Statutory Health Insurance Scheme Research Articles

Histology Findings after Two Years of Cytology/HPV Co-Testing in Germany.

Since 1 January 2020, diagnostic confirmation of abnormalities detected in the context of cytology/HPV co-testing in cervical cancer screening under the statutory health insurance scheme in women aged 35 and over has been performed according to predefined algorithms. A colposcopy is indicated even in the case of borderline/low-grade cytological changes and/or HPV persistence. In this article we compare the histology findings after primary screening examinations in 2020/21 with those from 2018/19, thus also comparing the results of two different screening approaches. Our analysis included all of the cytology, HPV, and histology results from all primary screening examinations, as well as the resulting diagnostic confirmation and curative cases, that could be obtained by 30 June 2023. In 2018/19 these comprised 650600 cytology and 1804 histology findings, and in 2020/21 there were 491450 cytology and 7156 histology findings. The absolute numbers of histology findings and the percentage ratios of these to all cytological diagnoses are presented with comparison factors. In 2020/21 there were 5.2 times more histology findings in relation to all previous cytology examinations than in 2018/19, as well as 10.6 times more biopsies, 3.8 times more conizations, and 1.2 times more hysterectomies. There was a particularly high increase in diagnostic confirmation of borderline/low-grade or only HPV-positive findings. With co-testing, 12.7 times more CIN1, 6.4 times more CIN2, and 3.5 times more CIN3 lesions were diagnosed. The proportion of biopsies without dysplasia was 7.6 times higher than in previous years. Cervical carcinomas were diagnosed 1.8 times more frequently, and endometrial carcinomas 0.7 times less frequently. More CIN lesions were found with co-testing, but the increase in histology findings of low-grade or no dysplasia was far greater than findings of CIN3. Lesions not requiring treatment accounted for 94.4% of biopsy results in 2020/21. The use of computer-assisted LBC with progression markers could reduce this.

Legal Aspects of Alzheimer Prediction

AbstractBackgroundWhen diagnostic and therapeutic measures are increasingly replaced by predictive methods and preventive treatments, the applicable law is also subject to a variety of effects. In particular, a major question is about the eligibility of predictive measures for reimbursement by the statutory health insurance schemes in different countries. Secondly, in spite of the chances associated with early knowledge about disease risks, there can be negative legal and factual disadvantages, e.g. disclosure obligations for insurance contracts. Thirdly, the existing requirements for medical information and consent must be reassessed: The decision about the determination of future risks is particularly and increasingly complex, while the extent of the legal obligation of the physician to inform about decision‐relevant but not specifically medical remote effects has not yet been conclusively clarified.MethodWe scrutinize existing legislation and jurisprudence from Germany, Switzerland and Spain to identify uncertainties, hindrances or gaps in the existing legal framework, suggest adjustment and recommend legally safe and ethically justified paths for medical care in light of the changes described above.ResultThe existing legal framework bears uncertainties for the application of increasingly available methods to predict the individual risk for Alzheimer’s dementia. Therefore, an ethico‐legal framework for responsible and patient‐oriented dementia prediction is being developed.ConclusionThe poster highlights the most pertinent legal questions and challenges associated with dementia prediction, and shows the integration of empirical data and ethical assessments into an ethico‐legal framework.

Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on Cervical Cancer Screening in Gynecological Practices in Germany.

Simple SummaryThe outbreak of the coronavirus disease 2019 (COVID-19) is a major challenge for healthcare systems and impedes cancer screening programs worldwide. However, no research has been performed that analyzes the effects of the COVID-19 pandemic on the newly implemented German Cervical Cancer Screening (CCS) program. Here, we showed a severe clinically relevant decrease of patients receiving CCS in Germany between the pre-pandemic time period of 2018–2019 and the pandemic years of 2020–2021. Given that this sudden drop in number of CCS per practice is unlikely, our data suggest a dramatic number of underdiagnosed cervical precancer lesions that may lead to increased cervical cancer burden in the future.Purpose: the aim of this cross-sectional study was to analyze the impact of the COVID-19 pandemic on Cervical Cancer Screening (CCS) in gynecological practices in Germany. Methods: The basis of the analysis was the Uniform Evaluation Standard (EBM) of the Statutory Health Insurance Scheme. This cross-sectional study included all women aged ≥20 years with at least one CCS (clinical and cytological examination) in 223 gynecological practices in Germany during the period 2018–2021. The number of patients with CCS per practice was shown for each year. The average number of patients per year was compared between the pre-pandemic time period (2018, 2019) and the pandemic time period (2020, 2021) using Wilcoxon tests. Analyses were conducted separately for clinical investigations and cytological investigations and were also stratified by age group (20–34, 35–50, >50 years). Results: CCS in gynecological practices significantly decreased in Germany between the pre-pandemic time period of 2018–2019 and the pandemic years of 2020–2021. This decrease was observed in all age groups but was stronger in women aged 20–34 (−25.6%) and weaker in women aged >50 (−15.2%). Conclusions: We found a statistically and clinically relevant decrease of patients receiving CCS in gynecological practices in Germany. This finding is even more exceptional because the new screening algorithm with direct invitations for each patient started in 2020 and was supposed to lead to a higher number of patients in its first years. However, the observed decline in the detection of cervical precancer lesions may lead to increased cervical cancer burden. Risk-based screening strategies and further measures are necessary to adapt to the ongoing COVID-19 pandemic and return to pre-pandemic CCS numbers.

Role of private prescriptions in the long-term use of benzodiazepines and Z-drugs: A patient-related follow-up study.

To analyse (1) how often patients insured under the statutory health insurance (SHI) scheme received repeated prescriptions for benzodiazepines or Z-drugs as private prescriptions and (2) how often doctors switched from SHI prescriptions to private prescriptions and vice versa when issuing repeat prescriptions. On basis of anonymized prescriptions from 874 ambulatory practices in Germany, we analysed the percentage of private prescriptions for Z-drugs, benzodiazepines/anxiolytics, and benzodiazepines/hypnotics and sedatives over 6 years (2014 to 2020). Of 2 200 446 prescriptions for a benzodiazepine or Z-drug, 38% were private prescriptions. In case of Z-drugs, the rate of private prescriptions was 44.1% for single prescriptions and 48.9% for refills. The difference was smaller for anxiolytics (23.3% vs. 26.0%) and, for benzodiazepine/hypnotics and sedatives, the proportion of private prescriptions for refills was even lower than for single prescriptions. In case of Z-drugs, the proportion of private prescriptions was, on average, 42.7% for the first prescription of a series of repeat prescriptions and 49.6% for the tenth prescription. The increase was smaller for anxiolytics and negligible for benzodiazepine/hypnotics and sedatives. Doctors stayed with their initial decision in more than three quarters of repeat prescriptions, be it a SHI or private prescription. While we observed a large number of private prescriptions for benzodiazepines and Z-drugs, the proportion was only slightly higher for refills than for single prescriptions. Doctors do not seem to issue private prescriptions as a strategy to mask especially long-term use of these substances.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces.

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance. Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants. The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less). Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Problems and Barriers Related to the Use of Digital Health Applications: Protocol for a Scoping Review.

BackgroundThe use of mobile health (mHealth) apps is increasing rapidly worldwide. More and more institutions and organizations develop regulations and guidelines to enable an evidence-based and safe use. In Germany, mHealth apps fulfilling predefined criteria (Digitale Gesundheitsanwendungen [DiGA]) can be prescribed and are reimbursable by the German statutory health insurance scheme. Due to the increasing distribution of DiGA, problems and barriers should receive special attention.ObjectiveThis study aims to identify the relevant problems and barriers related to the use of mHealth apps fulfilling the criteria of DiGA.MethodsThis scoping review will follow published methodological frameworks and the PRISMA-Scr (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews) criteria. Electronic databases (MEDLINE, EMBASE, PsycINFO, and JMIR), reference lists of relevant articles, and grey literature sources will be searched. Two reviewers will assess the eligibility of the articles by a two-stage (title and abstract as well as full text) screening process. Only problems and barriers related to mHealth apps fulfilling the criteria of DiGA are included for this research. The identified studies will be categorized and analyzed with MAXQDA.ResultsThis scoping review gives an overview of the available evidence and identifies research gaps regarding problems and barriers related to DiGA. The results are planned to be submitted to an indexed, peer-reviewed journal in the first quarter of 2022.ConclusionsThis is the first review to identify the problems and barriers related to the use of mHealth apps fulfilling the German definition of DiGA. Nevertheless, the findings can be applied to other contexts and health care systems as well.International Registered Report Identifier (IRRID)DERR1-10.2196/32702

Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians

Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Epidemiology and treatment of adult patients with atopic dermatitis : Analysis of longitudinal data of the statutory health insurance scheme

The goal was to report incidence, prevalence, and treatment patterns in adult atopic dermatitis (AD) patients in the German statutory health insurance system. Anonymized claims data were evaluated at patient level for 3.3million persons insured by six different statutory health insurance companies (SHI). Patients for whom the ICD-10 diagnosis code L20 (AD) was applied at least twice were analyzed and data on prescription patterns for AD were reported for the years 2011-2015. AD prevalence in adults was 1.6-1.9% in 2012-2015. Annual incidence was 0.28%. In Q3/Q4 2015, 44.2% of the adult population with AD diagnosis by adermatologist received prescriptions for AD medications: 1.6% low-potency topical glucocorticoids (without previous prescription of systemic drugs), 46.9% moderate or high-potency topical glucocorticoids or topical calcineurin inhibitors, 23.9% current systemic therapy (systemic glucocorticoids, ciclosporin, methotrexate, azathioprine, mycophenolate mofetil) and 27.6% systemic therapy in the past. The AD prevalence estimate was in the range of previous reports (1.35-4%) that used different methodologies. Based on treatment proxy, it appeared that almost more than half of AD patients treated with prescription ready-to-use drugs had asevere form of AD which required treatment with systemic drugs.

Vascular Diagnostic and Surgical Treatments Before Lower Limb Amputations in Patients with Arterial Vascular Diseases: A Population Based Study from 2013 to 2015 in Germany

Patients with peripheral artery disease (PAD) have an increased risk of lower limb amputation. Given the international wide variance in major amputations, the high mortality rates and follow up costs as well as the significantly reduced quality of life of patients with amputations, vascular diagnostics and vascular surgery treatments are of great importance for lower limb preservation in patients with PAD. This study examines these guideline based procedures in patients before a first lower limb amputation and PAD. This was a retrospective longitudinal study. Data from a large German statutory health insurance scheme were examined on patients with first amputation of lower extremities and PAD between 2013 and 2015 (incidence). Pre-defined vascular diagnostic and vascular surgical procedures were considered, as specified by guidelines within inpatient and outpatient care in a defined time before lower limb amputation. The overall estimated incidence of lower extremity amputations in the total population was 0.12% from 2013 to 2015. Of these, 51.7% had PAD; 81.8% of patients received at least one vascular diagnostic measure and 61.0% a vascular surgery procedure before the lower extremity amputation. There were only minor variations in the use of diagnostic or surgical treatments between patients with major and minor amputation. In total, 63.9% of patients had vascular surgery before the incident major amputation compared with 60.0% of patients with a minor amputation. Noticeable regional differences were found ranging from 91% (Berlin) to 67% (Bremen) regarding diagnostic procedures provided before amputation, and from 83% (Hamburg) to 55% (Saxony-Anhalt) regarding vascular surgery before amputations. Of patients with PAD, 18.2% did not receive a vascular diagnostic examination before amputation as specified in the guidelines, which reflects an underuse of health services. In one third of patients who did not receive vascular surgery, major amputation probably could have been avoided.

PNS100 The New Reimbursement Route for Digital Health Applications (DIGA) in Germany: Critical Appraisal and First Evaluation of the Possible Effect on the German Healthcare System

In Germany, 73 million citizens are insured under the statutory health insurance scheme. Until recently, there was no well-defined process for digital applications to get access to the statutory health insurance scheme. This changed when the Digital Supply Act (“Digitale-Versorgung-Gesetz“, DVG) came into effect in December 2019. With the DVG, Germany is the first country in Europe where digital health applications (“Digitale Gesundheitsanwendungen”, DiGA) can be prescribed and will be reimbursed upon an approval process at the German Federal Institute for Drugs and Medical Devices (BfArM). We assessed how the DVG will affect relevant stakeholders in the German healthcare system. We assessed the possible impact of the DVG on the German healthcare system by conducting qualitative structured interviews (N=20) with relevant stakeholders (physicians, patients, app manufacturers, healthcare insurance funds). Physicians are rather skeptical of DiGA designed to aid diagnosis but are more open towards DiGA for patient self-management especially in chronic diseases. Patients attach great importance to the demanding requirements for data protection and other quality criteria in the DiGA assessment. Most app manufacturers welcomed the introduction of the DVG, but are skeptical whether the reimbursement prices for DiGA will be sustainable for them. In contrast, representatives of healthcare insurance funds are concerned that the reimbursement of DiGA will lead to new burden for the German healthcare systems and that DiGA will not substantially enhance patient care. With the introduction of the DVG, DiGA can get access to the German healthcare systems more easily. As expected, different stakeholders have different opinions on the effect of the DVG. As soon as more data are available, budget impact and cost-effectiveness analyses should be performed to better understand the impact of the DVG on the German healthcare system.

Parity funding of health care contributions in Germany: A DSGE perspective

AbstractGermany reintroduced parity funding of the statutory health insurance scheme in January 2019 by lowering the contribution rates for employees and raising those for employers, leaving the total rate constant. This reduces the tax wedge between total labour costs and net wages. After a small demand impulse on impact, followed by a small downturn in the first two years after implementation, an estimated New Keynesian DSGE model indicates small positive long-run output and employment effects. However, the reduced tax wedge leads to lower public revenues. Aggregate macroeconomic and welfare effects will depend on how the government compensates for these revenue losses.

Waiting times in primary care depending on insurance scheme in Germany

BackgroundWaiting times for an outpatient appointment in Germany differ between insurants of the statutory and private health insurance schemes, especially for specialised care. The aim of this study was to uncover possible differences in waiting times depending on health insurance scheme and to identify predictors for excessive waiting times in primary care.MethodsWe used data of the Bertelsmann Foundation Healthcare Monitor, which is a repeated cross sectional study dealing with experiences in health care and attitudes towards current health policy themes. We analysed the surveys conducted from 2011 to 2013, with respondents assigned to their health insurance fund, namely AOK, BARMER GEK, BKK, DAK, TK, IKK, other statutory funds and private funds. The mean waiting times for an appointment and spent in a physician’s waiting room, and the satisfaction with waiting times were evaluated with respect to different health insurance funds. A logistic regression model was used to calculate the chance of excessive waiting times with respect to health insurance fund, age, sex, health and socioeconomic status. The ninetieth percentile of the waiting time distribution (10 days) was chosen as the cut-off point between average and excessive.ResultsA total of 5618 respondents were analysed. Mean waiting times in primary care were low (4.0 days) and homogeneous (SHIs: 3.6–4.9 days), even though privately insured respondents reported shorter waiting times for appointments (3.3 days). They also reported a greater satisfaction with waiting times (77.5%) than SHI insurants (64.5%). However, we identified a group (10.1%), who experienced excessive waiting times in primary care. Compared to privately insured respondents, the chance of excessive waiting times was increased for SHI insurants (highest odds ratio for BKK: 2.17; 95%-CI: 1.38–3.42). Additionally, higher age and residence in East Germany were associated with higher chances of waiting times of 10 days or more.ConclusionsPrimary care in Germany is readily accessible with generally short waiting times. However, barriers in access to the health care system affect a certain part of patients depending on insurance status, age and region of residence. Ways to improve the access need to be studied.

Germany ∙ Compliance: 18 Months Of The German Act On Fighting Corruption In The Healthcare Sector

The German Act on Fighting Corruption in the Healthcare Sector 2016 complements the already existing criminal offences against corrupt behaviour with provisions for the protection of fair competition in the healthcare sector as well as the (public’s) trust in the integrity of healthcare-related decisions, especially with regard to healthcare professionals licenced for the statutory health insurance scheme. The newly established provisions, sections 299a and 299b of the German Criminal Code 1998 (StGB), apply to the prescription and/or procurement of medicinal products, healthcare-services and products and medical devices as well as the referral of patients and test materials. While the new provisions eschew any direct reference to regulations of professional conduct and/or other provisions, the interpretation of the new law relies heavily on the adherence to provisions outside the Criminal Code, such as physician’s professional law. One and half years after the law has come into force it can be said that the main focus of the prosecutors is not the cooperation between pharmaceutical and medical device industry but the unlawful cooperation between the industry and physicians and/or hospitals. To avoid sufficient initial suspicion and following dawn raids by official prosecutors it is crucial for all players (industry, HCP’s) to bear the professional codes in mind as well as the relevant codes of conduct (FSA code of conduct, AKG code of conduct).

Compilation of Second Opinion Programs in the German Statutory Health Insurance

According to a new legislation passed in 2016, patients with an indication for elective procedures have the right to obtain a second opinion. The Federal Joint Committee has not yet provided a list of indications that this legislation will cover. Independently of this, the statutory health insurances can, nonetheless, pay for a second opinion. The aim of this article is to give an overview of current second opinion programs delivered by the statutory health insurance schemes. Websites of all German statutory health insurance schemes (n=117) were searched for second opinion programs and their features in November 2016. All data was extracted by one person and verified by a second person. In total, 78 second-opinion programs were identified. Half of all statutory health insurance schemes (50%, n=59) provide at least one second-opinion program. The majority of them was in the field of orthopedics (78%, n=61) and oncology (58%, n=45). Multiple replies were possible. In most cases, second-opinion programs were outsourced (58%; n=44), followed by forwarding patients to health service providers contracted with the statutory health insurance scheme (45% n=34). Only in 11% (n=8) was the second opinion delivered by staff of the statutory health insurance scheme. The second opinion was delivered based on submitted documents only (63%; n=48), direct patient-physician contact (43%; n=33), and contact by phone (14%; n=11). The delivery of the second opinion took 7 days in median, while the delivery based on submitted documents only (median 7) was faster than the delivery by direct-physician contact (median 14). The majority of those living in Germany have the possibility to obtain a second opinion. However, second-opinion programs are very heterogeneous so that patients are confused about their rights to second opinion.

Medication adherence and persistence according to different antihypertensive drug classes: A retrospective cohort study of 255,500 patients

BackgroundSuboptimal adherence to antihypertensives leads to adverse clinical outcomes. This study aims to determine and compare medication adherence and persistence to different first-line antihypertensive drug classes in a large cohort. MethodsA cohort study was performed using claims data for prescriptions in the German statutory health insurance scheme that insures approximately 90% of the population. A total of 255,500 patients with a first prescription of an antihypertensive were included and followed for 24months. Persistence was determined based on gaps in continuous dispensation. Adherence was analyzed by calculating the medication possession ratio (MPR). ResultsWithin a 2-year period, 79.3% of all incident users of antihypertensive monotherapy met the classification of non-persistence (gap >0.5 times the number of days supplied with medication) and 56.3% of non-adherence (MPR<0.8). Beta-blockers (42.5%) and angiotensin-converting enzyme inhibitors (31.9%) were the most widely prescribed drug classes. Non-persistence and non-adherence were highest for diuretics (85.4%, n=6149 and 66.3%, n=4774) and lowest for beta-blockers (77.6%, n=76,729 and 55.2%, n=54,559). The first gap of antihypertensive medication occurred in median 160–250days after initiation, and the average medication possession ratio for all drug classes was less than 0.8. Fixed combinations with diuretics showed a 19.8% lower chance for non-adherence (OR=0.802, 99.9% CI=[0.715–0.900], p<0.001) and an 8.4% lower hazard for non-persistence (HR 0.916, 99.9% CI=[0.863–0.973], p<0.001) compared with monotherapies. ConclusionsThis large cohort study reveals important differences in 2-year adherence and persistence between antihypertensives that were lowest for diuretics. Fixed-dose combinations with diuretics may facilitate adherence compared to single substance products. However, effective strategies to improve adherence to antihypertensives are needed regardless of drug class.

The Prevalence and Incidence of Diabetes in Germany.

The database of the German Institute of Medical Documentation and Information makes it possible for the first time to compute statistics on diabetes for all insurees of the statutory health insurance scheme in Germany. Data from this comprehensive source are less likely to be biased by differences in the membership structures of individual insurance carriers or by the underrepresentation of persons over age 80 that is seen in most population-based studies. International Classification of Diseases (ICD)-coded diagnosis data from the inpatient and outpatient sectors were used to define persons as having diabetes. Incidences were estimated from differences in prevalence from one year to the next and the expected mortality of persons with and without diabetes. A diabetes diagnosis was present in 6.4 million out of a total of 65.6 million insurees in 2009 and in 6.7 million out of 64.9 million insures in 2010. The corresponding age and sex standardized prevalences of diabetes were 9.7% in 2009 and 9.9% in 2010, respectively. The number of persons with type 2 diabetes was 4.6 million in 2009 and 4.7 million in 2010. The prevalence and incidence of type 2 diabetes rose steeply from age 50 to age 80. Peak incidence was at age 85, with 24 newly diagnosed cases of diabetes per 1000 person-years. On the basis of these data, we estimate that 5.8 million persons with type 2 diabetes are living in Germany today. The database used in this study is a valuable complement to population-based studies for monitoring the prevalence of diabetes, particularly in persons over age 80.

The policy and politics of the 2015 long-term care reform in the Netherlands

As of 2015 a major reform in LTC is taking place in the Netherlands. An important objective of the reform is to reign in expenditure growth to safeguard the fiscal sustainability of LTC. Other objectives are to improve the quality of LTC by making it more client-tailored. The reform consists of four interrelated pillars: a normative reorientation, a shift from residential to non-residential care, decentralization of non-residential care and expenditure cuts. The article gives a brief overview of these pillars and their underlying assumptions. Furthermore, attention is paid to the political decision-making process and the politics of implementation and evaluation. Perceptions of the effects of the reform so far widely differ: positive views alternate with critical views. Though the reform is radical in various aspects, LTC care will remain a largely publicly funded provision. A statutory health insurance scheme will remain in place to cover residential care. The role of municipalities in publicly funded non-residential care is significantly upgraded. The final section contains a few policy lessons.

Teachers' Health.

Almost 800,000 teachers were working in Germany in the 2012-13 school year. A determination of the most common medical problems in this large occupational group serves as the basis for measures that help maintain teachers' health and their ability to work in their profession. We present our own research findings, a selective review of the literature, and data derived from the German statutory health insurance scheme concerning medical disability, long-term illness, and inability to work among teachers. Compared to the general population, teachers have a more healthful lifestyle and a lower frequency of cardiovascular risk factors (except hypertension). Like non-teachers, they commonly suffer from musculoskeletal and cardiovascular diseases. Mental and psychosomatic diseases are more common in teachers than in non-teachers, as are nonspecific complaints such as exhaustion, fatigue, headache, and tension. It is commonly said that 3-5% of teachers suffer from "burnout," but reliable data on this topic are lacking, among other reasons because the term has no standard definition. The percentage of teachers on sick leave is generally lower than the overall percentage among statutory insurees; it is higher in the former East Germany than in the former West Germany. The number of teachers taking early retirement because of illness has steadily declined from over 60% in 2001 and currently stands at 19%, with an average age of 58 years, among tenured teachers taking early retirement. The main reasons for early retirement are mental and psychosomatic illnesses, which together account for 32-50% of cases. Although German law mandates the medical care of persons in the teaching professions by occupational physicians, this requirement is implemented to varying extents in the different German federal states. Teachers need qualified, interdisciplinary occupational health care with the involvement of their treating physicians.

The problems of long-term treatment with benzodiazepines and related substances.

Benzodiazepine abuse and dependence have been recognized and widely discussed for more than 40 years. With more than 230 million daily doses prescribed in Germany per year, the burden of reimbursement on the statutory health insurance carriers is high, albeit with a slight decline from year to year. At present, about 50% of all prescriptions in Germany are issued privately, even for patients who have statutory health insurance. We selectively review the literature on the epidemiology and treatment of benzodiazepine dependence and abuse in Germany. Estimates of the number of benzodiazepine-dependent persons in Germany range from 128 000 to 1.6 million. Most estimates take no account of the large number of private prescriptions (i.e., those that are not reimbursed by the statutory health insurance scheme), while many exclude prescriptions for elderly persons, for whom these drugs are frequently prescribed. For the outpatient treatment of benzodiazepine withdrawal, it is recommended that the drug should first be switched to an equivalent dose of another benzodiazepine with an intermediate or long-acting effect; the dose should then, in general, be reduced weekly. In case of consumption of a high dose (≥ 20 mg diazepam equivalent), hospitalization and the additional administration of carbamazepine or valproic acid are recommended. Flumazenil treatment can improve with - drawal symptoms and leads to higher abstinence rates. Antidepressants should be given only if the patient is depressed. The dependence potential of nonbenzodiazepine drugs such as zolpidem and zopiclon must also be borne in mind. Benzodiazepines are generally highly effective when first given, but they should generally be given only for strict indications and for a limited time. If these drugs still need to be given beyond the short term, timely referral to a specialist is indicated, and possibly also contact with the addiction aid system.

Zusatzbeiträge in der Gesetzlichen Krankenversicherung / Income-independent Surcharges in German Statutory Health Insurance

Summary Expenditure of the German statutory health insurance scheme will increase significantly in the future. In order to keep the system financially sound, current law plans to levy income independent surcharges. These will be complemented by a tax-financed social compensation scheme. In this paper, we analyse the effects of such surcharges on revenue on Germany’s statutory health insurance using a general equilibrium model with overlapping generations. Afterwards, we further develop the surcharges up to a flat rate employee contribution and ascertain their financial consequences and their employment and growth effects. The allocative effects of such a further development are positive. They will be more considerable if the introduction begins earlier and ends quickly. A moderate expenditure increase and a smaller shape of the compensation scheme will intensify these effects.