Zur Strategieanfälligkeit der Arzneimittelkomponente des IPHCC+RxGroups-Klassifikationssystems in einem morbiditätsorientierten Risikostrukturausgleich - Eine konzeptionelle und datengestützte Analyse

[Health-based risk adjustment. Effects and side effects]

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

Review on use of German health insurance medication claims data for epidemiological research

PURPOSE

The objective was to evaluate the use of German health insurance claims data on medications over the last 10 years by a review of published studies.

METHODS

PubMed and Scopus were searched for relevant studies published in 1998 through 2007.

RESULTS

A total of 70 studies were included. Use of these data increased from 32 reports (45.7%) between 1998 and 2005 to 38 (54.3%) over the last 2 years (2006-2007). Over half of the studies (57.1%; n = 40) were written in English and the most frequent research types were health service utilization (51.4%; n = 36) and cost analyses (18.6%; n = 13). In most of the studies (65.7%; n = 46), medication data were linked with other health care utilization claims (e.g. hospitalization data and physicians' outpatient services). Data validity was not taken into consideration in 40.6% (n = 13) of the 32 studies that also analysed hospitalization or physicians' outpatient diagnoses.

CONCLUSIONS

German health insurance medication claims data were increasingly used for research purposes over the last 10 years. Especially methodological and validation studies are clearly needed.