Scope and Incentives for Risk Selection in Health Insurance Markets With Regulated Competition: A Conceptual Framework and International Comparison

In health insurance markets with regulated competition, regulators face the challenge of preventing risk selection. This paper provides a framework for analyzing the scope (i.e., potential actions by insurers and consumers) and incentives for risk selection in such markets. Our approach consists of three steps. First, we describe four types of risk selection: (a) selection by consumers in and out of the market, (b) selection by consumers between high- and low-value plans, (c) selection by insurers via plan design, and (d) selection by insurers via other channels such as marketing, customer service, and supplementary insurance. In a second step, we develop a conceptual framework of how regulation and features of health insurance markets affect the scope and incentives for risk selection along these four dimensions. In a third step, we use this framework to compare nine health insurance markets with regulated competition in Australia, Europe, Israel, and the United States.

Assessment of innovative living and care arrangements for persons with dementia: a systematic review

BACKGROUND

Alternative forms of housing for persons with dementia have been developed in recent decades. These concepts offer small groups of residents familiar settings combined with efforts to provide normal daily life. The aim of this systematic review is to collate and analyze these more innovative forms of housing regarding residents' quality of life, behavioral aspects, as well as functional, cognitive and emotional aspects.

METHODS

Searches were conducted in PubMed, EMBASE and PsycInfo in November 2020. Studies comparing traditional and more innovative living environments for persons with dementia were eligible. Concepts are described based on the results of additional searches. Risk of bias of included studies was assessed using checklists from the Joanna Briggs Institute.

RESULTS

A total of 21 studies corresponding to 11 different concepts were included, namely Green Houses (USA), Group Living (Sweden), Cantou (France), Group Homes (Japan), Small-scale Group Living (Austria), Special Care Facilities (Canada), Shared-housing Arrangements (Germany), Residential Groups (Germany), Residential Care Centers / Woodside Places (USA/Canada), Small-scale Living (Netherlands/ Belgium), and Green Care Farms (Netherlands). The concepts are broadly similar in terms of care concepts, but partly differ in group sizes, staff qualifications and responsibilities. Several studies indicate that innovative forms of housing may encourage social behavior, preserve activity performance and/or positively influence emotional status compared to more traditional settings, while other studies fail to demonstrate these effects. Some studies also show increased behavioral and psychological symptoms of dementia (BPSD) in residents who live in more innovative housing concepts. The effect on cognition remains indistinct.

DISCUSSION

The positive effects may be attributable to the inherent characteristics, including small group sizes, a stimulating design, and altered staff roles and responsibilities. Arguably, some of these characteristics might also be the reason for increased BPSD. Studies had variable methodological quality and results have to be considered with caution. Future research should examine these effects more closely and should investigate populations' preferences with regards to housing in the event of dementia.

A complex intervention to promote prevention of delirium in older adults by targeting caregiver's participation during and after hospital discharge - study protocol of the TRAnsport and DElirium in older people (TRADE) project

Background

Among potentially modifiable risk factors for delirium, transfers between wards, hospitals and other facilities have been mentioned with low evidence. TRADE (TRAnsport and DElirium in older people) was set up to investigate i) the impact of transfer and/or discharge on the onset of delirium in older adults and ii) feasibility and acceptance of a developed complex intervention targeting caregiver’s participation during and after hospital discharge or transfer on cognition and the onset of delirium in older adults.

Methods

The study is designed according to the guidelines of the UK Medical Research Council (MRC) for development and evaluation of complex interventions and comprises two steps: development and feasibility/piloting. The development phase includes i) a multicenter observational prospective cohort study to assess delirium incidence and cognitive decline associated with transfer and discharge, ii) a systematic review of the literature, iii) stakeholder focus group interviews and iv) an expert workshop followed by a Delphi survey. Based on this information, a complex intervention to better and systematically involve family caregivers in discharge and transport was developed. The intervention will be tested in a pilot study using a stepped wedge design with a detailed process and health economic evaluation. The study is conducted at four acute care hospitals in southwest Germany. Primary endpoints are the delirium incidence and cognitive function. Secondary endpoints include prevalence of caregiver companionship, functional decline, cost and cost effectiveness, quality of discharge management and quality of admission management in admitting hospitals or nursing homes. Data will be collected prior to discharge as well as after 3, 7 and 90 days.

Discussion

TRADE will help to evaluate transfer and discharge as a possible risk factor for delirium. In addition, TRADE evaluates the impact and modifiability of caregiver’s participation during patient’s transfer or discharge on delirium incidence and cognitive decline providing the foundation for a confirmatory implementation study.

Trial registration

DRKS (Deutsches Register für klinische Studien) DRKS00017828. Registered on 17th September 2019. Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02585-0.

Amortization of gene replacement therapies: A health policy analysis exploring a mechanism for mitigating budget impact of high-cost treatments

With gene replacement therapies (GRTs) increasingly and rapidly reaching the healthcare marketplace, the vast potential for improving patient health is matched by the potential budgetary impact for healthcare payers. GRTs are highly valuable given their potential life-extending or even curative benefits and may provide significant cost-offsets compared with standard of care. Current healthcare systems are, however, struggling to fund such valuable but costly therapies. Some payers have already implemented specific financing models to account for the new treatment paradigms, but these do not address the budget impact in the year of acquisition or administration of these costly technologies. This health policy analysis aimed to assess the rationale and feasibility of amortization, within the context of financing healthcare technologies, and specifically GRTs. Amortization is an accounting concept applied to intangible assets that allows for spreading the cost an intangible asset over time, allowing for repayment to occur via interest and principal payments sufficient to repay the intangible asset in full by its maturity. Our systematic scoping review on the amortization of healthcare technologies found a very small literature base with even that being unclear and inconsistent in its understanding of the issues. Where amortization was proposed as a solution for funding costly, but highly valuable GRTs, the concept was not fully investigated in detail, nor was the feasibility of the approach fully challenged. However, by providing clear definitions of relevant concepts along with an example of amortization models applied to some example GRTs, we propose that amortization can offer a promising method for funding of extraordinarily high-value healthcare technologies, thereby increasing market and patient access for these technologies. Nonetheless, healthcare accounting principles and financing guidelines must evolve to apply amortization to the rapidly developing GRTs.

Time spent on self-management by people with diabetes: results from the population-based KORA survey in Germany

AIMS

Time needed for health-related activities in people with diabetes is assumed to be substantial, yet available data are limited. Time spent on self-management and associated factors was analysed using cross-sectional data from people with diagnosed diabetes enrolled in a population-based study.

METHODS

Mean total time spent on self-management activities was estimated using a questionnaire for all participants with diagnosed diabetes in the KORA FF4 study (n = 227, 57% men, mean age 69.7, sd 9.9 years). Multiple two-part regression models were fitted to evaluate associated factors. Multiple imputation was performed to adjust for bias due to missing values.

RESULTS

Some 86% of participants reported spending time on self-management activities during the past week. Over the entire sample, a mean of 149 (sd 241) min/week were spent on self-management-activities. People with insulin or oral anti-hyperglycaemic drug treatment, better diabetes education, HbA_1c 48 to < 58 mmol/mol (6.5% to < 7.5%) or lower quality of life, spent more time on self-management activities. For example, people without anti-hyperglycaemic medication invested 66 min/week in self-management, whereas those taking insulin and oral anti-hyperglycaemic drugs invested 269 min/week (adjusted ratio 4.34, 95% confidence interval 1.85-10.18).

CONCLUSIONS

Time spent on self-management activities by people with diabetes was substantial and varied with an individual's characteristics. Because of the small sample size and missing values, the results should be interpreted in an explorative manner. Nevertheless, time needed for self-management activities should be routinely considered because it may affect diabetes self-care and quality of life.

[Medical care of patients with spasticity following stroke : Evaluation of the treatment situation in Germany with focus on the use of botulinum toxin]

BACKGROUND

Upper limb spasticity is a common complication following stroke. Cohort studies found 19% of post-stroke patients had upper limb spasticity at 3 months and 38% of patients at 12 months. For focal spasticity, intramuscular injections of botulinum toxin are indicated. In Germany, it is assumed that patients with the described indication are undersupplied with botulinum toxin.

OBJECTIVE

The aim of the present study is to evaluate the medical care of patients with upper limb spasticity post-stroke with the focus on the use of botulinum toxin as one treatment option.

METHODS

A standardized questionnaire was developed and a postal survey of a representative national random sample of 800 neurologists to capture the actual medical care situation.

RESULTS

The response rate amounted to 37% (n = 292). 59% of the neurologists surveyed had never used botulinum toxin. In total, 87% of neurologists noticed barriers regarding the use of botulinum toxin, where the amount of the doctor's remuneration in 40% and the lack of reimbursement of costs in off-label use in 60% were the most commonly used answers. The achievement of an advanced training in using botulinum toxin was also stated as a general obstacle for resident neurologists.

DISCUSSION

Due to a response rate of 37% for the postal survey a selection bias cannot be excluded. Although botulinum toxin is recommended in the national treatment guidelines, many neurologists do not use botulinum toxin. The reasons can be seen from the barriers described.

Critical appraisal of RCTs by 3rd year undergraduates after short courses in EBM compared to expert appraisal

Introduction: An essential aim of courses in evidence-based medicine (EBM) is to improve the skills for reading and interpreting medical literature adequately. Regarding the conceptual framework, it is important to consider different educational levels. Aim: Our primary aim was to investigate the applicability of different instruments for the assessment of methodological study quality by 3rd grade students after short courses in EBM. Our secondary outcomes were agreement with expert assessments and student's knowledge and competences. Methods: We conducted four short courses in EBM of 90 minutes each for health care management and medical students focused on critical appraisal of the literature. At the end, the students assessed five publications about randomized controlled trials (RCTs) using five different instruments; the results were compared to expert assessments. Results: In total, 167 students participated in our EBM courses. Students' assessments showed a non-systematic over- and underestimation of risk of bias compared to expert assessments with no clear direction. Agreement with expert assessments ranged between 66% to over 80%. Across RCTs, evidence was found that the choice of instrument had an impact on agreement rates between expert and student assessments (p=0.0158). Three RCTs showed an influence of the instrument on the agreement rate (p<0.05 each). Discussion: Our results contrast sharply with those of many other comparable evaluations. Reasons may be a lack of students' motivation due to the compulsory courses, and the comparison to a reference standard in addition to self-ratings causing objectivity. Conclusion: Undergraduates should become familiar with the principles of EBM, including research methods, and the reading of scientific papers as soon as possible. For a deeper understanding, clinical experience seems to be an indispensable precondition. Based on our results, we would recommend an integration of lectures about EBM and critical appraisal at least twice during studies and with greater intensity shortly before graduation.

[Exposure to limited resources in the gastroenterology - results of a survey of hospital physicians]

Background and research question: The hospital sector is currently characterized by a high economic pressure. As well the DRG system as the investment financing by the federal states imply financial limitations. Hospitals react to this situation by trying to reduce costs and to increase case volume. It is questionable whether and to what extent patient care and the working conditions of the physicians are affected by these circumstances. Especially, gastroenterological patients were considered to be insufficiently covered by the DRG system in the past. Therefore, this study focuses on the gastroenterology. Method: Based on prior studies and several semi-structured interviews with gastroenterologists working in hospitals a discipline-specific questionnaire was developed. Three versions of the questionnaire were differentiated to correspond to the respective experiences of the target population (chief physician, senior physician, assistant physician). All in all, 1751 members of the "Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten" (DGVS) were addressed. The questionnaire was answered by 642 participants resulting in a response rate of 36.7 %. The answers were interpreted by using descriptive and multivariate analyses. Results: A significant economic pressure is perceived by the participating gastroenterologists. This pressure manifests itself primary in perceived deficits in nursing care and human attention towards the patients. Moreover, the work satisfaction is negatively affected. Identified difficulties in the personnel recruitment can only be partially attributed to economic reasons. However, rationing of services is relatively seldom. Also, a financially-oriented overprovision is not perceived as a primary concern. In general, assistant physicians were a bit more skeptical about the situation in the gastroenterology, e. g. patient care, than the chief physicians. Conclusions: In total, the situation in the gastroenterology is similar to other stationary disciplines. However, in certain questions (e. g. increased surgery) differences are observed. Concerning perceived insufficient coverage of gastroenterologic services in the DRG system further projects should be initiated to improve coverage of these services.

[Delineating Concept for Defining the Country Practitioner - - An Objective Approach for Implementation in the Field of Health Services Research]

In the context of the scientific discussions on health care research, a concrete and uniform definition of a country practitioner is still lacking. This would be essential, however, for the future design of the medical care structure in Germany. In particular, the ongoing discussions on the predicted shortage of physicians in rural and mostly economically undeveloped regions - a shortage that is already affecting parts of Germany - suggest the need for clarification of the concept of a country practitioner. Only on the basis of a uniform definition does it seem possible to develop and discuss effective solutions across regions and to be able to use them in a targeted manner. The multitude of existing approaches to solutions, which include, among others, telemedicine, health centres, community nurses, outpatient care services being undertaken by hospitals, and youth development, must be evaluated and adapted to actual needs. The article presents a newly developed multi-stage plan for the differentiation between rural and urban doctors, which enables the definition of "country practitioner" to be adapted according to the region. With the aid of the definition, a review and further development of the aforementioned approaches to solutions can take place. Moreover, by applying the concept of delineation, there is an opportunity to create completely new ideas and solutions in the context of health services research. The basis of the new approach to rural and urban medical delineation essentially consists of the following delineation steps: basic centre (Step I), rural settlement (Step II) and central geographic location (Step III). In the following, these 3 successive delineation steps are first separately and theoretically derived. Thereafter, the presented concept is applied to the region of Westphalia-Lippe. The developed model collectively offers a standardized approach that is feasible from a temporal and financial perspective. The primary aim of this paper is to contribute to the ongoing discussion on outpatient care research and, in particular, to the definition of the country practitioner. Using the model approach presented here, this definition also enables comparisons to be made between different regions of Germany.

Nursing Care Deficits in German Hospitals - Results of a Nationwide Survey of Supervisory Staff in Hospital

Introduction: Currently, almost every second hospital is in financial deficit. Because of financial restrictions in the nursing profession, the staff has not been adequately adjusted to the increasing case volume. Current studies emphasize the rising workload of nursing staff and the resulting deficits in patient care. The aim of this study was to research whether the supervisory staff (nursing directors, chief physicians and hospital managers) also perceives these problems. Method: First, semi-structured interviews with chief physicians, nursing directors, hospital managers and hospital owners were conducted. Based on these qualitative insights, occupational group-specific questionnaires were developed. In spring 2014, these were sent to almost 5 000 supervisors. Results: There was a response rate of 43%. All respondents confirmed considerable economic restrictions related to the patient care - the greatest deficits were perceived concerning nursing care and personal attention given to patients. Moreover, the nursing directors were of the opinion that the nursing staff did not have enough time to perform all the necessary services. In particular, inadequate staffing was seen to be the cause of the rationing of nursing services. However, not only financial constraints but also a shortage of skilled staff increased the likelihood of withholding nursing services. Conclusion: In sum, all supervisory groups perceived large deficits in nursing care. With the current staff levels, nursing directors can hardly ensure provision of all necessary nursing services. The nurse support program will improve this situation slightly. In the medium term, the implementation of other instruments is necessary.

High cost pool or high cost groups-How to handle high(est) cost cases in a risk adjustment mechanism?

Competitive social health insurance systems (at least) in Western Europe have implemented systems of morbidity based risk adjustment to set a level playing field for insurers. However, many high cost insured still are heavily underfunded despite risk adjustment, leaving incentives for risk selection. In most of these health care systems, there is an ongoing debate about how to deal with such underpaid high cost cases. This study develops four distinct concepts by adding variables to risk adjustment or by setting up a high cost pool for underpaid insured besides the risk adjustment system. Their features, incentives and distributional effects are discussed. With a data set of 6 million insured, performance is demonstrated for Germany. All models achieve a substantial improvement in model fit, measured in terms of R(2) as well as CPM. As the results of the various models are different in different dimensions, the trade-offs that have to be dealt with and should be addressed, when implementing a model to reduce underfunding of high cost cases.

Prevalence and treatment costs of type 2 diabetes in Germany and the effects of social and demographical differences

Treatment costs for type 2 diabetes account for a substantial amount of the expenses for statutory health care funds. Within a study sample of the year 2005, 6.8% of the insured were being treated for type 2 diabetes mellitus. Compared to the non-diabetic insured in the sample, patients included more males and older persons. Employed diabetics also showed lower mean gross salary when compared to the non-diabetic employed of the sample. In 2007, their mean costs for in- and outpatient care and drug prescriptions amounted to 2,622 Euros per patient. The impacts of social and demographical patient characteristics on total treatment costs were measured with a multiple linear regression model, controlling for the hypoglycemic therapy of the patient. Here, the impact of age, gender and intensive insulin therapy became evident. A higher annual salary had a negative, yet non-significant, effect.

Demand-side strategies to deal with moral hazard in public insurance for long-term care

Moral hazard in public insurance for long-term care may be counteracted by strategies influencing supply or demand. Demand-side strategies may target the patient or the insurer. Various demand-side strategies and how they are implemented in four European countries (Germany, Belgium, Switzerland and the Netherlands) are described, highlighting the pros and cons of each strategy. Patient-oriented strategies to counteract moral hazard are used in all four countries but their impact on efficiency is unclear and crucially depends on their design. Strategies targeted at insurers are much less popular: Belgium and Switzerland have introduced elements of managed competition for some types of long-term care, as has the Netherlands in 2015. As only some elements of managed competition have been introduced, it is unclear whether it improves efficiency. Its effect will depend on the feasibility of setting appropriate financial incentives for insurers using risk equalization and the willingness of governments to provide insurers with instruments to manage long-term care.

Evaluation of an integrated care program for schizophrenia: concept and study design

Concept and design of an independent scientific evaluation of different pathways of care for schizophrenia patients in Germany with respect to effectiveness and efficiency are presented. In this prospective, observational study, schizophrenia patients receiving an integrated care treatment, the intervention group (IG), are compared with patients under routine care conditions treated by the same physician (first control group, CG 1). A second control group (CG 2) of patients treated by office-based psychiatrists not participating in the integrated care program will be recruited and their data compared with the two other groups. The total amount of psychiatric hospital days after 12 months is defined as primary outcome parameter. Secondary outcome parameters comprise the frequency of psychiatric inpatient readmissions, severity of schizophrenia symptoms, remission rates and quality of life. Patients undergo assessments at baseline, month 6 and 12 using standardized and experimental questionnaires. Routine data of a regional German social health insurance fund complement information on included patients. Additionally, a cost-effectiveness and cost-utility analysis will be performed. Until now, 137 psychiatrists included 980 patients in the integrated care project in Lower Saxony, Germany, and 47 psychiatrists (IG and both CGs) are willing to participate in the independent evaluation. For the first time, a prospective observational controlled evaluation study of a countrywide integrated care project planning to recruit 500 schizophrenia patients has started using comprehensive assessments as well as routine data of a social health insurance fund.

[Secondary data analysis of the prevalence of alcohol dependence (F10.2) in Germany]

BACKGROUND AND AIM

Compared to other European countries, alcohol consumption and abuse in Germany is on a high level. Even in smaller quantities, frequent alcohol consumption can generate organic damages and thus lead to secondary diseases that have a significant societal relevance regarding direct and indirect costs for the healthcare system. After several publications have already addressed the prevalence of acute alcohol intoxication and alcohol abuse in adolescents, the question arises how the prevalence of alcohol abuse develops on the basis of the accounting data of outpatient and inpatient care providers in the population of adults aged 18 and over and what tendency can be observed within a multi-year period. Within this study, the coding of alcohol abuse (F10.2 diagnosis) was analyzed separately for outpatient and inpatient sector in the insured population ≥ 18 years and presented over time.

PATIENTS AND METHODS

The development of the prevalence of alcohol abuse was analyzed on the basis of secondary random sample data from one nation-wide working statutory health insurance with a total population of more than 3 million insurants in the 5-year period from 2006 to 2010. For the presentation of the prevalences, insurant numbers were used. For the identification of the relevant insurants, only confirmed outpatient F10.2 diagnoses or inpatient F10.2 diagnoses were used. The age and sex distributions of the dataset were adjusted to the distribution in the statutory health insurance to ensure representativeness. The analyses of each single year only allude to insured persons aged ≥ 18 years. With the help of the statistics of the insured of statutory health insurance, for each calendar year, projections of the detected prevalence rates were determined to estimate the number of cases on the statutory health insurance level and their development over time.

RESULTS

The results show a tendency of slightly increasing prevalence of alcohol dependence from 2006 to 2010. For insured persons with at least one inpatient or outpatient F10.2 diagnosis, the prevalence continuously rises from 1,04% in 2006 to 1.14% in 2010; the prevalence of insured persons who received an alcohol dependence diagnosis only in the outpatient sector, increased from 0,67% to 0,79% in that time scale. In all analyzes, there was a ratio of 30% affected women to 70% affected men. From 2006 to 2010, the proportion of insured persons with hospitalization caused by alcohol dependence decreased steadily from 14,51% to 12,24%.

CONCLUSION

For the analyzed group of persons aged ≥ 18 years, the present analysis results show a tendency of slightly increasing prevalences of alcohol abuse, however at the same time combined with a decreasing proportion of hospitalized patients. Similar nationwide studies from 2010 on the basis of secondary data of a health insurance company and inclusion of outpatient and inpatient diagnoses also indicate prevalences of alcohol dependence of about 1.18%, but they base on the age range of 15- to 64-year-old insurants.