[Financial Influence on Medical Decisions in Germany - A Review of the Reasons and State of Research on Economization in Inpatient Care]

Increased economization in the German health care system may have an impact on medical decisions. A selective literature search presents an overview of the current evidence on the influence of financial incentives on inpatient healthcare in Germany. Due to the current economic pressure, physicians increasingly feel subjected to financial constraints concerning indication and treatment decisions. There is evidence for financially initiated upcoding and volume expansion. Little is known about the extent, the impact on quality of care, nor on vulnerable groups. The literature clearly documents effects of financial pressure on job satisfaction, perceived stress, and the health of attending physicians. The current discussion on the economization of physician practice is important, especially with regard to disincentives and job satisfaction. Little is known about the risks to patient health.

Increased instruction time and stress-related health problems among school children

While several studies suggest that stress-related mental health problems among school children are related to specific elements of schooling, empirical evidence on this causal relationship is scarce. We examine a German schooling reform that increased weekly instruction time and study its effects on stress-related outpatient diagnoses from the universe of health claims data of the German Social Health Insurance. Exploiting the differential timing in the reform implementation across states, we show that the reform slightly increased stress-related health problems among school children. While increasing instruction time might increase student performance, it might have adverse effects in terms of additional stress.

Is it good to be too light? Birth weight thresholds in hospital reimbursement systems

Birth weight manipulation has been documented in per-case hospital reimbursement systems, in which hospitals receive more money for otherwise equal newborns with birth weight just below compared to just above specific birth weight thresholds. As hospitals receive more money for cases with weight below the thresholds, having a (reported) weight below a threshold could benefit the newborn. Also, these reimbursement thresholds overlap with diagnostic thresholds that have been shown to affect the quantity and quality of care that newborns receive. Based on the universe of hospital births in Germany from the years 2005-2011, we investigate whether weight below reimbursement relevant thresholds triggers different quantity and quality of care. We find that this is not the case, suggesting that hospitals' financial incentives with respect to birth weight do not directly impact the care that newborns receive.

Heterogeneous Effects of a Nonlinear Price Schedule for Outpatient Care

Nonlinear price schedules generally have heterogeneous effects on health-care demand. We develop and apply a finite mixture bivariate probit model to analyze whether there are heterogeneous reactions to the introduction of a nonlinear price schedule in the German statutory health insurance system. In administrative insurance claims data from the largest German health insurance plan, we find that some individuals strongly react to the new price schedule while a second group of individuals does not react. Post-estimation analyses reveal that the group of the individuals who do not react to the reform includes the relatively sick. These results are in line with forward-looking behavior: Individuals who are already sick expect that they will hit the kink in the price schedule and thus are less sensitive to the co-payment. Copyright © 2016 John Wiley & Sons, Ltd.

Knowledge as a Predictor of Insurance Coverage Under the Affordable Care Act

BACKGROUND

The Affordable Care Act established policy mechanisms to increase health insurance coverage in the United States. While insurance coverage has increased, 10%-15% of the US population remains uninsured.

OBJECTIVES

To assess whether health insurance literacy and financial literacy predict being uninsured, covered by Medicaid, or covered by Marketplace insurance, holding demographic characteristics, attitudes toward risk, and political affiliation constant.

RESEARCH DESIGN

Analysis of longitudinal data from fall 2013 and spring 2015 including financial and health insurance literacy and key covariates collected in 2013.

SUBJECTS

A total of 2742 US residents ages 18-64, 525 uninsured in fall 2013, participating in the RAND American Life Panel, a nationally representative internet panel.

MEASURES

Self-reported health insurance status and type as of spring 2015.

RESULTS

Among the uninsured in 2013, higher financial and health insurance literacy were associated with greater probability of being insured in 2015. For a typical uninsured individual in 2013, the probability of being insured in 2015 was 8.3 percentage points higher with high compared with low financial literacy, and 9.2 percentage points higher with high compared with low health insurance literacy. For the general population, those with high financial and health insurance literacy were more likely to obtain insurance through Medicaid or the Marketplaces compared with being uninsured. The magnitude of coefficients for these predictors was similar to that of commonly used demographic covariates.

CONCLUSIONS

A lack of understanding about health insurance concepts and financial illiteracy predict who remains uninsured. Outreach and consumer-education programs should consider these characteristics.

Do they know what is at risk? Health risk perception among the obese

The perception of health risks and risky health behaviors are closely associated. In this paper, we investigate the accuracy of health risk perceptions among obese individuals, aged 50-62 years. We compare subjective risk perceptions for various diseases elicited in the American Life Panel to individual's objective risks of the same diseases. We find that obese individuals significantly underestimate their 5-year risks of arthritis or rheumatism and hypertension, whereas they systematically overestimate their 5-year risks of a heart attack and a stroke. Obese individuals are thus aware of some but not all obesity-related health risks. For given diseases, we document substantial heterogeneities in the accuracy of expectations across individuals.