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In this paper, we use unique health record data that cover outpatient care and the associated costs to quantify the health care costs of a sizable increase in the retirement age in Germany. For the identification, we exploit a sizable cohort-specific pension reform which abolished an early retirement program for all women born after 1951. Our results show that health care costs significantly increase by about 2.9% in the age group directly affected by the increase in the retirement age (women aged 60–62). We further show that the cost increase is mainly driven by the following specialist groups: Ophthalmologists, general practitioners (GPs), neurology, orthopedics, and radiology. While the effects are significant and meaningful on the individual level, we show that the increase in health care costs is modest relative to the positive fiscal effects of the pension reform. Specifically, we estimate an aggregate increase in the health costs of about 7.7 million euro for women born in 1952 aged 60–62 which amounts to less than 2% of the overall positive fiscal effects of the pension reform. [ABSTRACT FROM AUTHOR]

Background: Out-of-hospital cardiac arrest is one of the most frequent causes of death in Europe. Emergency medical services often struggle to reach the patient in time, particularly in rural areas. To improve outcome, early defibrillation is required which significantly increases neurologically intact survival. Consequently, many countries place Automated External Defibrillators (AED) in accessible public locations. However, these stationary devices are frequently not available out of hours or too far away in emergencies. An innovative approach to mustering AED is the use of unmanned aerial systems (UAS), which deliver the device to the scene. Methods: This paper evaluates the economic implications of stationary AED versus airborne delivery using scenario-based cost analysis. As an example, we focus on the rural district of Vorpommern-Greifswald in Germany. Formulae are developed to calculate the cost of stationary and airborne AED networks. Scenarios include different catchment areas, delivery times and unit costs. Results: UAS-based delivery of AEDs is more cost-efficient than maintaining traditional stationary networks. The results show that equipping cardiac arrest hot spots in the district of Vorpommern-Greifswald with airborne AEDs with a response time < 4 min is an effective method to decrease the time to the first defibrillation The district of Vorpommern-Greifswald would require 45 airborne AEDs resulting in annual costs of at least 1,451,160 €. Conclusion: In rural areas, implementing an UAS-based AED system is both more effective and cost-efficient than the conventional stationary solution. When regarding urban areas and hot spots of OHCA, complementing the airborne network with stationary AEDs is advisable. [ABSTRACT FROM AUTHOR]

This paper contributes to the discussion of whether non-indicated ultrasound examinations of the thyroid gland contribute to overtreatment and excess health care expenditures. Using two sources of claims data from Germany, we analyzed data from patients who underwent a TSH blood test which is the initial diagnostic measure to check for possible presence of thyroid dysfunction. In a matching analysis, we compared health costs of two groups of patients. One consisted of patients who underwent an early thyroid ultrasound that according to medical guidelines—at this point—was probably not indicated. The other group consisted of patients, who underwent no ultrasound examination at all or later in the course of the disease, making probable a correct indication. Both groups were made comparable by the means of a matching procedure. Average thyroid-specific health costs were substantially higher for the first group in the quarter in which the ultrasound examination took place. Some deviation in these specific costs persisted over a substantial period of time, with drug expenditures exhibiting the biggest difference. If, however, total health costs were considered, difference in costs was only found in the initial quarter. We conclude that non-indicated ultrasound examination of the thyroid gland may have some moderate effects on thyroid-specific costs. Yet the data do not suggest that long-lasting overtreatment and excess health expenditures are initiated by non-indicated ultrasound in Germany. [ABSTRACT FROM AUTHOR]

Like many OECD countries, Germany is currently facing a shortage of long-term care (LTC) workers. This situation is concerning in the context of the ageing of the German population. A potential reason why Germany fails to recruit and retain LTC workers is that LTC jobs are particularly demanding (physical and psychological strain) which may be harmful to health. However, there is a lack of empirical evidence demonstrating this effect. This article fills the gap in the literature by exploring to what extent LTC jobs reduce workers' health over time. We estimate a dynamic panel data model on the German Socio-Economic Panel (v.35; 1984–2018), which allows adressing selection issues into occupations. Our paper provides innovative findings on the impact of LTC occupations on workers' health. We confirm that LTC jobs have a negative impact on self-reported health. Our results have strong policy implications: we emphasize the need to provide sufficient assistance to LTC workers, who are at risk of facing more health issues than other workers. This issue is key to increase the attractiveness of LTC jobs and reduce turnover in the LTC workforce. [ABSTRACT FROM AUTHOR]

This paper investigates consumer preferences in the German statutory health insurance market. It further aims to test whether preferences differ by age and health status. Evidence is provided by a discrete choice experiment conducted in 2014 using the six most important attributes in sickness fund competition and ten random generated choice sets per participant. Price is found to be the most important attribute followed by additional benefits, managed care programmes, and distance to nearest branch. Other positive attributes of sickness funds are found to balance out a higher price, which would allow a sickness fund to position itself as high quality. However, significant differences in preferences were found between age and health status group. In particular, compromised health is associated with higher preference for illness-related additional benefits and less distance to the lowest branch, but lower preference for a lower price. Based on these differences, a distinct sickness fund offer could be constructed that would allow passive risk selection. [ABSTRACT FROM AUTHOR]

We develop a novel approach integrating epidemiological and economic models that allows data-based simulations during a pandemic. We examine the economically optimal opening strategy that can be reconciled with the containment of a pandemic. The empirical evidence is based on data from Germany during the SARS-CoV-2 pandemic. Our empirical findings reject the view that there is necessarily a conflict between health protection and economic interests and suggest a non-linear U-shape relationship: it is in the interest of public health and the economy to balance non-pharmaceutical interventions in a manner that further reduces the incidence of infections. Our simulations suggest that a prudent strategy that leads to a reproduction number of around 0.75 is economically optimal. Too restrictive policies cause massive economic costs. Conversely, policies that are too loose lead to higher death tolls and higher economic costs in the long run. We suggest this finding as a guide for policy-makers in balancing interests of public health and the economy during a pandemic. [ABSTRACT FROM AUTHOR]

This study evaluates the mental and physical strain experienced by informal caregivers. Econometric problems due to individuals selecting themselves into informal care provision are tackled using informative and detailed data on more than 2 million insureds from the largest sickness fund in Germany and applying the propensity score matching technique to estimate the average effect of treatment on the treated. This effect indicates how carers have fared relative to a counterfactual situation in which they would have been non-carers. The radius matching is applied in combination with a strict caliper to obtain a high degree of observational similarity between caring and non-caring individuals. The findings suggest that carers take more psychoactive drugs as well as analgesics and gastrointestinal agents. Females consume about 5 daily defined doses of antidepressants more when they care for dependent relatives. In case of tranquilizers and analgesics, the estimated effect for females amounts about 1 daily defined dose. Considering gastrointestinal agents, the effect amounts to 2 daily defined doses. Thus, informal caregiving appears to be a burdensome task with implications for both mental and physical health. [ABSTRACT FROM AUTHOR]

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers. [ABSTRACT FROM AUTHOR]

This paper presents a new approach to deal with spatial inequalities in risk adjustment between health insurances. The shortcomings of non-spatial and spatial fixed effects in risk adjustment models are analysed and opposed against spatial kernel estimators. Theoretical and empirical evidence suggests that a reasonable choice of the spatial kernel could limit the spatial uncertainty of the modifiable area unit problem under heavy-tailed claims data, leading to more precise predictions and economically positive incentives on the healthcare market. A case study of the German risk adjustment shows a spatial risk spread of 86 Euro p.c., leading to incentives for spatial risk selection. The proposed estimator eliminates this issue and conserves incentives for services optimisation. [ABSTRACT FROM AUTHOR]

Previous research found that physical appearance affects the risk-taking of sex workers through offering unprotected services. This paper utilizes a large individual-level data set covering 16,583 pay-for-sex contracts in 2011 and 2012 by 2,517 female suppliers in Germany. Results based on instrumental variables suggest that the incentive for risk-taking is about twice as high than when assuming random assignment of risk-taking. [ABSTRACT FROM AUTHOR]

In this paper, we analyze how a nationwide population-based skin cancer screening program (SCS) implemented in Germany in 2008 has impacted the number of hospital discharges following malignant skin neoplasm diagnosis and the malignant melanoma mortality rate per 100,000 inhabitants. Our panel data, drawn from the Eurostat database, cover subregions in 22 European countries, measured at the lowest nomenclature of territorial units for statistics (NUTS) level for 2000-2013. Applying fixed effects methods, we find a significantly positive and robust effect of the German SCS on the number of patients diagnosed with malignant skin neoplasm. However, the program does not significantly influence the melanoma mortality rate. This finding conflicts with the decreased melanoma mortality rate found for the pilot SCS program in northern Germany. Our results indicate that Germany's nationwide SCS program is effective in terms of a higher diagnosis rate for malignant skin neoplasms and thus may contribute to an improvement in the early detection of skin cancer. [ABSTRACT FROM AUTHOR]

Over the last decades, methods for the economic evaluation of health care technologies were increasingly used to inform reimbursement decisions. For a short time, the German Statutory Health Insurance makes use of these methods to support reimbursement decisions on patented drugs. In this context, the discounting procedure emerges as a critical component of these methods, as discount rates can strongly affect the resulting incremental cost-effectiveness ratios. The aim of this paper is to identify the appropriate value of a social discount rate to be used by the German Statutory Health Insurance for the economic evaluation of health technologies. On theoretical grounds, we build on the widespread view of contemporary economists that the social rate of time preference (SRTP) is the adequate social discount rate. For quantifying the SRTP, we first apply the market behaviour approach, which assumes that the SRTP is reflected in observable market interest rates. As a second approach, we derive the SRTP from optimal growth theory by using the Ramsey equation. A major part of the paper is devoted to specify the parameters of this equation. Depending on various assumptions, our empirical findings result in the range of 1.75-4.2% for the SRTP. A reasonable base case discount rate for Germany, thus, would be about 3%. Furthermore, we deal with the much debated question whether a common discount rate for costs and health benefits or a lower rate for health should be applied in health economic evaluations. In the German social health insurance system, no exogenously fixed budget constraint does exist. When evaluating a new health technology, the health care decision maker is obliged to conduct an economic evaluation in order to examine whether there is an economically appropriate relation between the value of the health gains and the additional costs which are given by the value of the consumption losses due to the additional health care expenditures. Therefore, a discount rate lower than the SRTP for consumption should be applied if an increase in the consumption value of health is expected. However, given the limited empirical evidence on the relationship between consumption and the value of health, it is hardly possible to make reliable forecasts of this value. Regarding the practice of the German evaluation authority, it is not recommended to use differential discounting in the base case. Instead, the issue of differential discounting should be addressed in sensitivity analyses. Reducing the discount rate for health compared to the rate for costs by a figure in the range between near 0% and 3% may be considered to be appropriate for Germany. [ABSTRACT FROM AUTHOR]

Recently, several checklists systematically assessed factors that affect the transferability of cost-effectiveness (CE) studies between jurisdictions. The role of the threshold value for a QALY has been given little consideration in these checklists, even though the importance of a factor as a cause of between country differences in CE depends on this threshold. In this paper, we study the impact of the willingness-to-pay (WTP) per QALY on the importance of transferability factors in the case of smoking cessation support (SCS). We investigated, for several values of the WTP, how differences between six countries affect the incremental net monetary benefit (INMB) of SCS. The investigated factors were demography, smoking prevalence, mortality, epidemiology and costs of smoking-related diseases, resource use and unit costs of SCS, utility weights and discount rates. We found that when the WTP decreased, factors that mainly affect health outcomes became less important and factors that mainly effect costs became more important. With a WTP below €1,000, the factors most responsible for between country differences in INMB were resource use and unit costs of SCS and the costs of smoking-related diseases. Utility values had little impact. At a threshold above €10,000, between country differences were primarily due to different discount rates, utility weights and epidemiology of smoking-related diseases. Costs of smoking-related diseases had little impact. At all thresholds, demography had little impact. We concluded that, when judging the transferability of a CE study, we should consider the between country differences in WTP threshold values. [ABSTRACT FROM AUTHOR]

This paper provides an overview of cancer management, particularly with respect to colorectal cancer (CRC), in Germany. The information presented reflects findings from the peer-review literature and government documentation, as well as interviews with cancer and CRC specialists. Topics such as epidemiology, expenditure, CRC screening, pharmaceutical and non-pharmaceutical treatment are discussed in this paper. Furthermore, insights into the German reimbursement system with regard to cancer management as well as regulatory aspects are presented. [ABSTRACT FROM AUTHOR]

The aim of this methodological paper is to summarize evidence on how to implement cost-benefit assessment according to the new German legislative framework (Competition Enhancement Act). Given the complexity of existing health policy frameworks within industrialised countries in adapting health economics in their respective regulatory scheme, no clear international scientific consensus on which health economic methods should be chosen for assessment can be determined. Nevertheless, a broad consensus on the internal properties of methods itself can be found. Based on these common international standards in methodology, this work provides a minimum catalogue of methods and criteria that meet legal and local German requirements with regard to specific factors of its health care system. Aside from categorising clearly defined standards (e.g., study forms, cost and benefit categories) the suggested catalogue specifies some intensively debated areas in Germany (e.g., the QALY, modelling, the perspective used in the assessment). After the proposition of certain methods the paper leads to a first recommendation of a detailed assessment-process itself specific for the German way in implementing cost-benefit ratios within regulatory decision making in Germany. [ABSTRACT FROM AUTHOR]

This paper employs a large-scale, individual-level, panel dataset to analyse the effect of EU accession on the probability of out-migration on the part of Hungarian physicians and dentists between 2003 and 2011. The study uses event history modelling and competing risk models. The results show that EU accession did not at the time affect the probability of out-migration while after the end of the transitional period of restrictions on the free movement of labour from the new EU member states to Austria and Germany, the probability of doctors' migration increased considerably. Relative wages and peer pressure also exercise a significant role in the out-migration decisions of young medical doctors. We also find that more than half of those medical doctors who left the country during the observation period returned some time later. The data furthermore suggest a massive flow of doctors to domestic jobs outside the health care system. [ABSTRACT FROM AUTHOR]

Objective: The goal of the present paper is to provide evidence on the behavior of physician practice cost functions.Data Sources: Our study is based on the data of 3686 physician practices in Germany for the years 2006 to 2008.Study Design: We apply a translog functional form and include a comprehensive set of variables that have not been previously used in this context. A system of four equations using three-stage least squares is estimated.Principal Findings: We find that a higher degree of specialization leads to a decrease in costs, whereas quality certification increases costs. Costs of group practices are higher than of solo practices. The latter finding can be explained by the existence of indivisibilities of expensive technical equipment. Smaller practices do not reach the critical mass to invest in certain technologies, which leads to differences in the type of health care services provided by different practice types.Conclusions: This is the first study to use physician practices as the unit of observation and to consider the endogenous character of physician input. Our results suggest that identifying factors that influence physician practice costs is important for providing evidence-based physician payment systems and to enable decision-makers to set incentives effectively. [ABSTRACT FROM AUTHOR]

Hospitals account for about 40% of all healthcare expenditure in high-income countries and play a central role in healthcare provision. The ways in which they are paid, therefore, has major implications for the care they provide. However, our knowledge about reforms that have been made to the various payment schemes and their country-level effects is surprisingly thin. This study examined the uniquely comprehensive introduction of diagnosis-related groups (DRGs) in Germany, where DRGs function as the sole pricing, billing, and budgeting system for hospitals and almost exclusively determine hospital revenue. The introduction of DRGs, therefore, completely overhauled the previous system based on per diem rates, offering a unique opportunity for analysis. Using aggregate data from the Organisation for Economic Co-operation and Development and recent advances in econometrics, we analyzed how hospital activity and efficiency changed in response to the reform. We found that DRGs in Germany significantly increased hospital activity by around 20%. In contrast to earlier studies, we found that DRGs have not necessarily shortened the average length of stay. [ABSTRACT FROM AUTHOR]

In response to the growing burden of obesity, public primary prevention programs against obesity have been widely recommended. Several studies have estimated the cost-effectiveness of diabetes-prevention trials for different countries. Nevertheless, it is still controversial if prevention conducted in more real-world settings and among people with increased risk but not yet exhibiting increased glucose tolerance can be a cost-saving strategy to cope with the obesity epidemic. We examine this question in a simulation model based on the results of the M.O.B.I.L.I.S program, a German lifestyle intervention to reduce obesity, which is directed on the high-risk group of people who are already obese. The contribution of this paper is the use of 4-year follow-up data on the intervention group and a comparison with a control group formed by SOEP respondents as inputs in a Markov model of the long-term cost savings through this intervention due to the prevention of type 2 diabetes. We show that from the point of view of a health insurer, these programs can pay for themselves. [ABSTRACT FROM AUTHOR]

The objective of this paper is to quantify selection effects related to blood donation behavior and their impact on donors' perceived health status. We rely on data from the 2009 and 2010 survey waves of the German socio-economic panel ( N = 12,000), including information on health-related, demographic and psychographic factors as well as monetary donation behavior and volunteer work. We propose a propensity score matching approach to control for the healthy donor effect related to the health requirements for active blood donations. We estimate two separate models and quantify selection biases between (1) active and inactive blood donors and (2) active donors and non-donors. Our results reveal that active donors are more satisfied with their health status; after controlling for selection effects, however, the differences become non-significant, revealing selection biases of up to 82 % compared with non-donors. These differences also exist between active and inactive donors, but the differences are less distinct. Our methodological approach reveals and quantifies selection biases attributable to the healthy donor effect. These biases are substantial enough to lead to erroneous statistical artifacts, implying that researchers should rigorously control for selection biases when comparing the health outcomes of different blood donor groups. [ABSTRACT FROM AUTHOR]

The author discusses the Institute for Quality and Efficiency in Health Care (IQWIG) of Germany. He states that IQWIG will turn into a full HTA agency which will assess benefits and costs of drugs and therapies. He highlights that in 2010, IQWiG will start with a number of cost-benefit assessments to support decision making on reimbursement of drugs for the German sickness funds. He crtiticised that IQWiG methods paper is not very specific about the perspective of the sickness funds' insurants.

Purpose: This study aims to determine the intention to use hospital report cards (HRCs) for hospital referral purposes in the presence or absence of patient-reported outcomes (PROs) as well as to explore the relevance of publicly available hospital performance information from the perspective of referring physicians. Methods: We identified the most relevant information for hospital referral purposes based on a literature review and qualitative research. Primary survey data were collected (May–June 2021) on a sample of 591 referring orthopedists in Germany and analyzed using structural equation modeling. Participating orthopedists were recruited using a sequential mixed-mode strategy and randomly allocated to work with HRCs in the presence (intervention) or absence (control) of PROs. Results: Overall, 420 orthopedists (mean age 53.48, SD 8.04) were included in the analysis. The presence of PROs on HRCs was not associated with an increased intention to use HRCs (p = 0.316). Performance expectancy was shown to be the most important determinant for using HRCs (path coefficient: 0.387, p <.001). However, referring physicians have doubts as to whether HRCs can help them. We identified "complication rate" and "the number of cases treated" as most important for the hospital referral decision making; PROs were rated slightly less important. Conclusions: This study underpins the purpose of HRCs, namely to support referring physicians in searching for a hospital. Nevertheless, only a minority would support the use of HRCs for the next hospital search in its current form. We showed that presenting relevant information on HRCs did not increase their use intention. [ABSTRACT FROM AUTHOR]

This paper shows that patients with private health insurance (PHI) are being offered significantly shorter waiting times than patients with statutory health insurance (SHI) in German acute hospital care. This behavior may be driven by the higher expected profitability of PHI relative to SHI holders. Further, we find that hospitals offering private insurees shorter waiting times when compared with SHI holders have a significantly better financial performance than those abstaining from or with less discrimination. [ABSTRACT FROM AUTHOR]

This paper analyses the effect of absolute deductibles on the cost of insurance for outpatient services. Moreover, cost savings on retained losses are estimated. Sharing risks between the insured and the insurer reduces total expenditure for outpatient benefits by up to 35%. In particular, optimal deductibles are determined in their utilitarian sense: the maximum possible savings on medical expenses are computed from the ground up. As part of the study, the effect of age and gender on these savings is analysed. The analysis is based on data taken from the private medical insurance industry in Germany. Similarities and discrepancies with respect to results obtained in the RAND Health Insurance Experiment conducted in the United States from 1971 to 1982 are highlighted. [ABSTRACT FROM AUTHOR]

This paper analyses the effect of the onset of disability on the well-being of individuals. In particular, we are interested in studying whether people can adapt to disability over time after its onset. Using longitudinal data from the German Socio-Economic Panel (GSOEP) for the period 1984–2006, we estimate life satisfaction equations using a fixed-effects model for working-age males (aged 21–58). The results show that disability has a significant negative effect on life satisfaction, but, in time, hedonic adaptation will return disabled males to life satisfaction levels registered by those who have not become disabled. These findings contribute to supporting the idea within psychology literature that individuals bounce back from painful events or adversities (such as the onset of disability) to achieve initial life satisfaction scores. [ABSTRACT FROM AUTHOR]

This paper analyses (1) the impact of the inclusion of statins in the German reference pricing scheme in 2005 on the statin market, and (2) the effect of switching behaviour subsequent to the policy change on healthcare utilisation and costs. Patients with prescriptions for statins in 2004 were observed for 1 year before and 1 year after the policy change, which went into effect on 1 January 2005. Data on outpatient and inpatient visits, pharmaceutical consumption, and cost to the sickness fund were collected from a sickness fund with more than 5.8 million insured members in 2005. Compared to patients who were not affected by the policy change, patients treated previously with atorvastatin experienced higher non-adherence and increased discontinuation of treatment ( P < 0.0001). Compared to patients who continued treatment with atorvastatin (non-switchers), patients who switched to another statin were hospitalised more often ( P = 0.0439). However, difference-in-differences in hospitalisation due to coronary heart disease ( P = 0.8751) and emergency visits ( P = 0.5624) did not differ significantly between the two groups. Patients who switched more than once experienced a significant increase in hospital visits ( P = 0.0061) and hospital visits due to cardiovascular disease ( P = 0.0096) compared to non-switchers. Difference-in-differences in outpatient healthcare utilisation did not differ between non-switchers and switchers. Total savings resulting from the policy change ranged from € 94.4 million to € 108.7 million. Although manufacturers usually comply with reference pricing by reducing their retail prices to the reference price, regulators have to be aware of the consequences in cases where manufacturers react as in this situation. [ABSTRACT FROM AUTHOR]

The Federal Joint Committee (FJC; Gemeinsamer Bundesausschuss, G-BA) defines the health-care elements that are to be reimbursed by sickness funds. To define a directive, the FJC can commission benefit assessments, which provide an overview of the scientific evidence regarding the efficacy and benefits of an intervention. This paper describes the operational implementation of the legal requirements with regard to the benefit assessments of medicines. Such benefit assessments are sometimes referred to as “isolated benefit assessments,” to distinguish them from benefit assessments as part of a full economic evaluation... [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic has entered its third year and continues to affect most countries worldwide. Active surveillance, i.e. testing individuals irrespective of symptoms, presents a promising strategy to accurately measure the prevalence of SARS-CoV-2. We aimed to identify the most cost-effective active surveillance strategy for COVID-19 among the four strategies tested in a randomised control trial between 18th November 2020 and 23rd December 2020 in Germany. The four strategies included: (A1) direct testing of individuals; (A2) direct testing of households; (B1) testing conditioned on upstream COVID-19 symptom pre-screening of individuals; and (B2) testing conditioned on upstream COVID-19 symptom pre-screening of households. Methods: We adopted a health system perspective and followed an activity-based approach to costing. Resource consumption data were collected prospectively from a digital individual database, daily time records, key informant interviews and direct observations. Our cost-effectiveness analysis compared each strategy with the status quo and calculated the average cost-effective ratios (ACERs) for one primary outcome (sample tested) and three secondary outcomes (responder recruited, case detected and asymptomatic case detected). Results: Our results showed that A2, with cost per sample tested at 52,89 EURO, had the lowest ACER for the primary outcome, closely followed by A1 (63,33 EURO). This estimate was much higher for both B1 (243,84 EURO) and B2 (181,06 EURO). Conclusion: A2 (direct testing at household level) proved to be the most cost-effective of the four evaluated strategies and should be considered as an option to strengthen the routine surveillance system in Germany and similar settings. [ABSTRACT FROM AUTHOR]

In response to rapidly rising pharmaceutical costs, many countries have introduced health technology assessment (HTA) as a 'fourth hurdle'. We evaluated the causal effect of HTA based regulation on access to pharmaceuticals by using the introduction of Germany's HTA system (AMNOG) in 2011. We obtained launch data on pharmaceuticals for 30 European countries from the IQVIA (formerly IMS) database. Using difference-in-difference models, we estimated the effect of AMNOG on launch delay, the ranking order of launch delays and the availability of pharmaceuticals. We then compared the results for Germany to Austria, Czechia, Italy, Portugal and the UK. Across all six countries, launch delay decreased from the pre-AMNOG period (25.01 months) to the post-AMNOG period (14.34 months). However, the introduction of AMNOG consistently reduced the magnitude of the decrease in launch delay in Germany compared to the comparator countries (staggered DiD: + 4.31 months, p = 0.05). Our logit results indicate that the availability of pharmaceuticals in Germany increased as a result of AMNOG (staggered logit: + 5.78%, p = 0.009). We provide evidence on the trade-off between regulation and access. This can help policymakers make better informed decisions to strike the right balance between cost savings achieved through HTA based regulation and access to pharmaceuticals. [ABSTRACT FROM AUTHOR]

Objective: Development of an aggregate quality index to evaluate hospital performance in cardiovascular events treatment. Methods: We applied a two-stage regression approach using an accelerated failure time model based on variance weights to estimate hospital quality over four cardiovascular interventions: elective coronary bypass graft, elective cardiac resynchronization therapy, and emergency treatment for acute myocardial infarction. Mortality and readmissions were used as outcomes. For the estimation we used data from a statutory health insurer in Germany from 2005 to 2016. Results: The precision-based weights calculated in the first stage were higher for mortality than for readmissions. In general, teaching hospitals performed better in our ranking of hospital quality compared to non-teaching hospitals, as did private not-for-profit hospitals compared to hospitals with public or private for-profit ownership. Discussion: The proposed approach is a new method to aggregate single hospital quality outcomes using objective, precision-based weights. Likelihood-based accelerated failure time models make use of existing data more efficiently compared to widely used models relying on dichotomized data. The main advantage of the variance-based weights approach is that the extent to which an indicator contributes to the aggregate index depends on the amount of its variance. [ABSTRACT FROM AUTHOR]

As the German population is continually aging and the majority of older adults still wish to 'age in place', the need for informal care provided by family and friends will correspondingly continue to increase. In addition, while the need for formal (professional) care services is also likely to increase, the supply already does not meet the demand in Germany today. The aim of our study is the elicitation of people's willingness to provide informal care by means of a discrete choice experiment. The self-complete postal survey was disseminated to a random sample of the German general population in Lower Saxony. Data cleansing resulted in a final sample size of 280 participants. A conditional logit and a latent class model were estimated. All attributes were judged as highly relevant by the respondents. The results revealed that an increase in the care hours per day had the greatest negative impact overall on the willingness to provide informal care in our sample. The marginal willingness-to-accept for 1 h of informal care was €14.54 when having to provide informal care for 8 h in reference to 2 h per day. This value is considerably higher than the national minimum wage of €9.82. A three-class latent class model revealed preference heterogeneity. While a monetary compensation is often discussed to increase the willingness and availability of informal care in a country, our results show that this statement could not be generalized within our entire sample. [ABSTRACT FROM AUTHOR]

The skilled labour shortage in nursing is an issue not unique to Germany. Unattractive characteristics of nursing jobs are one reason for the low supply in nursing personnel. In our study, we analyse the influence of job characteristics on the attractiveness of nursing jobs. We address this issue via factorial survey analysis, an experimental method particularly suited to assessing personal opinions and less prone to social desirability bias than standard interview methods. Around 1300 (current and former) nurses in a distinct region in Germany were asked to rate a set of synthetic job postings, each of which contained information on 9 systematically varied job characteristics. We find that, first, attractiveness of care jobs is most strongly affected by rather "soft" characteristics such as atmosphere within the team and time for patients. "Hard" factors play a considerably smaller role. Second, one hard factor, contract duration, is estimated to be among the most important job factors, however. This is a remarkable finding given that nursing occupations suffer from severe skill shortages. Third, though wage has a statistically significant influence on attractiveness, enormous wage raises would be needed to yield higher attractiveness gains than the top-rated soft factors, or to compensate for less pleasant job characteristics with respect to those factors. Last, even after controlling for other job characteristics, hospital nursing is still rated as more attractive than geriatric nursing. [ABSTRACT FROM AUTHOR]

We use German SHARE data to study the relationship between district general practitioner density and the quality of preventive care provided to older adults. We measure physician quality of care as the degree of adherence to medical guidelines (for the management of risk factors for cardiovascular disease and the prevention of falls) as reported by patients. Contrary to theoretical expectations, we find only weak and insignificant effects of physician density on quality of care. Our results shed doubt on the notion that increasing physician supply will increase the quality of care provided in Germany's present health care system. [ABSTRACT FROM AUTHOR]

Primary antibody deficiencies are the most common forms of primary immunodeficiencies. Substitution therapy with polyvalent immunoglobulins has been established as the standard therapy for antibody deficiencies for several decades. Until now mainly intravenous immunoglobulins (IVIG) have been used in Germany, and the majority of patients receive treatment in hospital outpatient clinics. In recent years subcutaneous administration of immunoglobulins (SCIG) has been developed which is administered as home self-infusion. Studies indicate no significant differences in immunoglobulin substitution therapy between SCIG and IVIG concerning outcome. We carried out a cost-minimization analysis to compare the two treatment alternatives in Germany. Under base case assumptions the treatment with SCIG is cost saving from the perspective of the German statutory health insurance. The main cost drivers are IVIG and SCIG; the incremental cost of SCIG compared to IVIG is most sensitive to changes in the immunoglobulin price and changes in the body weight of the patient. [ABSTRACT FROM AUTHOR]

Cytology-based screening programs for cervical cancer have been effective in reducing cancer incidence and preventing premature deaths worldwide. However, there is concern about the relatively low sensitivity of current screening procedures. Although the causal association between infection with certain high-risk types of human papilloma virus (HPV) and the development of cervical cancer has been clearly established, testing for the major risk factor is not part of current screening practice. We created a tree decision model over time to evaluate different policy choices for implementing a population-based screening program. Results of the economic analysis indicate that testing with any implemented HPV DNA testing (stand alone or in combination with the Papanicolaou smear) is superior to cytology and measures presently in use. Additional costs per life-years gained cannot be reported because the HPV branches had fewer discounted overall costs (€222 million vs. €82 and €76 million, respectively), and they saved more life years (19,599 vs. 19,163 and 903, respectively) then the smear alternative. Any HPV DNA testing is preferable over the current state of the art performed in Germany. This is true not only for economic reasons but also for life-years gained. Therefore HPV DNA testing must become an essential component to back up the relatively weak sensitivity of the standard procedure. [ABSTRACT FROM AUTHOR]

Background: Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes. Methods: A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications. Results: An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources. Conclusions: This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes. [ABSTRACT FROM AUTHOR]

In this study, we investigated the relationship between changes in demand-side determinants and changes in hospital admissions. We used longitudinal market-wide data, including a novel detailed measure of population morbidity. To assess the effect of ageing, we interacted age with shifts in the population structure for both the surviving population and the population in their last year of life. We used fixed effects models and addressed the endogeneity of morbidity with instrumental variables. We found that changes in morbidity had the largest impact on changes in hospital admissions. Changes in the size of the surviving population had the second largest impact, which differed substantially across the age spectrum. There was a large response in admissions to changes in the size of the population aged 60-79 years. The end-of-life effect had the smallest impact and began to play a greater role only in the population aged 80 years and older. In many studies, end of life presumably approximates high morbidity. Our results demonstrated robustness in several tests. We performed estimations in separate major diagnostic categories and included changes in personal preferences. We argue that the determinants included in our estimations capture the vast majority of change on the demand side. Taken together, our findings provide evidence that these determinants explain one-fifth of changes in hospital admissions. [ABSTRACT FROM AUTHOR]

Background: The impact of various post-procedural complications after transcatheter aortic valve implantation (TAVI) on resource use and their consequences in the German reimbursement system has still not been properly quantified.Methods: In a retrospective observational study, we use data from the German DRG statistic on patient characteristics and in-hospital outcomes of all isolated TAVI procedures in 2013 (N = 9147). The impact of post-procedural complications on reimbursement, length of stay and mechanical ventilation was analyzed using both unadjusted and risk-adjusted linear and logistic regression analyses.Results: A total of 235 (2.57%) strokes, 583 (6.37%) bleeding events, 474 (5.18%) cases of acute kidney injury and 1428 (15.61%) pacemaker implantations were documented. The predicted reimbursement of an uncomplicated TAVI procedure was €33,272, and bleeding events were associated with highest additional reimbursement (€12,839, p < 0.001), extra length of stay (14.58 days, p < 0.001), and increased likelihood of mechanical ventilation for more than 48 h (OR 17.91, p < 0.001). A more moderate complication-related impact on resource use and reimbursement was found for acute kidney injury (additional reimbursement: €5963, p < 0.001; extra length of stay: 7.92 days, p < 0.001; ventilation >48 h: OR 6.93, p < 0.001) as well as for stroke (additional reimbursement: €4125, p < 0.001; extra length of stay: 4.68 days, p < 0.001; ventilation >48 h: OR 5.73, p < 0.001). Pacemaker implantations, in contrast, were associated with comparably small increases in reimbursement (€662, p = 0.006) and length of stay (3.54 days, p = 0.006) and no impaired likelihood of mechanical ventilation more than 48 h (OR 1.22, p = 0.156). Interestingly, these complication-related consequences remain mostly unchanged after baseline risk-adjustment.Conclusions: Post procedural complications such as bleeding events, acute kidney injuries and strokes are associated with increased resource use and substantial amounts of additional reimbursement in Germany, which has important implications for decision making outside of the usual clinical sphere. [ABSTRACT FROM AUTHOR]

Introduction: Telemonitoring for COPD has gained much attention thanks to its potential of reducing morbidity and mortality, healthcare utilisation and costs. However, its benefit with regard to clinical and economic outcomes remains to be clearly demonstrated.Objective: To analyse the effect of Europe's largest COPD telemonitoring pilot project on direct medical costs, health resource utilisation and mortality at 12 months.Methods: We evaluated a population-based cohort using administrative data. Difference-in-difference estimators were calculated to account for time-invariant unobservable heterogeneity after removing dissimilarities in observable characteristics between the telemonitoring and control group with a reweighting algorithm.Results: The analysis comprised 651 telemonitoring participants and 7047 individuals in the standard care group. The mortality hazards ratio was lower in the intervention arm (HR 0.51, 95 % CI 0.30-0.86). Telemonitoring cut total costs by 895 € (p < 0.05) compared to COPD standard care, mainly driven by savings in COPD-related hospitalisations in (very) severe COPD patients (-1056 €, p < 0.0001). Telemonitoring enrolees used healthcare (all-cause and COPD-related) less intensely with shorter hospital stays, fewer inpatient stays and smaller proportions of people with emergency department visits and hospitalisations (all p < 0.0001). Reductions in mortality, costs and healthcare utilisation were greater for (very) severe COPD cases.Conclusion: This is the first German study to demonstrate that telemonitoring for COPD is a viable strategy to reduce mortality, healthcare costs and utilisation at 12 months. Contrary to widespread fear, reducing the intensity of care does not seem to impact unfavourably on health outcomes. The evidence offers strong support for introducing telemonitoring as a component of case management. [ABSTRACT FROM AUTHOR]

Background: Attention-deficit/hyperactivity disorder (ADHD) imposes a substantial burden on patients and their families.Objective: A retrospective, propensity score-matched cohort study compared treatment patterns, healthcare resource utilization (HRU) and costs among children/adolescents with ADHD aged 6-17 years at treatment initiation (index) in Germany who received atomoxetine (ATX) or long-acting methylphenidate (LA-MPH) monotherapy.Methods: Patients received at least one prescription for their index medication (ATX/LA-MPH) during 2006-2010; the first prescription marked the index date. ATX- and LA-MPH-indexed cohorts were matched 1:1 (n = 737); a patient subset was identified that had not received ADHD-indicated medications in 12 months prior to index (novel initiators: ATX, n = 486; LA-MPH, n = 488). Treatment patterns were evaluated among novel initiators, and HRU and costs among the matched cohorts in the 12 months after index.Results: No significant differences in baseline characteristics were found between the novel initiator patient subsets. ATX-indexed novel initiators had significantly longer persistence to index medication [mean (standard deviation; SD) days: 222.0 (133.9) vs 203.2 (135.0), P = 0.029) but higher switching rates (8.8 vs 5.5 %, P = 0.045) than LA-MPH-indexed novel initiators. The total ATX-indexed cohort required more prescriptions [any medication; mean (SD): 20.9 (11.5) vs 15.7 (9.0), P < 0.001] and outpatient visits [mean (SD): 10.1 (6.3) vs 8.3 (5.3), P < 0.001], and incurred significantly higher total median healthcare costs (€1144 vs €541, P < 0.001) versus matched LA-MPH patients.Conclusions: These real-world data indicate that, among children/adolescents with ADHD in Germany, ATX-indexed patients may require more prescriptions and physician visits, and incur higher total healthcare costs, than matched LA-MPH patients. [ABSTRACT FROM AUTHOR]

Hazardous alcohol consumption in Germany is a main threat to health. By using insurance claim data from the German Statutory Health Insurance and a classification strategy based on ICD10 diagnoses-codes we analyzed a sample of 146,000 subjects with more than 19,000 hazardous alcohol consumers. Employing different regression models with a control function approach, we calculate life years lost due to alcohol consumption, annual direct and indirect health costs, and the burden of pain and suffering measured by the Charlson-Index and assessed pain diagnoses. Additionally, we simulate the net accumulated premium payments over expenses in the German Statutory Health Insurance and the Statutory Pension Fund for hazardous alcohol consumers from a lifecycle perspective. In total, €39.3 billion each year result from hazardous alcohol consumption with an average loss of 7 years in life expectancy. Hazardous alcohol consumers clearly do not "pay their way" in the two main German social security systems and also display a higher intangible burden according to our definitions of pain and suffering. [ABSTRACT FROM AUTHOR]

Background: In 2009, the European Medicines Agency granted approval for two higher-valent pneumococcal conjugate vaccines. This study aims to evaluate the cost-effectiveness of universal infant (<2 years old) vaccination with a 13-valent pneumococcal conjugate vaccine (PCV13) in comparison with a 10-valent pneumococcal conjugate vaccine (PCV10) for the prevention of pneumococcal disease in Germany.Methods: A population-based Markov model was developed to estimate the impact of PCV13 and PCV10 on invasive pneumococcal disease (IPD), non-invasive pneumonia (PNE), and acute otitis media (AOM) over a time horizon of 50 years. The model included the effects of the historical vaccination scheme in infants as well as indirect herd effects and replacement disease. We used German epidemiological data to calculate episodes of IPD, PNE, and AOM, as well as direct and indirect effects of the vaccination. Parameter uncertainty was tested in univariate and probabilistic sensitivity analyses.Results: In the base-case analysis, the ICER of PCV13 versus PCV10 infant vaccination was EUR 9826 per quality-adjusted life-year (QALY) gained or EUR 5490 per life-year (LY) gained from the societal perspective and EUR 3368 per QALY gained or EUR 1882 per LY gained from the perspective of the German statutory health insurance. The results were particularly sensitive to the magnitude of indirect effects of both vaccines.Conclusions: Universal infant vaccination with PCV13 is likely to be a cost-effective intervention compared with PCV10 within the German health care system, if additional net indirect effects of PCV13 vaccination are significant. [ABSTRACT FROM AUTHOR]

Background: The German Institute for Quality and Efficiency in Health Care (IQWiG) uses patient-relevant outcomes to inform decision-makers.Objective: IQWiG conducted a pilot study to examine whether discrete choice experiments (DCEs) can be applied in health economic evaluations in Germany to identify, weight, and prioritize multiple patient-relevant outcomes, using the example of antiviral therapy for chronic hepatitis C (HCV). A further objective was to contribute to a more structured approach towards eliciting and comparing preferences across key stakeholders.Methods: In autumn 2010, a DCE questionnaire was sent to patients with chronic HCV to estimate preferences across seven outcomes ("attributes"), including treatment efficacy [sustained viral response (SVR) at 6 months], adverse effects (flu-like symptoms, gastrointestinal symptoms, psychiatric symptoms, and skin symptoms/alopecia), and measures of treatment burden (duration of therapy, frequency of injections). A linear model and an effects coded full model were applied to assess the relative importance of the attributes.Results: In total N = 326 patients were included. A clear preference for SVR was shown; frequency of injections and duration of therapy shared the second rank, while psychiatric symptoms ranked third. The duration of flu-like symptoms was the least important attribute.Conclusion: Our findings indicate that it is possible to perform a DCE at the national level in a health technology assessment agency. The weighting of multiple outcomes allows an indication-specific and evidence-based measure to be used in health economic evaluations. In decision-making in health care, the approach generally allows for consideration of patient-relevant trade-offs regarding the benefits and harms of medical interventions. [ABSTRACT FROM AUTHOR]

Background: Since 2011, an early benefit assessment (EBA) of new drugs constricts free price setting in Germany. According to the Pharmaceutical Market Restructuring Act (AMNOG), pharmaceutical companies are obliged to demonstrate added benefit of new drugs over comparative treatment. Benefit is usually evaluated by the Institute for Quality and Efficiency in Health Care (IQWiG). The final appraisal is made by the Federal Joint Committee, Germany's highest-ranking decision body in the health sector, triggering drug prize negotiations between companies and statutory health insurance funds. One of four evaluation criteria is quality of life (QoL). QoL outcomes have, however, only rarely been pivotal in EBAs.Objective: This study determined methodological requirements for QoL measurement and data presentation in the EBA.Design: In a qualitative content analysis, documents of all EBAs completed by 2014 were searched for the term QoL. Relevant passages of all EBAs of 2011-2013 were independently extracted and reduced to key content by two researchers. Recurring patterns were identified and verified through comparison with EBAs of 2014.Results: We identified a range of requirements regarding QoL assessment, analysis, presentation, and interpretation, which go beyond official regulations. Disease-specific questionnaires are preferred and have to be validated according to certain standards and in the respective patient group. Effects must exceed the minimal important difference, which in turn must be validated in compliance with specific requirements. Often, instruments were not accepted as QoL measures, sometimes inconsistently across EBAs. Another frequent reason for non-acceptance of QoL data was that more than 30 % of randomized patients could not be analyzed due to missing data.Conclusions: Non-compliance with methodological requirements for QoL evidence impairs chances for positive benefit evaluation. [ABSTRACT FROM AUTHOR]

As a result of strong financial incentives created by the German parental leave reform on January 1, 2007, some 1000 births have been shifted from the last days of 2006 to the first days of 2007, especially by working mothers. This fact is already described in the literature, yet there is no evidence as to the mechanisms and only scarce evidence regarding the effects on newborn health. I use new data to study the timing of C-sections and the induction of births around the day the reform took effect. I estimate that postponed C-sections and inductions account for nearly 80 % of the pre-reform shortfall and nearly 90 % of the post-reform excess number of births. Despite concerns voiced by doctors before the reform, hardly any evidence can be found for detrimental health effects of those shifts, as measured by changes in gestational age, birth weight, APGAR scores, neonatal mortality, or hospitalization. [ABSTRACT FROM AUTHOR]

Background: Information on costs of managing adverse events (AEs) associated with current treatments in metastatic melanoma is limited. This study estimates costs of AEs in eight countries: Australia (AU), Canada (CA), France (FR), Germany (GE), Italy (IT), the Netherlands (NL), Spain (ES), and the UK.Methods: A literature search was conducted to identify grade 3/4 AEs from product label, published trials, conference abstracts, and treatment guidelines. Resource utilization for the management of each type of AE was determined via interviews with 5 melanoma clinicians in each country. Outpatient and inpatient costs were estimated for each type of AE using country-specific tariffs or government/published sources.Results: In outpatient settings, the most costly AEs per incident included cutaneous squamous cell carcinoma (CSCC) (€1063, £720; NL/UK), anemia (€1443, €1329, €1285; ES/IT/FR), peripheral neuropathy (€1289; ES), and immune-related diarrhea (AUS$1,121; AU). In inpatient settings, the most costly AEs per hospitalization included hypophysitis (€10,265; €5316; CAN$9735; AUS$7231: ES/FR/CA/AU), dyspnea (€9077; GE), elevated liver enzymes (€6913, CAN$8030, AUS$6594; FR/CA/AU), CSCC (CAN$8934; CA), peripheral neuropathy (€6977, €4144, CAN$9472; NL/ES/CA), and diarrhea (£4284, €4113; UK/ES).Conclusions: Costs of managing AEs can be significant, and thus effective treatments with lower rates of severe AEs would be valuable. [ABSTRACT FROM AUTHOR]

To identify the influences on the diffusion of generics after patent expiry, we analyzed 65 generic entries using prescription data of a large German sickness fund between 2007 and 2012 in a sales model. According to theory, several elements are responsible for technology diffusion: (1) time reflecting the rate of adaption within the social system, (2) communication channels, and (3) the degree of incremental innovation, e.g., the modifications of existing active ingredient's strength. We investigated diffusion in two ways: (1) generic market share (percentage of generic prescriptions of all prescriptions of a substance) and, (2) generic sales quantity (number of units sold) over time. We specified mixed regression models. Generic diffusion takes considerable time. An average generic market share of about 75 % was achieved not until 48 months. There was a positive effect of time since generic entry on generic market share (p < 0.001) and sales (p < 0.001). Variables describing the communication channels and the degree of innovation influenced generic market share (mostly p < 0.001), but not generic sales quantity. Market structure, e.g., the number of generic manufacturers (p < 0.001) and prices influenced both generic market share and sales. Imperfections in generic uptake through informational cascades seem to be largely present. Third-party payers could enhance means to promote generic diffusion to amplify savings through generic entry. [ABSTRACT FROM AUTHOR]

Objective: Seasonal influenza occurs in annual epidemics. The virus can cause severe illness and concomitant diseases with the highest risk for children, the elderly, and individuals with disease dispositions. The study objective is to assess the influenza burden in Germany.Methods: This retrospective claims data analysis used the Health Risk Institute research database containing anonymized data of 4 million individuals. The study period comprised the influenza season 2012/2013 in which patients with documented influenza were identified. Disease frequency rates were calculated for a population with disease dispositions and a population not at high risk. Disease burden was assessed based on health-services utilization during the influenza season. Vaccine rates were calculated by identifying vaccinations.Results: We observed 65,826 patients with influenza, resulting in 1,160,646 documented influenza cases after extrapolation. Overall, otitis media and pneumonia was higher in the influenza-infected population compared to the non-influenza-infected population and especially high in children. Hospitalization cost amounted to €87,202,485 with a mean stay of 7 days, and total outpatient costs were €14,947,976. Vaccination rates were <4 % for children and 37 % for patients aged >60.Conclusions: Seasonal influenza can cause severe outcomes with hospitalizations and excess costs. Especially influenza-infected children are affected by concomitant diseases with higher disease burden. Furthermore, documented vaccination rates are quite low. [ABSTRACT FROM AUTHOR]

The implementation of a graded return-to-work (RTW) program to reintegrate the long-term sick started in Germany in 1971 and has been manifested in the Social Code Book V since 1989. Based on a return plan by the physician and the insured, participants increase their working hours slowly over a specified period of time. As participants are still classified as incapable of working they still receive sick leave benefits. Using claims data from the Techniker Krankenkasse, the largest German sickness fund, the study aims at identifying participants and analyzing the full return-to-work and the impact of the RTW program. Thereby, we account for socio-economic factors, insurance-based characteristics, and medical and health-related information. We consider a possible selection bias by using individual weights to analyze determinants of length of the sickness absence by applying models for survival analysis (Cox proportional hazard model). As a main result - depending on the central assumption of unconfoundedness - sickness absence is positively related to participation in the RTW program for those with sickness absence longer than 120 days. For mental disorders, our results indicate an even stronger effect. The study results emphasize the need further promotion of this instrument among those insured, physicians and employers, as occupational health management is one key for a successful return-to-work. [ABSTRACT FROM AUTHOR]

Objective: In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.Methods: The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.Results: Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.Conclusion: From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance. [ABSTRACT FROM AUTHOR]