Waiting times in primary care depending on insurance scheme in Germany

Attitudes towards the dual health insurance system and inequalities in health care in Germany - results of a population survey

BACKGROUND

In Germany, type of health insurance is an important aspect of health care inequalities because there is a dual structure of statutory and private health insurance and there are incentives for a preferential treatment of privately insured patients. Two questions will be addressed in the study: What are the public attitudes towards the dual system of health insurance and inequalities in health care between those with statutory and private insurance? Are these attitudes associated with socio-demographic characteristics, health insurance and political party preferences?

METHODS

Based on a random sample, an online survey among the adult population (18 + years) in Germany was conducted (N = 2,201). Attitudes towards statutory and private health insurance were assessed using four items. Two items related to inequalities in access and quality of care; two were aimed at the system structure and remuneration. Age, gender, education, migration history, region of residence, health insurance and political party preference were included in the analyses as predictors.

RESULTS

About 77% of respondents agreed with the statement that all insured persons in Germany have the same access to medically necessary care. Women were less convinced in this respect. Just over 20% agreed with the statement that people with statutory and private health insurance receive the same quality of medical care. Agreement was particularly high among men, older people and those with private insurance. Almost 80% were in favor of abolishing the coexistence of statutory and private health insurance. Agreement was lower among privately insured people and supporters of the liberal party; however, even in these subgroups, a majority of over 60% were in favor of abolition. Just over 15% found the different remuneration of services for those with statutory and private insurance acceptable. Agreement was significantly higher among older people and those with private insurance.

CONCLUSIONS

A clear majority of the German population perceives inequalities in the quality of medical care between those with statutory or private health insurance and is in favor of abolishing the dual system of statutory and private health insurance. These majorities can be found in all socio-demographic subgroups and across all political party lines.

Forgone and delayed care in Germany- inequalities and perceived health risk of unmet need

BACKGROUND

Subjective unmet need is an established indicator of unequal access to medical care and is often measured by delaying and forgoing medically necessary treatment. Research on delayed and forgone care among the general population in Germany including different reasons, social deprivation measures, and the perceived health risk of unmet need is sparse. This study aims to examine reasons, inequalities, and health-related consequences of unmet need in terms of delayed and forgone care.

METHODS

A cross-sectional online survey was carried out based on a randomly drawn sample of the German adult population in December 2022 (N = 2,201). Respondents were asked whether medical treatments were delayed or forgone in the past 12 months due to different reasons (waiting time, travel distance, financial costs). If unmet need was indicated, the respondents were subsequently asked about their perception of related health risks. Associations with individual social (sex, age, migration history, education, income) and regional factors (social deprivation) as well as insurance status were examined using multilevel logistic regressions analyses.

RESULTS

Among N = 1,955 respondents who indicated need for medical care, 30% reported at least one reason for forgone care (waiting time 23%, financial costs 11%, travel distance 9%). In terms of delayed care, highest rate was found for waiting time (34%). Multilevel analyses revealed significant associations of unmet need with female sex, younger age, lower education, lower income, and statutory health insurance. Associations varied depending on the reason for unmet need. Differences in regional social deprivation were particularly found for forgone care due to distance. Between half and nearly two-thirds of the participants reported worsening of symptoms in case of unmet need. Associations with social characteristics were inconsistent.

DISCUSSION

Unmet need is a prevailing issue in Germany and associated with perceived worsening of health, various indicators of social inequality, and health insurance. Reducing waiting times (e.g. through the further development of appointment service centres) and private co-payments as well as ensuring health care provision in deprived areas can contribute to a decrease of barrier-related unmet need and health risks. However, more in-depth studies are required to account for the complex nature of health care access.

Macular hole surgery in times of the COVID-19 pandemic

To assess whether there were any differences in patient presentation, morphological and functional features as well as surgical treatment for full-thickness macular holes (FTMH) during the lockdown periods amidst the COVID-19 pandemic compared to the previous year. A retrospective analysis was conducted on all patients with FTMH who received treatment at a large tertiary center during the lockdown periods from March 16 to June 16, 2020, and December 9, 2020, to June 6, 2021 (35 eyes, mean age 66 years). Corresponding periods from the previous year were chosen as a control group (41 eyes, mean age 71 years). The patients' demographics, preoperative and postoperative best-corrected visual acuity (BCVA), symptom duration, time from presentation to surgical treatment, and surgical technique were determined. The minimal and base diameters of the FTMH were assessed using spectral-domain optical coherence tomography. During the lockdown periods in the COVID-19 pandemic, there were no significant differences in the number of patients, duration of symptoms, time from presentation to surgical treatment, surgical technique, macular hole size, base diameter, closure rate or pre- and postoperative BCVA between the two groups. However, there was a significant increase in the number of patients who presented directly at the clinic on an emergency basis without prior contact with a community-based ophthalmologist. This study suggests that the diagnosis and the provision of timely surgical treatment of FTMH were not affected by the COVID-19 pandemic. However, patients more frequently sought immediate emergency care at the hospital. This could be attributed to challenges in scheduling and obtaining appointments at outpatient clinics during the COVID-19 pandemic.

Social disparities in access and quality of consultation in outpatient care in Germany

BACKGROUND

Overall, research on social determinants of access and quality of outpatient care in Germany is scarce. Therefore, social disparities (according to sex, age, income, migration background, and health insurance) in perceived access and quality of consultation in outpatient care (primary care physicians and specialists) in Germany were explored in this study.

METHODS

Analyses made use of a cross-sectional online survey. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Perceived access was assessed by waiting time for an appointment (in days) and travel time to the practice (in minutes), while quality of consultation was measured by consultation time (in minutes) and quality of communication (scale of four items, Cronbach's Alpha 0.89).

RESULTS

In terms of primary care, perceived access and quality of consultation was worse among women compared to men. Estimated consultation time was shorter among people with statutory health insurance compared to privately insured respondents. Regarding specialist care, people aged 60 years and older reported shorter waiting times and better quality of communication. Lower income groups reported lower quality of communication, while perceived access and quality of consultation was worse among respondents with a statutory health insurance. Variances explained by the social characteristics ranged between 1% and 4% for perceived access and between 3% and 7% for quality of consultation.

CONCLUSION

We found social disparities in perceived access and quality of consultation in outpatient care in Germany. Such disparities in access may indicate structural discrimination, while disparities in quality of consultation may point to interpersonal discrimination in health care.

Impact of the cost-of-living crisis on patient preferences towards virtual consultations

INTRODUCTION

Since 2021, the world has been facing a cost-of-living crisis which has negatively affected population health. Meanwhile, little is known about its impact on patients' preferences to access care. We aimed to analyse public preference for the modality of consultation (virtual vs face-to-face) before and after the onset of crisis and factors associated with these preferences.

METHODS

An online cross-sectional survey was administered to the public in the United Kingdom, Germany, Italy and Sweden. McNemar tests were conducted to analyse pre- and post-crisis differences in preferences; logistic regression was used to examine the demographic factors associated with public preferences.

RESULTS

Since the onset of crisis, the number of people choosing virtual consultations has increased in the United Kingdom (7.0% vs 9.5% P < 0.001), Germany (6.6% vs 8.6%, P < 0.008) and Italy (6.0% vs 9.8%, P < 0.001). Before the crisis, a stronger preference for virtual consultations was observed in people from urban areas (OR 1.28, 95% CI 1.05-1.56), while increasing age was associated with a lower preference for virtual care (OR 0.966, 95% CI 0.961-0.972). Younger people were more likely to switch to virtual care, while change to face-to-face was associated with younger age and lower income (OR 1.34, 95% CI 1.12-1.62). Older adults were less likely to change preference.

CONCLUSIONS

Since the onset of the cost-of-living crisis, public preference for virtual consultations has increased, particularly in younger population. This contrasts with older adults and people with lower-than-average incomes. The rationale behind patients' preferences should be investigated to ensure patients can access their preferred modality of care.

Financial risk protection in private health insurance: empirical evidence on catastrophic and impoverishing spending from Germany's dual insurance system

Financial risk protection from high costs for care is a main goal of health systems. Health system characteristics typically associated with universal health coverage and financial risk protection, such as financial redistribution between insureds, are inherent to, e.g. social health insurance (SHI) but missing in private health insurance (PHI). This study provides evidence on financial protection in PHI for the case of Germany's dual insurance system of PHI and SHI, where PHI covers 11% of the population. Linked survey and claims data of PHI insureds (n = 3105) and population-wide household budget data (n = 42,226) are used to compute the prevalence of catastrophic health expenditures (CHE), i.e. the share of households whose out-of-pocket payments either exceed 40% of their capacity-to-pay or push them (further) into poverty. Despite comparatively high out-of-pocket payments, CHE is low in German PHI. It only affects the poor. Key to low financial burden seems to be the restriction of PHI to a small, overall wealthy group. Protection for the worse-off is provided through special mandatorily offered tariffs. In sum, Germany's dual health insurance system provides close-to-universal coverage. Future studies should further investigate the effect of premiums on financial burden, especially when linked to utilisation.

Outcomes of cervical spinal stenosis surgery in patients aged ≥ 65 years based on insurance status: a single-center cohort study from a tertiary center in Germany

OBJECTIVE

The prevalence of degenerative disorders of the spine, such as cervical spinal stenosis with cervical spine myelopathy (CSM) in the geriatric population, has rapidly increased worldwide. To date, there has been no systematic analysis comparing outcomes in older patients suffering from progressive CSM and undergoing surgery depending on their health insurance status. We sought to compare the clinical outcomes and complications after anterior cervical discectomy and fusion (ACDF) or posterior decompression with fusion in patients aged ≥ 65 years with multilevel cervical spinal canal stenosis and concomitant CSM with special focus on their insurance status.

METHODS

Clinical and imaging data were retrieved from patients' electronic medical records at a single institution between September 2005 and December 2021. Patients were allocated into two groups with respect to their health insurance status: statutory health insurance (SHI) vs. private insurance (PI).

RESULTS

A total of 236 patients were included in the SHI group and 100 patients in the privately insured group (PI) group. The overall mean age was 71.7 ± 5.2 years. Regarding comorbidities, as defined with the age-adjusted CCI, SHI patients presented with higher rates of comorbidities as defined by a CCI of 6.7 ± 2.3 and higher prevalence of previous malignancies (9.3%) when compared to the PI group (CCI 5.4 ± 2.5, p = 0.051; 7.0%, p = 0.048). Both groups underwent ACDF (SHI: 58.5% vs. PI: 61.4%; p = 0.618), and the surgical duration was similar between both groups. Concerning the intraoperative blood transfusion rates, no significant differences were observed. The hospital stay (12.5 ± 1.1 days vs. 8.6 ± 6.3 days; p = 0.042) and intenisve care unit stay (1.5 ± 0.2 days vs. 0.4 ± 0.1 days; p = 0.049) were significantly longer in the PI group than in the SHI group. Similar in-hospital and 90-day mortality rates were noted across the groups. The presence of comorbidities, as defined with the age-adjusted CCI, poor neurological status at baseline, and SHI status, was significant predictor for the presence of adverse events, while the type of surgical technique, operated levels, duration of surgery, or blood loss was not.

CONCLUSIONS

Herein, we found that surgeons make decisions independent of health insurance status and aim to provide the most optimal therapeutic option for each individual; hence, outcomes were similar between the groups. However, longer hospitalization stays were present in privately insured patients, while SHI patients presented on admission with poorer baseline status.

The COVID-19 Pandemic and Cancer Patients in Germany: Impact on Treatment, Follow-Up Care and Psychological Burden

In response to the ongoing coronavirus disease 2019 (COVID-19) pandemic, governments imposed various measures to decrease the rate of disease spread, and health care policy makers prioritized resource allocation to accommodate COVID-19 patients. We conducted a cross-sectional online survey in Germany (July 2020-June 2021) to assess the frequency of changes to cancer care among cancer patients and to explore the psychological impact of the pandemic writ large. Cancer patients who contacted the Cancer Information Service (Krebsinformationsdienst, KID) of the German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ) via email were invited to complete an online questionnaire, capturing demographics, cancer specifics (e.g., type, disease phase, primary place of treatment, etc.), and any changes to their medical, follow-up, psycho-oncological or nursing care. General level of psychological distress was measured using the Hospital Anxiety and Depression Scale (HADS) along with face-validated items regarding worries and social isolation specific to the pandemic. In total, 13% of 621 patients reported a change to their treatment or care plan. Of those patients with changes, the majority of changes were made to follow-up care after treatment (56%), to monitoring during treatment (29%) and to psychological counseling (20%). Of the overall sample, more than half of patients (55%) reported symptoms of anxiety and 39% reported symptoms of depression. Patients with a change in cancer care were more likely to report symptoms of depression than those with no change (AOR: 2.18; 95% CI: 1.26-3.76). Concern about the pandemic affecting the quality of health care was a predictor of both anxiety (AOR: 2.76; 95% CI: 1.75-4.35) and depression (AOR: 2.15; 95% CI: 1.43-3.23). Results showed that the majority of cancer patients in our study did not experience a change in their cancer care. However, the level of anxiety and psycho-social burden of cancer patients during the pandemic was high throughout the study period. Our findings underscore the need for health care services and policy makers to assess and to attend cancer patients' medical needs, with added emphasis on patients' psychological and social well-being. This applies particularly in situations where the healthcare system is strained and prioritization is necessary.

What do patients expect? Assessing patient-centredness from the patients' perspective: an interview study

OBJECTIVE

Although there has been much conceptual work on patient-centredness (PC), patients' perspectives on PC were neglected. In a previous study, participating patients rated the relevance of 16 dimensions of an integrative model of PC as high to very high. However, it remained unclear which specific behaviours described in the dimensions were considered most relevant. Thus, the aim of the current study was to further explore which of the specific behaviours described in the model are especially relevant for the high ratings in the previous study.

METHODS AND DESIGN

We conducted semistructured interviews with 20 patients with chronic diseases (16 females, 4 males, mean age: 52 years). Patients answered questions regarding their experiences in the German healthcare system and how optimal healthcare would look like from their perspective. Furthermore, patients were asked to reflect on the most important aspects which they had mentioned in the interview before. Data were analysed via content analysis.

RESULTS

Participants addressed many different aspects of PC, but mostly focused on three major themes: (1) time appropriate access to care, (2) competence, empathy and being taken seriously by HCPs, (3) HCPs' individual consideration of each patient's situation (eg, wishes and needs). Minor themes were: (1) taking a holistic perspective of the patient, (2) patient-centred communication, (3) integration of multidisciplinary treatment elements, (4) transparency regarding waiting time and (5) reduction of unequal access to care.

CONCLUSION

This study enriches the construct of PC by depicting essential aspects of PC from the patients' perspective. The results allow prioritising strategies to implement patient-centred care. Thus, this study helps to pursue the ultimate goal of fostering patient-centred healthcare delivery in Germany.

Is the quality of skin cancer screening in Germany related to the specialization of the physician who performs it?: Results of a nationwide survey among participants of skin cancer screening

BACKGROUND

Skin cancer screening (SCS) is an important measure for secondary prevention of skin cancer, which is the most common cancer type worldwide. This study aimed to describe patient-reported quality of SCS in Germany according to the specialization of the performing physician and different patient characteristics.

METHODS

Data from 1260 participants 35-65 years of age (54.4% female) who underwent SCS and participated in National Cancer Aid Monitoring in 2019 were evaluated using chi-squared tests.

RESULTS

Waiting times for SCS from a dermatologist were significantly longer than those for other physicians (31.1 versus [vs.] 15.7 days; P < .001). Each body area examined during the standardized inspection was examined significantly more frequently by dermatologists than by other physicians (eg, upper body, 96.6% vs. 91.7%; P < .001). Dermatologists more often offered consultation for skin cancer prevention (74.0% vs. 67.6%; P = .026) and provided written information (47.8% vs. 34.8%; P < .001). Patients with statutory insurance had to pay more frequently for additional services during SCS from a dermatologist than from other physicians (24.7% vs. 17.1%, P = .012).

CONCLUSION

Results of this study revealed differences in the provision of preventive information and the quality of visual examination during SCS between dermatologists and other physicians. These results highlight the need for quality assurance measures.

Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

BACKGROUND

Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use.

METHODS

Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation.

RESULTS

From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate.

CONCLUSIONS

Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

While you're waiting, a waiting room-based, cardiovascular disease-focused educational program: protocol for a randomised controlled trial

INTRODUCTION

Patients with cardiovascular disease (CVD) frequently attend outpatient clinics and spend a significant amount of time in waiting rooms. Currently, this time is poorly used. This study aims to investigate whether providing CVD and cardiopulmonary resuscitation (CPR) education to waiting patients in a cardiology clinic of a large referral hospital improves motivation to change health behaviours, CPR knowledge, behaviours and clinic satisfaction post clinic, and whether there is any impact on reported CVD lifestyle behaviours or relevant CPR outcomes at 30 days.

METHODS AND ANALYSIS

Randomised controlled trial with parallel design to be conducted among 330 patients in the waiting room of a chest pain clinic in a tertiary referral hospital. Intervention (n=220) participants will receive a tablet-delivered series of educational videos catered to self-reported topics of interest (physical activity, blood pressure, diet, medications, smoking and general health) and level of health knowledge. Control (n=110) participants will receive usual care. In a substudy, intervention participants will be randomised 1:1 to receive an extra video on CPR or no extra video. The primary outcome will be the proportion of intervention and control participants who report high motivation to improve physical activity, diet and blood pressure monitoring at end of clinic. The primary outcome of the CPR study will be confidence to perform CPR post clinic. Secondary analysis will examine impact on clinic satisfaction, lifestyle behaviours, CPR knowledge and willingness to perform CPR post clinic and at 30-day follow-up.

ETHICS AND DISSEMINATION

Ethics approval has been received from the Western Sydney Local Health District Human Research Ethics Committee. All patients will provide informed consent via a tablet-based eConsent framework. Study results will be disseminated via the usual channels including peer-reviewed publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ANZCTR12618001725257.

Capturing modelled and perceived spatial access to ambulatory health care services in rural and urban areas in Germany

Studies on social and regional inequalities in access to health care often use spatial indicators such as physician density to measure access to health care. However, the concept of access is more complex, comprising, among others, patient perceptions. In this study, we evaluate the association between different spatial measures of access (i.e. physician density, distance to the nearest provider, and measures based on floating catchment area methods) and measures of perceived spatial access to ambulatory health care in rural and urban areas in Germany. Using correlation and regression analysis, we found that the significance and strength of the relation between perceived and modelled spatial access depends on the type of area and the physician group. The distance to the nearest physician is associated with perceived spatial access to GPs only in rural areas but not in urban areas. More sophisticated measures of spatial access seem not to explain perceived access better than the simpler indicators.

Waiting Time as an Indicator for Health Services Under Strain: A Narrative Review

As pressure increases on public health systems globally, a potential consequence is that this is transferred to patients in the form of longer waiting times to receive care. In this review, we overview what waiting for health care encompasses, its measurement, and the data available in terms of trends and comparability. We also discuss whether waiting time is equally distributed according to socioeconomic status. Finally, we discuss the policy implications and potential approaches to addressing the burden of waiting time. Waiting time for elective surgery and emergency department care is the best described type of waiting time, and it either increases or remains unchanged across multiple developed countries. There are many challenges in drawing direct comparisons internationally, as definitions for these types of waiting times vary. There are less data on waiting time from other settings, but existing data suggest waiting time presents a significant barrier to health care access for a range of health services. There is also evidence that waiting time is unequally distributed to those of lower socioeconomic status, although this may be improving in some countries. Further work to better clarify definitions, identify driving factors, and understand hidden waiting times and identify opportunities for reducing waiting time or better using waiting time could improve health outcomes of our health services.

Differences in Perceived Waiting Time by Health Insurance Type in the Inpatient Sector: An Analysis of Patients With Breast Cancer in Germany

Although the relationship between health insurance and waiting time has been established in the ambulatory sector in Germany, research in the inpatient sector is limited. This study aims to contribute to previous work through analyzing differences in perceived waiting time by health insurance type during the inpatient stays of patients with breast cancer in Germany. This study utilizes cross-sectional data from 2017 of patients with breast cancer (N = 4626) who underwent primary breast cancer surgery in a certified breast care center in Germany. Results from multilevel logistic regression models indicate a significant effect of health insurance status on perceived waiting time, net of other relevant factors (patient’s sociodemographic background, Union for International Cancer Control stage, grading, self-reported and classified health, type of surgery, and chemotherapy). Patients with statutory insurance were significantly more likely than privately insured patients to report long waiting times for examinations/procedures, discharge, and to speak with the physician. There were no significant differences in waiting time for nursing staff between private and statutory insurance holders. Results align with previous findings in the ambulatory sector and suggest a private health insurance advantage, with private patients receiving priority to some health care services. Disparities in health care accessibility and quality need to continue to be addressed and discussed, as well as the impact of health insurance type on other indicators of health.

Analysing the landscape for prescription to non-prescription reclassification (switch) in Germany: an interview study of committee members and stakeholders

Background

Non-prescription medicines are increasingly used in Germany, aided by prescription-to-non-prescription reclassification (or switch). This study aimed to examine the barriers and enablers to reclassification of medicines in Germany and provide recommendations for change.

Methods

Face-to-face conversational interviews with purposively selected key informants in Germany were conducted in 2017 by a researcher informed in the area. Interviews were transcribed, coded in NVIVO and systematically analysed using a framework approach.

Results

Twenty-four interviews were conducted with 32 participants including members of the committee considering reclassifications, and representatives from government, industry, health insurance, academia, and pharmacy, medical, and patients’ organisations.

A range of enablers and barriers emerged that influence reclassification including effects on the committee and process, or the desire of pharmaceutical companies to pursue reclassifications. Enabling market factors included the large population and a culture of self-medication. Enabling health system factors include the pharmacy-only category. Some pharmacy factors appeared enabling (e.g. a positive experience after reclassifying emergency contraception) while others appeared to hinder reclassification (e.g. insufficient pharmacy practice research). Some medical factors were enabling (e.g. reported waiting times) and others limited reclassification (e.g. opposition to some reclassifications). Some committee and government openness to reclassification and self-medication reportedly enabled reclassification, while conservatism was considered a barrier, particularly for classifications with special conditions for supply such as initial doctor diagnosis or other complexities. Some improvements to the committee constitution and considerations were recommended. Some participants found the reclassification process after the committee recommendation opaque, with opportunity for delays and political interference.

Industry factors included both enablers such as capability in reclassification, and barriers, such as a perceived low market potential of some reclassifications, and doubt that some candidates would be approved.

A need for more data emerged strongly, both pre-reclassification in applications, and post-reclassification.

Many participants saw merit with reclassification in non-traditional areas such as hypertension, diabetes and oral contraception.

Conclusions

Many factors influence reclassification in Germany. Recommended improvements included aspects of the process and committee consideration, and more data collection. Sufficient market exclusivity linked to data collection could aid the generation of evidence to aid committee considerations and encourage more applications of high quality.