supplemental hospital and dental coverage.

Aging and Outcome in Patients With Peripheral Artery Disease and Critical Limb Ischemia

Background, objectives, designAging of the population is one of the major challenges facing public health systems. The impact of aging on acute and long-term outcome of patients with peripheral artery disease (PAD) and critical limb ischemia (CLI) is currently not sufficiently clarified. This analysis consists of comprehensive, anonymized data obtained from the largest public health insurance in Germany. ResultsA total of 41,740 PAD patients with an index hospitalization between January 1, 2009, and December 31, 2011, and a follow-up time up to 4 years were included (40-49 years: n = 1179; 50-59 years: n = 5415; 60-69 years: n = 10,565; 70-79 years: n = 13,313; 80-89 years: n = 9714; and 90-100 years: n = 1554). Advanced age was associated with female gender (men-women ratio up to 1:3.3), less smoking, less frequent obesity, more often chronic heart failure (up to 9-fold), chronic kidney disease (up to 4-fold), fewer angiographies (up to 0.8-fold), fewer endovascular (up to 0.5-fold) and surgical revascularizations (up to 0.9-fold), higher rates of amputation (up to 2.5-fold), acute renal failure (up to 3.7-fold), in-hospital mortality (up to 12-fold), myocardial infarction (up to 2.8-fold), ischemic stroke (up to 1.5-fold), infection (up to 1.4-fold), and sepsis (up to 1.8-fold) (each P < .001). During follow-up, advanced age was a highly significant independent predictor of long-term mortality, myocardial infarction, and stroke (each P < .001). Lengths of hospital stay (up to 1.3-fold longer) and reimbursement costs (up to 1.1-fold higher) were clearly associated with advanced age (each P < .001). ConclusionsThis study demonstrates the impact of aging on morbidity, in-hospital treatment, complications, and acute and long-term outcome of PAD patients.

A Longitudinal Investigation of Willingness to Pay for Health Insurance in Germany.

To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany. Survey data from a cohort study in Saarland, Germany, from 2008-2010 and 2011-2014 (n1 =3,124; n2 =2,761) were used. Paneldata were taken at two points from an observational, prospective cohort study. WTP estimates were derived using a contingent valuation method with a payment card. Participants provided data on sociodemographics, lifestyle factors, morbidity, and health care utilization. Fixed effects regression models showed higher individual health care costs to increase WTP, which in particular could be found for members of private health insurance. Changes in income and morbidity did not affect WTP among members of social health insurance, whereas these predictors affected WTP among members of private health insurance. The fact that individual health care costs affected WTP positively might indicate that demanding (expensive) health care services raises the awareness of the benefits of health insurance. Thus, measures to increase WTP in old age should target at improving transparency of the value of health insurances at the moment when individual health care utilization and corresponding costs are still relatively low.

Hail risk management in fruit production: anti-hail net versus hail insurance in Germany

Hail risk management in fruit production: anti-hail net versus hail insurance in Germany

Analysis of Driving Factors of Willingness to Use and Willingness to Pay for Existing Pharmacological Smoking Cessation Aids Among Young and Middle-Aged Adults in Germany.

Smoking cessation is a challenging task with a high risk of relapse. Depending on the choice of medication and duration of therapy, the costs of using a smoking cessation aid can be high. Additionally, these costs are not covered by health insurance in Germany. Information on willingness to use (WTU) and willingness to pay (WTP) for smoking cessation aids is valuable for developing different smoking cessation strategies. The study analyses WTU and WTP for three pharmacological smoking cessation aids (nicotine replacement therapy (NRT), bupropion and varenicline) among young and middle-aged adults in Germany and attempts to determine their major driving factors. Two cross-sectional internet-based surveys of smokers over 18 years of age were conducted in 2014 and 2015 in Germany. Respondents were asked about smoking-related issues and WTU and WTP for each therapy. The contingent valuation method with payment cards was used to measure WTP. Descriptive statistics, logistical regression and accelerated failure-time regression models were performed. The total sample size is 505. Half of the respondents are willing to use NRT and one-third are willing to use bupropion and/or varenicline. WTU induces positive WTP; however, the magnitude of WTP is beneath the market price. WTU significantly increases with a higher addiction level and if smokers have previously heard about the therapy. This study indicates different points to be considered for policy development. Promotion information and improving awareness about medication aids might increase WTU, and development of monetary incentives for young smokers could create a better chance for successful smoking cessation.

The Politics of ‘Social Accountability’ in England and Germany: Democratic Control and Moral Imperatives

This article investigates how politicians in England and Germany approach social accountability during the introduction of markets in the national health care systems. It analyses the discourse among members of parliament during the law making process of the 2012 NHS Health Care Act in England and the 2011 Act for Financing of Statutory Health Insurance in Germany. Generally, the new social accountability reform agenda is attractive to policy makers as it foregrounds public engagement and bottom-up participation (Peters 2001). Social accountability refers to institutional practices that favour participatory and horizontal mechanisms that depart from traditional hierarchical Principal-Agent forms.

Multicentric lymphoma in 411 dogs - an epidemiological study

To provide an overview of the epidemiology of canine multicentric lymphoma in Germany. A total of 411 dogs with multicentric malignant lymphoma were retrospectively analysed regarding breed, age, sex, weight and the number of animals dogs with hypercalcaemic lymphoma and B-/T-immunophenotype, and compared to two reference populations (total own clinic population, n = 52 142; dogs with health insurance in Germany, n = 123 423). In total, 298 (72.5%) of the 411 dogs belonged to 86 different breeds, while 113 (27.5%) dogs were mixed breed. In comparison to both reference populations, a breed predisposition for the American Pitbull Terrier (odds ratio [OR] 5.2 and 18.5), American Staffordshire Terrier (OR 3.3 and 4.6), Briard (OR 5.6 and 9.5), Bullmastiff (OR 7.8 and 5.0), Irish Setter (OR 3.3 and 4.1) and Rottweiler (OR 2.8 and 3.6) was found. Golden Retrievers (n=22, OR 1.3 and 0.9) and Bernese Mountain Dogs (n=22, OR 2.4 and 2.0) were frequently affected in absolute numbers, but when compared to the reference populations an OR < 3 was detected. Mean body weight was 30.2±13.7kg; only 75 (18%) dogs weighed <15kg. Amongst the small dogs (<15kg), there was a large number of West Highland White Terriers (n=12). Mean age of the dogs with lymphoma was 7.9±2.7years. Dogs weighing ≥ 15 kg were significantly (p < 0.001) younger (7.6± 2.4years) compared to dogs weighing <15kg (9.3±3.2years). Dogs with a B-cell immunophenotype (8.5±2.6years) were significantly older compared to dogs with a T-cell immunophenotype (6.4± 1.8years) (p<0.001). There was no gender predisposition (54% male, 46% female). Hypercalcaemia as an indicator of T-cell lymphoma was present in 44 (11.4%) of the dogs. A T-cell and B-cell immunophenotype was found in 20.6% and 79.4% of the dogs, respectively. This study confirms previous data about breed predispositions for canine malignant multicentric lymphoma and demonstrates that further breeds are predisposed (Briard, West Highland White Terrier, Irish Setter). Small-breed dogs (<15kg BM) appear to be affected with lymphoma at a greater age.

Linking Annual Prescription Volume of Antidepressants to Corresponding Web Search Query Data: A Possible Proxy for Medical Prescription Behavior?

Persons using the Internet to retrieve medical information generate large amounts of health-related data, which are increasingly used in modern health sciences. We analyzed the relation between annual prescription volumes (APVs) of several antidepressants with marketing approval in Germany and corresponding web search query data generated in Google to test whether web search query volume may be a proxy for medical prescription practice. We obtained APVs of several antidepressants related to corresponding prescriptions at the expense of the statutory health insurance in Germany from 2004 to 2013. Web search query data generated in Germany and related to defined search terms (active substance or brand name) were obtained with Google Trends. We calculated correlations (Person's r) between the APVs of each substance and the respective annual "search share" values; coefficients of determination (R) were computed to determine the amount of variability shared by the 2 variables. Significant and strong correlations between substance-specific APVs and corresponding annual query volumes were found for each substance during the observational interval: agomelatine (r = 0.968, R = 0.932, P = 0.01), bupropion (r = 0.962, R = 0.925, P = 0.01), citalopram (r = 0.970, R = 0.941, P = 0.01), escitalopram (r = 0.824, R = 0.682, P = 0.01), fluoxetine (r = 0.885, R = 0.783, P = 0.01), paroxetine (r = 0.801, R = 0.641, P = 0.01), and sertraline (r = 0.880, R = 0.689, P = 0.01). Although the used data did not allow to perform an analysis with a higher temporal resolution (quarters, months), our results suggest that web search query volume may be a proxy for corresponding prescription behavior. However, further studies analyzing other pharmacologic agents and prescription data that facilitate an increased temporal resolution are needed to confirm this hypothesis.

Regional Distribution of Physicians: the Role of Comprehensive Private Health Insurance in Germany

Regional Distribution of Physicians: the Role of Comprehensive Private Health Insurance in Germany

Demand and Selection Effects in Supplemental Health Insurance in Germany

This paper empirically assesses the selection effects and determinants of the demand for supple-mental health insurance that covers hospital and dental benefits in Germany. Our representative dataset provides doctor-diagnosed indicators of the individual’s health status, risk attitude, demand for medical services and insurance purchases in other lines of insurance as well as rich demographic and socioeconomic information. Controlling for a wide range of individual preferences, we find evidence of adverse selection for individuals aged 65 and younger for hospital coverage despite initial individual underwriting by insurers. The reverse is true for individuals older than 65; individuals with supplemental hospital coverage are healthier on average. In addition, insurance affinity and income are the most important drivers of the demand for both types of coverage.

PHP145 - Use of real World evidence in German amnog applications

The statutory health insurance in Germany comprises 90% of the German population covering nearly all healthcare services with only little co-payments. German health insurance claims data therefore constitute an important basis for real world evidence (RWE) on epidemiology and cost information. Aim of this study was to investigate to which extent RWE was used for estimation of prevalence and incidence in German AMNOG assessments since introduction 4 years ago and also its impact on price discounts. German AMNOG assessments submitted until December 2014 were evaluated. They were screened for use of RWE in assessing prevalence and incidence and also target populations. After description and discussion of methods and data sources used, statistics were applied to explore a potential influence of use and quality of RWE data on price discounts. In total, 108 AMNOG dossiers were included. Real world evidence was used in 42.6% of these dossiers to assess prevalence and incidence as well as target populations. German claims data were employed in 8 dossiers (7.4%), registry data in 7 dossiers (6.5%), other data sources like Delphi panels in 37 dossiers (34.3%). The impact of quality of RWE evidence on negotiated discounts is inconclusive with limited data available. German claims data comprise comprehensive information such as demographics, outpatient and inpatient care, prescriptions, devices and aids, incapacity to work and sick leave payments. The routine documentation of diagnoses, procedures and prescriptions as well as the ability to evaluate patient histories are particularly useful for prevalence and incidence analyses, especially regarding the target population and cost estimations which are of paramount importance in price negotiations following the AMNOG assessment. German claims data constitute a valuable and valid data source for assessing epidemiologic evidence in German AMNOG assessments. Indication specific claims data analyses are a meaningful complement to literature research.

Regional distribution of physicians: the role of comprehensive private health insurance in Germany.

In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients. The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010. Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3% in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect. From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.

Who Opts Out of the Statutory Health Insurance?

The coexistence of social health insurance and private health insurance in Germany is subject to intense public debate. As only few have the opportunity to choose between the two systems, they are often regarded as privileged by the health insurance system. Applying a hazard model in discrete time, this paper examines the role of incentives set by the regulatory framework as well as the influence of individual personality characteristics on the decision to opt out of the statutory system. To address potential endogeneity of one of the key explanatory variables an instrumental variable approach is also applied. The estimation results yield robust evidence on the choice of health insurance type that is consistent with rational decision making, with both incentives set by regulation and personality traits as relevant determinants.