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Germany: Health system review
Abstract
This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. In the German health care system, decision-making powers are traditionally shared between national (federal) and state (Land) levels, with much power delegated to self-governing bodies. It provides universal coverage for a wide range of benefits. Since 2009, health insurance has been mandatory for all citizens and permanent residents, through either statutory or private health insurance. A total of 70 million people or 85% of the population are covered by statutory health insurance in one of 132 sickness funds in early 2014. Another 11% are covered by substitutive private health insurance. Characteristics of the system are free choice of providers and unrestricted access to all care levels. A key feature of the health care delivery system in Germany is the clear institutional separation between public health services, ambulatory care and hospital (inpatient) care. This has increasingly been perceived as a barrier to change and so provisions for integrated care are being introduced with the aim of improving cooperation between ambulatory physicians and hospitals. Germany invests a substantial amount of its resources on health care: 11.4% of gross domestic product in 2012, which is one of the highest levels in the European Union. In international terms, the German health care system has a generous benefit basket, one of the highest levels of capacity as well as relatively low cost-sharing. However, the German health care system still needs improvement in some areas, such as the quality of care. In addition, the division into statutory and private health insurance remains one of the largest challenges for the German health care system, as it leads to inequalities.
... Given that most citizens in Germany are members of statutory health insurances (i.e., about 85% of the population [53]), medical students are used to the practice of free access to evidence-based health services without additional costs (e.g., DiGA can be prescribed on the expense of health insurances [54]). This may explain why 93% of medical students preferred no payment for DMHIs. ...
BACKGROUND
The impact of digital mental health interventions (DMHIs) in the prevention and therapy of common mental disorders (CMDs) on healthcare has been debated in view of the currently low utilization rates. Potential reasons may include lacking awareness or familiarity with DMHIs as well as concerns about their quality, trusted sources and the evidence base, which calls for context-sensitive information campaigns. Medical students represent a suitable user case to develop information strategies as they were previously shown to have a comparatively high risk for CMDs themselves. Further, in their role as future physicians, they will prescribe DMHIs. Yet, little is known about medical students´ information preferences regarding DMHIs.
OBJECTIVE
The aim of the study was to explore information preferences for DMHIs among medical students in Germany for personal use.
METHODS
A discrete choice experiment (DCE) was conducted, which was developed using an exploratory sequential mixed-methods research approach. Five attributes (i.e., source, delivery mode, timing, recommendation, and quality criteria) each with 3-4 levels were identified using formative research. Twenty-four choice sets each with two alternatives were divided into three versions of the DCE, each with eight different choice sets, to which participants were randomly assigned. DCE data were analyzed employing logistic regression models to estimate preference weights and relative importance of attributes. To identify subgroups of students varying in information preferences, we additionally performed a latent class analysis (LCA).
RESULTS
Out of N=309 eligible participants data, n=231 were included in the main analysis due to reliable data (70.1% women, age: M=24.1 years, SD=4.0 years). Overall, medical students preferred to receive information about DMHIs from the student council and favored being informed via social media early (i.e., during their pre-clinic phase or their freshman week). Recommendations from other students or health professionals were preferred over recommendations from other users or no recommendation at all. Information about the scientific evidence base were the preferred quality criterion. Overall, timing of the provision of information was the most relevant attribute (32.6%). LCA revealed two distinct subgroups. Class 1 preferred to receive extensive information about DMHIs in a seminar, while class 2 wanted to be informed digitally (via e-mail or social media) and as early as possible in their studies.
CONCLUSIONS
Medical students have specific needs and preferences regarding DMHI information. Timing of information (early in medical education) was considered more important than information source or delivery mode, which should be prioritized by decision makers (e.g., members of faculties of medicine, university, ministry of education). This DCE provides novel insights into what is important when informing medical students about DMHIs and how complex and potentially well-accepted information strategies can be deduced by considering the preferences of the target group.
CLINICALTRIAL
The DCE was pre-registered at the Open Science Framework (OSF) in October 2022: https://osf.io/2s9u8.
... To do this, the Institute for Quality and Efficiency in Healthcare (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen) performs an initial advisory assessment, followed by a final evaluation of the Federal Joint Committee (FJC; Gemeinsamer Bundesausschuss). The FJC operates in this context as a regulator and decision-maker, and the decisions it reaches by means of the AMNOG process are binding for statutory health insurers, which, as the main payers in the German healthcare system, provide health insurance coverage to almost 90% of the population in Germany [4]. Although the act does not explicitly set a willingness-to-pay (WTP) threshold, the process itself implicitly establishes a WTP for health improvement. ...
Objectives:
The German Pharmaceutical Market Restructuring Act (AMNOG, 2011) is a two-stage process to regulate the price of new pharmaceuticals in which price negotiations are conducted based on evidence-based medical benefit assessments using data from prior clinical trials. Although the act does not explicitly set a willingness-to-pay (WTP) threshold, the process itself implicitly establishes a WTP for health improvement. We evaluated the implicit WTP for prescription pharmaceuticals post-AMNOG in the German healthcare system from the decision-maker/payer perspective.
Methods:
We extracted data on patient-group-specific annual treatment costs and endpoints from 2011 to 2021 from the dossiers assessed by the German Federal Joint Committee (FJC; Gemeinsamer Bundesausschuss). Using incremental cost-effectiveness ratios (ICERs), we calculated a WTP for the indications (I) diabetes, (II) cardiovascular disease, and (III) psoriasis weighted according to patient group size, first from the perspective of the decision-maker (approach A), and second from the perspective of the industry (approach B). To put clinical outcome measures into relation to one another, minimum clinically important differences (MCIDs) were derived from the literature and compared.
Results:
The annual treatment costs of newly authorized drugs were substantially higher (both pre- and post-negotiation) than that of their comparators (e.g., psoriasis, pre-negotiation: €20,601.59, post-negotiation: €16,763.57; comparators: €5178.00). However, although newly launched drugs were more expensive than their comparators, they brought greater medical benefits and were more aligned with value (r = 0.59, P < 0.001) than older drugs. We estimated WTP to vary widely by indication group [€33,814.08 per 1 percentage point hemoglobin A1c (HbA1c) reduction for diabetes, €10,970.83 per life year gained for cardiovascular disease, and €663.46 per 1% PASI decrease for psoriasis; approach A]. WTP was converted to MCID thresholds: diabetes: €16,907.04; cardiovascular drugs: no MCID existent to convert; and psoriasis: €33,173.00. WTP remained constant over time for diabetes and cardiovascular drugs but increased for psoriasis drugs.
Conclusion:
This paper is one of the first to estimate the implicit WTP for prescription pharmaceuticals post-AMNOG and suggests that the WTP may vary between different therapeutic areas. Additionally, making different assumptions (approach A versus approach B) with regard to the assumed effectiveness in indication areas that had been declared as having no additional benefit by the FJC may explain the different perspectives of decision-makers and of the pharmaceutical industry on the value of a pharmaceutical.
... Approximately 85% of the German population is insured by statutory health insurance (SHI) funds [32]. Specifically, the AOK PLUS sickness fund consists of data on 3.4 million patients insured by AOK PLUS in the regions of Saxony and Thuringia. ...
Real-world evidence in multiple sclerosis (MS) is limited by the availability of data elements in individual real-world datasets. We introduce a novel, growing database which links administrative claims and medical records from an MS patient management system, allowing for the complete capture of patient profiles. Using the AOK PLUS sickness fund and the Multiple Sclerosis Documentation System MSDS 3D from the Center of Clinical Neuroscience (ZKN) in Germany, a linked MS-specific database was developed (MSDS-AOK PLUS). Patients treated at ZKN and insured by AOK PLUS were recruited and asked for informed consent. For linkage, insurance IDs were mapped to registry IDs. After the deletion of insurance IDs, an anonymized dataset was provided to a university-affiliate, IPAM e.V., for further research applications. The dataset combines a complete record of patient diagnoses, treatment, healthcare resource use, and costs (AOK PLUS), with detailed clinical parameters including functional performance and patient-reported outcomes (MSDS 3D). The dataset currently captures 500 patients; however, is actively expanding. To demonstrate its potential, we present a use case describing characteristics, treatment, resource use, and costs of a patient subsample. By linking administrative claims to clinical information in medical charts, the novel MSDS-AOK PLUS database can increase the quality and scope of real-world studies in MS.
Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.
Background
IBDBIO‐ASSIST was a randomised controlled trial assessing the efficacy of care provided by IBD nurse specialists in Germany in improving health‐related quality of life (QoL) in IBD patients on biologic therapy.
Aim
To evaluate patient‐related outcomes and economic consequences associated with integrating IBD nurses into usual care.
Methods
We randomly assigned 1086 patients with IBD on biologic therapy to a control group (CG) receiving usual care or an intervention group (IG) receiving additional care from an IBD nurse specialist. The primary outcome was disease‐specific QoL (sIBDQ) assessed at 6, 12 and 18 months.
Results
At baseline, patients in both groups were highly satisfied with their treatment situation and had relatively high sIBDQ values (range: 1–7; CG: 5.12; IG: 4.92). In the intention‐to‐treat (ITT) analysis of the overall sample, there was no significant difference in sIBDQ between groups at the assessment time points. However, a per‐protocol analysis of patients with impaired QoL at baseline (EQ‐VAS < 75 [median]), showed improvement in sIBDQ over 6 months that became significant at month 12 and remained significant through month 18 (baseline: IG 4.24; CG 4.31; 18 months: IG 5.02; CG 4.76; p = 0.017).
Conclusion
High baseline satisfaction of IBD patients with treatment and the relatively high baseline sIBDQ values may have contributed to the lack of significant difference in sIBDQ scores for the overall sample. However, patients with impaired QoL derived significant benefit from additional care provided by an IBD nurse specialist, leading to meaningful improvements in sIBDQ over the long term.
Background: In 2019, Germany introduced a law to reimburse high-incidence populations for pre-exposure prophylaxis (PrEP), prescribed as tenofovir-disoproxil/emtricitabine (TDF/FTC), via statutory health insurance (SHI). We studied changes in TDF/FTC-prescriptions after the implementation of this law and during the COVID-19 pandemic.
Methods: We performed an interrupted time series analysis with monthly prescriptions per defined time period as the outcome. We considered the introduction of SHI-covered PrEP (09/2019) as an interruption, and four COVID-19 waves and two national lockdowns (2020–2021) as explanatory variables. We extrapolated prescriptions had the lockdowns not occurred, and compared this to the actual prescriptions. We performed sub-analyses based on stratification by five federal states with the highest proportion of PrEP users. We assessed the models’ goodness-of-fit based on the adjusted R -squared using RStudio.
Results: The best fitting model included SHI-covered PrEP and the first COVID-19 lockdown (04/2020). The decrease in prescriptions during the first lockdown was significant nationally, and in the five federal states for single-month prescriptions. The first lockdown resulted in reductions of 57.7% (95% prediction interval (PI): 23.0%–92.4%) for single-month prescriptions, while 17.4% (95% PI: 0.28%–34.5%) nationally, and 13.9% (95% PI: -3.67%–31.5%) for 3-month prescriptions.
Conclusion: Introduction of SHI-covered PrEP resulted in a doubling of TDF/FTC-prescriptions nationwide in the first month alone. A drop in prescriptions was most apparent after the first lockdown, and particularly affected PrEP initiations, possibly due to reduced healthcare access and behavioural changes. Ongoing monitoring of TDF/FTC-prescriptions is needed to safeguard access to preventative care such as PrEP and particularly PrEP initiation during public health crises like COVID-19.
Background
Sepsis survivors often suffer from new morbidities. Current rehabilitation therapies are not tailored to their specific needs. The perspective of sepsis survivors and their caregivers on rehabilitation and aftercare is insufficiently understood. We aimed to assess how sepsis survivors in Germany rated the suitability, extent and satisfaction with rehabilitation therapies that they underwent in the year following the acute sepsis episode.
Methods
Prospective mixed-methods, multicenter study among a cohort of adult ICU-treated sepsis survivors and their caregivers. Interviews were conducted 6 and 12 months after ICU discharge by telephone and comprised closed as well as open-ended questions. Primary outcomes were the utilization and patient satisfaction with inpatient and outpatient rehabilitation and post-sepsis aftercare in general. Open-ended questions were analyzed according to the principles of content analysis.
Results
Foun hundred interviews were performed with 287 patients and/or relatives. At 6 months after sepsis, 85.0% of survivors had applied for and 70.0% had undergone rehabilitation. Among these, 97% received physical therapy, but only a minority reported therapies for specific ailments including pain, weaning from mechanical ventilation, cognitive deficits of fatigue. Survivors were moderately satisfied with the suitability, extent, and overall results of received therapies and perceived deficits in the timeliness, accessibility, and specificity of therapies as well as deficits in the structural support frameworks and patient education.
Conclusion
From the perspective of survivors who undergo rehabilitation, therapies should already begin in hospital, be more appropriate for their specific ailments and include better patient and caregiver education. The general aftercare and structural support framework should be improved.
(1) Background: Patients’ experiences and satisfaction with their treatment are becoming increasingly important in the context of quality assurance, but the measurement of these parameters is accompanied by several disadvantages such as poor cross-country comparability and methodological problems. The aim of this review is to describe and summarize the process of measuring, publishing, and utilizing patient experience and satisfaction data in countries with highly developed healthcare systems in Europe (Germany, Sweden, Finland, Norway, the United Kingdom) and the USA to identify possible approaches for improvement. (2) Methods: Articles published between 2000 and 2021 that address the topics described were identified. Furthermore, patient feedback in social media and the influence of sociodemographic and hospital characteristics on patient satisfaction and experience were evaluated. (3) Results: The literature reveals that all countries perform well in collecting patient satisfaction and experience data and making them publicly available. However, due to the use of various different questionnaires, comparability of the results is difficult, and consequences drawn from these data remain largely unclear. (4) Conclusions: Surveying patient experience and satisfaction with more unified as well as regularly updated questionnaires would be helpful to eliminate some of the described problems. Additionally, social media platforms must be considered as an increasingly important source to expand the range of patient feedback.
Cancer is the leading cause of morbidity and mortality in the world. It has been reported that the incidence of new cancer cases in the world is 19.3 million with a death rate of 10 million in 2020. Chemotherapeutic drugs are used in cancer treatment. The most well-known anthracycline is doxorubicin. The anthracycline antibiotic doxorubicin (Adriamycin; Doxorubicin) was first produced in the 1960s from Streptomyces peucetius (Arcamone et al., 1969). Doxorubicin has been used as an anticancer drug for over forty years (Warpe et al., 2015). It is considered one of the most effective broad-spectrum anti-cancer anthracycline antibiotics when administered alone or in combination with other anti-cancer agents. It has been determined to be highly effective against various types of cancer, including malignancies (bladder, breast, lung, etc.), hematological neoplasia (Hodgkin's disease and non-Hodgkin lymphomas, and pediatric leukemia) (Wenningmann et al.,2019). Oxidative stress is produced due to the imbalance between reactive oxygen species generation in response to cell damage and endogenous antioxidant activation, leading to myocardial toxicity. Increased oxidative stress and antioxidant factor deficiency play an important role in doxorubicin-induced cardiotoxicity. By increasing the production of reactive oxygen species, doxorubicin impairs mitochondrial function and causes mutations in mitochondrial DNA. Cardiac damage due to mitochondrial damage and oxidative phosphorylation and decreased amount of antioxidant defense (catalase, superoxide dismutase and peroxidase) make cardiomyocytes more susceptible to cardiotoxicity compared to other cells. Although doxorubicin is used as one of the anti-cancer anthracycline antibiotics, it has been reported in studies that it causes chronic toxicity in vital organs such as the heart, tissues such as testes and ovaries, and this effect is more common in patients receiving doxorubicin (Altieri et al., 2016). In this study, the pharmacological effect of doxorubicin, an anticancer drug, and its toxicity in the heart and reproductive system were compiled with the information obtained from the literature.
After unification, the gap in infant mortality rates between the two parts of Germany widened until 1996 before converging. The reasons for these changes have not, so far, been apparent.
To investigate trends in neonatal and postneonatal mortality in the eastern (the new Länder) and western (the old Länder) part of Germany after unification in 1990 and to identify the scope for further improvement.
Examination of trends in birth weights, birth weight specific neonatal mortality and cause specific postneonatal mortality in the two parts of Germany from 1990 to 1996 and 1997 by analysing routinely available vital statistics data.
In both parts of Germany, neonatal mortality fell considerably, by 33 per cent in the east and 17 per cent in the west, from 4.5 and 3.5 per thousand live births in 1990 to 3.0 and 2.9 in 1997, respectively. This was attributable to an improvement in survival of infants at all birth weights but especially among those with very low birth weights, accounting for an estimated 83 to 85 per cent of the overall improvement. The birth weight distribution showed a slight worsening in the new and the old Länder with an increase in the proportion of those under 1500 g and, in the east, a 24 per cent increase in the proportion of high birth-weight infants of 4000 and more grams. Trends in postneonatal mortality revealed a worsening of about 32 per cent in the east from 1990 to 1991 followed by a decline of over 50 per cent up to 1997, leading to comparable mortality rates of 1.8 per thousand live births in the east and 2.0 in the west. While both parts experienced a decrease of 40 to 48 per cent in deaths from all diseases, the decline in deaths because of accidents and injuries was markedly higher in the new Länder although they are still exceeding the western rate by 3.7 per 100,000 live births in 1997.
Since unification, the two parts of Germany underwent a complex process that has led finally to convergence of parameters of infant health that are most likely to have been because of improvements in the quality of perinatal care. To improve infant mortality in Germany, policy measures should focus on preventive rather than curative measures as the proportion of very low birthweight babies is increasing in both parts of Germany.
Since their introduction in 1993, the structure of physician drug budgets in Germany has changed frequently. Although highly disputed, they have limited the pharmaceutical expenditure of the Statutory Health Insurance Scheme for nearly one decade. This raises the question of how these savings have been achieved. It is assumed that under budget constraints physicians aim to eliminate drug therapies with low or disputed effectiveness, and substitute existing drug therapies with cheaper generic therapies. Therefore, data for the prescription behavior of physicians are analyzed from the last ten years. Since the introduction of drug budgets, physicians have steadily reduced the number of prescriptions for drugs with disputed effectiveness, while prescriptions for drugs with undisputed effectiveness remained at a constant level. It can be projected that the number of prescribed drugs with disputed effectiveness will be zero by 2007 or 2008. From 1992 to 2000 expenditure for drugs with disputed effectiveness charged to the Statutory Health Insurance Scheme was reduced by € 3.0 billion. Fur-thermore, the market share of prescriptions as a percentage of the total pharmaceutical market and the turnover of generics as a percentage of the total market has steadily increased over the last ten years. The increased prescription of generics has generated savings of € 2.7 billion in the year 2002. It is concluded that drugs budgets have induced a change in prescription behavior, which has possibly led to improved drug therapy effectiveness.
There has been growing interest in the comparison of health system performance within and between countries, using a range of different indicators. This study examines trends in amenable mortality, as one measure of health system performance, in sixteen high-income countries.
Amenable mortality was defined as premature death from causes that should not occur in the presence of timely and effective health care. We analysed age-standardised rates of amenable mortality under age 75 in 16 countries for 1997/1998 and 2006/2007.
Amenable mortality remains an important contributor to premature mortality in 16 high-income countries, accounting for 24% of deaths under age 75. Between 1997/1998 and 2006/2007, amenable mortality fell by between 20.5% in the US and 42.1% in Ireland (average decline: 31%). In 2007, amenable mortality in the US was almost twice that in France, which had the lowest levels.
Amenable mortality continues to fall across high-income nations although the USA is lagging increasingly behind other high income countries. Despite its many limitations, amenable mortality remains a useful indicator to monitor progress of nations.
The introduction in 1996 of free choice among sickness funds in Germany was accompanied by a "risk structure compensation" (RSC) mechanism based on average spending by age and sex. Because chronically ill people were not adequately taken into account, competition for newly insured consumers concentrated on the healthy. The introduction in 2002 of disease management programs addresses this problem: Insured people in such programs are treated as a separate RSC category, making them a more "attractive" group that no longer generates a deficit. The degree of sickness fund activities and the fierce dispute with physicians are valid indicators that the incentives work.