Key Aspects of a Sustainable Health Insurance System in Germany.

Appl Health Econ Health Policy DOI 10.1007/s40258-016-0223-8

ORIGINAL RESEARCH ARTICLE

Key Aspects of a Sustainable Health Insurance System in Germany Matthias Pelster1

•

Vera Hagemann2 • Franziska Laporte Uribe3

Springer International Publishing Switzerland 2016

Abstract Background The main goals of health-care systems are to improve the health of the population they serve, respond to people’s legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design. Objective This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges. Methods We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semistructured interviews with stakeholders in the system, and an online questionnaire.

& Matthias Pelster [email protected] Vera Hagemann [email protected] Franziska Laporte Uribe [email protected] 1

Institute of Banking, Finance, and Accounting, Leuphana University of Lueneburg, Scharnhorststr. 1, 21335 Lu¨neburg, Germany

2

Department of Work and Organizational Psychology, Faculty of Psychology, Ruhr-University Bochum, Universita¨tsstr. 150, 44780 Bochum, Germany

3

German Center for Neurodegenerative Diseases e. V. (DZNE), DZNE site Witten, Stockumer Str. 12, 58453 Witten, Germany

Results We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance. Conclusion We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.

Key Points for Decision Makers This study suggests that the German health-care system is in urgent need of holistic and needsoriented hospital planning and regulation of special treatment centers. We suggest supra-regional implementation of hospital planning but also highlight the need for further research in this area to support this process. Moreover, the study suggests more initiatives are needed to increase (administrative) innovation in the health-care system, as well as additional incentives to increase prevention. We find that firms in particular should have an interest in investing in methods of prevention for their employees to improve their well-being and thus their overall workforce. Finally, the study highlights the need for approaches to improve analytical quality assurance. We propose a compromise that allows the use of (anonymized) data to enhance quality control and prevention methods, while respecting the privacy of the data.

M. Pelster et al.

1 Introduction Economic factors play an increasingly important role in health care. This economization can be seen in the growing significance of cost effectiveness for health insurance funds when covering services and treatments, in the privatization and closing of hospitals, and in the performance-oriented pay structures of medical personnel [1–6]. As a result, public and political discussions about the consequences and flaws of existing pay structures and their effect on different aspects of health-care provision in Germany are ongoing. This is true even though the German health-care system is ranked seventh in the current Euro Health Consumer Index (EHCI), which is the industry standard of modern healthcare monitoring [7]. Germany employs a universal multi-payer health-care system. The German health-care system is unique among OECD countries, consisting of a combination of statutory health insurance (‘‘sickness funds’’) and private insurance. The German system allows people with higher income to opt out of contributing to the statutory health insurance (SHI) and purchase private health insurance instead [8]. Every one below a certain income (EUR 54,900 in 2015) is subject to the non-profit sickness funds at a fee that is a fixed percentage of their income. The fee is paid partially by employers and partially by employees. The part of the fee paid by employers is equal for all statutory health insurance companies (as a percentage), whereas the part of the fee paid by employees differs across SHIs. Everyone above the income threshold, self-employed persons, and university students are free to opt out of the statutory insurance and purchase private insurance instead. However, they can also choose to contribute voluntarily to SHI at a fixed rate independent of their income. Opting for private insurance may result in substantial savings for younger individuals in good health. Additionally, officials, pensioners, and their families receive governmental schemes that are complemented by private health insurance. Hence, these groups also do not contribute to the SHI. Basic coverage through statuary health insurance funds is regulated but sickness funds can provide some additional coverage. Coverage through private insurance funds is negotiable as long as a basic coverage is guaranteed.1 In Germany, health-care planning falls under the responsibility of both federalism and corporatism. The La¨nder (supra-regional level) have the responsibility of planning inpatient capacities and to finance investments in 1

The basic coverage of private insurance funds is similar to regulated SHI coverage. However, it significantly differs with respect to the possible deductibles. While a deductible of up to EUR5000 is possible for private insurance funds, the highest possible deductible for SHI coverage is EUR600/900 [9].

hospitals and other health-care-related institutions.2 In addition, the La¨nder supervise other actors in their constituency, such as corporate actors and pharmaceutical manufacturers. This sharing of decision-making powers between the federal government, the La¨nder, representing the supra-regional level, and corporate organizations [e.g. statutory health insurances (SHIs)/insurance agencies/ sickness funds, physicians], and the delegation of planning, regulatory, and managerial competencies to SHIs or joint committees of stakeholders is a fundamental facet of the German health-care system. The German health-care system is highly complex; therefore, it can appear to be nontransparent. Decision makers include the Federal Ministry of Health, the 16 La¨nder, SHI companies, and doctor associations [10]. Thus, the allocation of funds and the establishment of reasonable incentive systems are difficult and subject to manipulation by many lobbying groups. Often, monetary interests outweigh the health-related interests of service recipients and patients [11]. The ongoing discussion on the impact of the growing economization of health care, particularly in Germany but also worldwide, is strengthened by the existence of various interest groups (e.g. politicians, public and private insurances, and physicians) within the system that are quite powerful and try to strengthen their positions [12]. Another factor is the cultural implications present in health care. Any implementation of regulations in health care must consider the cultural background of the population [2]. In Germany, the cultural background places strong emphasis on the free choice of service providers, the free choice of insurers, and ready access to outpatient and inpatient care [13], Interview 2 (I2). Free choice and easy access can only be made possible by utilizing large amounts of financial, physical and human resources in health care. Thus, analyses of incentive systems in health care cannot focus exclusively on economic factors [14]. Analysis of the German health-care system, or any health-care system, must consider the reliability of the health-care supply and the acceptance and satisfaction of the overall population with the health-care system. For example, Koch et al [15] provide an international comparison of the satisfaction of service recipients with the national health-care system. Health care is systemically important. As a result, it must be supported financially in areas where it is not possible to ensure supply profitably. In addition to a cost-benefit analysis, a certain level of health care must be maintained independent of costs. However, the degree to which health care is systemically important is subject to a system’s cultural background and discussion [as noted by one of the 2

The Federal Republic of Germany is a federal parliamentary republic and consists of 16 constituent states, called the La¨nder.

Key Aspects of a Sustainable Health Insurance System in Germany

interviewees (Interview 1) in our study]. For more details, see Sect. 2. Policymakers, stakeholders and service recipients have to embrace the systemic importance of health care. It seems like the primary goal of the growing economization within the health-care system and the introduction and adjustments of incentive systems is to reduce health-care costs. However, this isolated view of the health-care system has led to several misplaced incentives or incentives that produce unwanted results. For example, Transparency International claims that misdirected incentives lead to a misallocation of services in health care [11]. Consequently, there must be clarity about the social goal of the healthcare system before existing incentive systems can be analyzed with regard to their desired results and the results they produce. Go¨pffarth [1] argues that ‘‘a culture of innovation and experimentation is important for discovering possible improvement’’. Our paper contributes to this discussion by presenting the results of a study that aimed to identify the key challenges for the German health-care system and health insurance system in the medium- and long-term future. We were especially interested in those challenges that call for urgent action and identifying the underlying factors driving these challenges. We focused on the well-balanced adjustment of several incentive systems or, in other words, on adjustments of incentive systems in an effort to reduce unforeseen disincentives. We wanted to evaluate the role, if any, of an unbalanced incentive system introduced through growing economization as a cause of several challenges that the German system must face. However, we did not neglect possible causes of upcoming challenges that are not related to economization and incentive systems. Finally, we intended to identify possible solutions for putting the German health-care system in a better position to face these challenges. To summarize, we set out to answer the following research questions: 1.

2.

3.

What are the key challenges the German health-care system is likely to face in the medium- and long-term future? Are unbalanced incentive systems that are established within the German health-care system a driver of these challenges? What are possible solutions to meet these challenges?

recent publications were included on occasion. Second, between March and July 2014, based on the literature review, an interview guideline was developed, and semi-structured interviews with different stakeholders and key informants were conducted to capture additional aspects that have not been captured in published accounts or in official documents. Hence, the interviews are an exploratory investigation. Finally, we aimed to validate the interview results using an online questionnaire including closed and open questions as well as Likert-type rating scales. The online survey was conducted between September and October 2014, and its data were analyzed in November 2014. To start our investigation, we performed a review of the published and grey literature on health-care planning in Germany. We also included press articles to obtain up-todate information on the most recent public debates. The literature review was limited to articles and monographs published between 2010 and 2015 to reflect the most recent structures and developments. Next, we conducted semi-structured interviews with stakeholders to explore their expert opinions on challenges the German health-care system is currently facing or is likely to face in the future, as well as to identify additional aspects not reflected in the literature. Interview partners were selected according to their professional roles in organizations involved with the health-care system or according to their expertise with national and regional planning processes. We enrolled seven experts in the study as interview partners, including four experts from private health insurance companies (I3, I5) or the statutory health insurance system (I4, I6) and three participants with a background in politics and/or research (I1, I2, I7). Informed oral consent was obtained from all experts. The interview guideline included three sections: the first section covered the challenges that the German health-care system is currently facing or is likely to face in the future; the second section addressed the causes for these challenges; and the third section proposed possible solutions. One question was included to reflect aspects from other health-care systems that might be helpful in successfully facing challenges in the German health-care system. The main questions for each section were as follows (a more detailed overview of the questions can be found in the ‘‘Appendix’’): 1.

2 Methodology

2.

We applied a mixed-method approach. First, in January and February 2014, we conducted a review of the published and grey literature on health-care planning in Germany. More

3.

What are the major challenges faced by the German health-care system and the German health insurance system in particular? Which aspects call for immediate action? What are the main reasons for these challenges? What role can be attributed to unbalanced incentives systems and the dualism of statuary and private health insurance funds? What are possible solutions for these challenges?

M. Pelster et al.

The recorded interview audio-data were transcribed and anonymized. Data were analyzed using a structured content analysis based on Mayring [16, 17]. In the following, the codings I1 through I7 have been used to reference specific interviews. Finally, we wanted to validate the interview results using an online questionnaire. The survey consisted of 39 items that could be answered on a 5-point Likert scale: 0 (totally disagree), 1 (rather disagree), 2 (rather agree), 3 (agree), and 4 (totally agree). Seventeen items aimed to identify major challenges, and 22 items posed possible solutions to those challenges that we had identified through the literature review and expert interviews. A list of all the items can be found in the ‘‘Appendix’’. Again, we tried to include people from all stakeholder groups in this survey. We invited 426 people involved in politics, private or statutory health insurance, and research to participate. As incentives, the participants could win one of eight vouchers for a common online store worth approximately EUR50 each. A total of 112 people filled in the questionnaire, yielding a response rate of 26.3 %. Of those participants, there were 31 women and 63 men, with missing data for 18 participants. The mean age was 40.2 years [standard deviation (SD) = 11.58]. Most participants (55 %) were employed in research, 10 % of the participants were employed in the medical sector, and 5 % had a background in politics.

3 Results We combined the results from the interviews with insights from the literature. Because the survey was developed in accordance with the insights from the interviews, the survey results are included in this section. Table 1 presents an overview regarding the results of the survey. The organization of this section is in accordance with the results from the interviews. The results from the interview process were divided into two separate clusters. On the one hand, we identified several challenges upon which our interviewees agreed. Specifically, interviewees argued that better hospital planning, regulation of special treatment centers, and increased innovation, are key for the German health-care system. Moreover, all interviewees agreed that the development of networks and increased cooperation between service providers are major challenges that the system must face. However, on these topics, interviewees disagreed about the specifics. Additionally, all interviewees argued that the German health-care system has to increase the success rate of health prevention measures in the general population. However, again, the details ranged from increased coverage of health issues in schools to the use of data mining to allow for early warning signals and treat diseases before they spread.

On the other hand, we observed that our interviewees strongly disagreed about other topics. The three topics that created the most disagreement were competition in the health-care system, methods to measure and ensure quality in the system, and the special setup of the German healthcare system with SHI and private insurance. Although we structured the presentation of the results into certain topics, we acknowledge that many of these topics are highly interconnected. 3.1 Innovation, Process Innovation and Incentive Systems for Innovation Several of our interviewees called for more innovation in health care, both in technology and in administration. Interviewees argued that the German legislation needs to provide additional freedom to produce a continuous stream of innovations (I2, I4). Interviewees placed a significant emphasis on innovation in administration (I2, I4). Interview I2 stated, ‘‘One challenge for the health-care system is, of course, to introduce innovation into the German health-care system. At first, innovation is connected with product innovation. However, this does not concern us as much as process innovation.’’ Interviewee I4 added, ‘‘That means we need a more innovation-friendly health-care system. […] is not as much a problem of technological innovation but rather of administrative innovation. One has to separate these two. ‘‘ Interviewee I2 elaborated on innovation: ‘‘Generally, within the context of innovation, firms only invest into anything new if the verifiable hope exists that these innovations yield some return and the firm can skim off these profits. To make that possible, we have patent protection for products that protects innovation. As far as administrative innovation is concerned, this is rather opaque in other sectors and cannot be copied as a result. However, this is missing in health care. […] The Joint Federal Committee can oblige competitors to copy the innovation. Hence, something is collectivized that was contracted selectively and the individual SHIC should have skimmed of profits.’’ The assessment that the German system impedes effective innovation is also underlined by results from the literature review [1]. As far as existing incentive systems within the German health-care system are concerned, both sides of service providers and the service recipients must be considered. For the service recipients, few incentive systems are in place. Interviewees argued that many approaches to incentive systems serve only as an ‘‘eye-catcher’’ to provoke short-term attention. A long-term change in behavior at the service recipient level can be achieved only with intrinsic motivation (I4). One interviewee noted that the most prominent exception is the differentiated additional

Key Aspects of a Sustainable Health Insurance System in Germany Table 1 Overview regarding descriptive and significant results from the survey Item

M

SD

The German health-care system offers too few incentives (e.g. profit gain) for health insurance funds to create and process innovations

2.16

1.02

More opportunities for competition in quality between health insurance funds must be provided

2.77

0.97

Experts not working in research

2.75

0.58

Researchers Reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the quality of health care

2.20 1.50

0.91 1.02

Reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the efficiency of health care

1.48

1.03

There is a need for consistent standards to build and run specialized medical centers

2.20

0.92

Using consistent standards for specialized medical centers can improve the quality of patient care

2.27

1.02

Patient-centered care should become more prominent in the health-care system

2.85

0.86

Statistical significance

Innovation, process innovation and incentive systems for innovation

Hospital planning, special treatment centers, and medical care in rural areas In the German health-care system, there is insufficient hospital planning F(1/54) = 4.99, p \ 0.05, gp2 = 0.09

Cooperation and networks in health care The segmentation between outpatient and inpatient care must be overcome Experts not working in research

2.27

1.31

Researchers

2.80

1.12

The creation of networks contributes to improving health care in rural areas

2.95

0.87

Possible solutions to meet the various challenges faced by the German health-care system are … increased delegation of medical care and treatment provided by physicians to specialized and trained medical personnel

2.52

1.25

… increased academic training and professionalization of the nursing profession

1.47

1.11

2.28

0.99

2.88

0.86


1.88

1.34

Researchers

2.82

1.07

2.59

1.06


1.82

1.21

Researchers

2.33

1.15

2.43

1.13

F(1/92) = 4.26, p \ 0.05, gp2 = 0.04

New job profile needed?

… improved education in all health-related professions Prevention and inclusion of service recipients There is a need for increased integration of measures aimed at health prevention in schools Centralizing patient data (using, for example, an electronic health card) to create a database (‘‘data mining’’) can be an important factor in improving quality and reducing costs

F(1/92) = 13.78, p \ 0.001, gp2 = 0.13

Measurement of quality in health care The German health-care system lacks working quality measurement systems It is essential to create a unified (government-regulated) institution to control the quality standards set within the German health-care system and thereby increase the quality of patient care F(1/92) = 4.05, p \ 0.05, gp2 = 0.04

Costs, demographic change, change in expectations of the health-care system The process of demographic change is an essential cost factor in the German health-care system Competition in health care The German health insurance funds system offers no opportunities for competition in quality Experts not working in research

2.69

1.25

Researchers

1.68

1.10

More opportunities for competition in quality between health insurance funds must be provided

2.77

0.97

The dualism of statutory and private health insurance funds is a problem in the German health-care system

2.06

1.37

The dualism of statutory and private health insurance funds should be eliminated

1.95

1.46

Coexistence of statutory and private health insurance in the German health-care system

F(1/54) = 9.01, p \ 0.01, gp2 = 0.14

M. Pelster et al. Table 1 continued Item

M

SD

The reason that the dualism of statutory and private health insurance funds has become a problem lies within the separation of fees for medical treatment between the scale of fees for physicians ¨ ) and the Doctors’ Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher (GOA Bewertungsmaßstab (unified rating approach, EBM) ¨ ) and the Doctors’ Fee Scale within the Statutory Health The scale of fees for physicians (GOA Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) should be combined to create one unified scale of fees

2.64

1.10


2.00

1.52

Researchers

2.52

0.94

Statistical significance

F(1/92) = 4.26, p \ 0.05, gp2 = 0.04

5-point Likert-scale: 0 (totally disagree), 1 (rather disagree), 2 (rather agree), 3 (agree), 4 (totally agree) M mean, SD standard deviation, F analysis of variance F statistics, p level of significance, gp2 effect size

payment for dental prostheses (I4). Most other additional payments that service recipients have to fulfill are not intended to work as incentive systems but are meant to ensure financing of the system (I4). With regard to statutory health-care providers, interviewees argued that the system provides too few incentives for innovation. In accordance with this argument, the results from the survey showed that experts agree that the system provides too few financial incentives for innovations and process innovations [mean (M) = 2.16, SD = 1.02]. They also recommended that quality competition between health care providers should be strongly facilitated (M = 2.77, SD = 0.97) (see also section on quality measurement below and I4). Even more problematic, current incentive systems facilitate myopia among statutory health-care providers, according to one interviewee (I4). One example would be the administrative innovation mentioned above. Interviewee I4 said, ‘‘It is useful to come to an understanding of innovation again—that other rules and mechanisms have to exist to allow for more flexibility.’’ As a result, investments and the pursuit of innovations are rather small. This argument is supported by the fact that well-functioning innovations are transmitted to all statutory health-care providers and thus serve not only the inventor but rather all providers. Overall, the interviewees argued that the level of innovation in the German health-care system is too low. They recommended that investment in research and development should be increased (I1, I4). To ensure innovation in health care for future generations, Heinrich-Bo¨ll-Stiftung [18] recommends the implementation of a separate fund to exclusively finance research and development. The financial means should be covered from the public health-care fund. In this context, it is noteworthy that the German Bundestag3 enacted the Care Provision Strengthening Act on June 11, 2015, which, among other things, aims to promote innovative forms

3

The German Bundestag is the constitutional and legislative body at the federal level in Germany.

of care, with EUR300 million per annum from 2016 to 2019 administered by the Federal Joint Committee. 3.2 Hospital Planning, Special Treatment Centers, and Medical Care in Rural Areas Interviewees also very prominently argued that well-functioning hospital planning is crucial (I4): ‘‘There are things [to improve] at short notice, like functioning hospital planning. This is impossible to ignore. […] It makes sense that hospital planning exists because we can guarantee [supply reliability] for the entire area.’’ ‘‘In part, the La¨nder do not fulfill their tasks. I do not know whether they [the La¨nder] always know which tasks they have. The Grundgesetz4 literally requires the La¨nder to implement a hospital planning. I do not know how seriously they pursue this and what kind of competencies they bring to the table.’’ The survey supported this result. Experts agreed on deficient hospital planning in Germany (M = 2.25, SD = 0.89). Experts who did not work in research (M = 2.75, SD = 0.58) agreed on this matter significantly more strongly than researchers (M = 2.20, SD = 0.91) did [analysis of variance (F statistics): F(1/54) = 4.99, p \ 0.05, gp2 = 0.095]. This aspect has been previously discussed in the literature. For example, Ettelt et al. [10] argued, ‘‘Health care planning in Germany largely reflects the fragmentation of decision-making resulting from a combination of federalism and corporatism.’’ Compared to other OECD-countries, Germany exhibits an over-supply of hospitals (8.3 hospital beds per 1000 inhabitants in Germany compared with the 2011 OECD25 average of 5.0 hospital beds per 1000 inhabitants).6 However, many hospitals are supported by municipalities that cover losses sustained by hospitals [19–21]. In 2013, 42 % of 4

The ‘‘Grundgesetz’’ is the German constitution. Effect size: partial eta squared (0.02 small, 0.13 medium, 0.26 large). 6 Note that although the number of hospital beds is decreasing, the capacity of hospital beds is actually increasing because the average hospital stay is decreasing significantly. 5


all general hospitals in Germany sustained losses. This phenomenon concerns smaller hospitals with fewer than 300 beds more than larger ones [22]. Although this is necessary in regions where the supply of hospitals is small, it certainly is not necessary when capacities are too high. For example, a comparative assessment of hospitals in Hessen (one of the 16 German federal states) reaches the conclusion that many hospitals sustain losses because, particularly in urban areas, too many hospitals compete for patients. The authors of the study quantify the potential savings at EUR100 million for seven hospitals, which corresponds to several billion Euros for all 2000 hospitals in Germany [23, 24]. Hence, hospital planning must be more regulated. Highly specialized clinics and clinics that provide high-quality medicine cannot be readily available within 50 km of every part of the country. However, it is important to convey this information to the public (I1) As a result of poor hospital planning, the German health-care system supports too many small and poorly equipped hospitals, which deteriorates the quality of service in these hospitals (I1; see also [25]) (Interviewee I4 referenced the health-care system in the Netherlands. As a result of a large transparency initiative, several hospitals were closed due to a lack of treatment quality). Additionally, the literature showed that the competitive design of hospitals is often viewed critically. Hospitals have to realize profits to be able to fund investments for innovation. As a result, hospitals aim to close divisions that are not profitable regardless of the systemic importance of these divisions. In contrast, hospitals should invest in divisions that are profitable. This situation raises the question of whether these investments lead to excess capacities because, overall, the German health-care system suffers from overcapacity [20, 21, 26]. Ettelt et al [10] found that planning in the German healthcare system is significantly obstructed by fragmented decision making. Note also that decision-making liability and financing liability are currently not pooled in a single responsible entity. Hence, the entity making the decisions is not liable financially. As a solution to this problem, several interviewees argued that planning must be achieved on a regional level and must involve the population in decision making (I1, I2, [27]). The Care Structures Act (CSA) is a first step in that direction because it transfers decisionmaking power to the regional level [28]. However, the main goal of the CSA is to secure the long-term availability of physicians in all regions. As of today, rural and poor areas in particular, experience a significant shortage of physicians (I2, I5, I7, [29]), which obviously cannot be solved exclusively by generating financial incentives7 (I7, [30]). In 7

Although medical coverage exceeds the need on average (108.6 % coverage rate), approximately one-third of the planning areas feature a coverage rate below 100 % [31].

addition, interviewee I4 stressed the need for policy makers to include insurance companies in the decision-making process. The survey yields different results. Here, solutions that favor an empowerment of regional decision makers to enhance quality (M = 1.50, SD = 1.02) and efficiency (M = 1.48, SD = 1.03) in health are rejected. Connected to the issue of hospital planning are the design and distribution of special treatment facilities in Germany. Many severe diseases are not treated in special treatment centers but rather in local hospitals. For example, Rupprecht and Schulte [32] reported that more than twothirds of all cancer cases are not treated in specialized centers but in local hospitals. Interviewees I4 and I6 argued that treatment in highly specialized clinics would significantly increase not only the probability of survival but also the quality of life after treatment. However, the German system does not support a unique official certification for specialization centers. Instead, several competing certifications exist. As a result, the standards of these centers vary, as does the quality. Experts from the survey stated that consistent standards are obligatory for developing and carrying out specialized centers (M = 2.20, SD = 0.92). These consistent standards would improve the quality of patient treatment (M = 2.27, SD = 1.02), and patientcentered treatment would be more grounded in the health system (M = 2.85, SD = 0.86). Additionally, service recipients do not have a clear point of reference regarding where specialization centers can be found. Interviewees I4 and I6 argued: first, too many specialization centers create unnecessary costs; second, instead of being able to support high-end specialization centers, many centers of lower quality must be supported, which in turn affects the quality. For example, in Baden-Wu¨rttemberg, a German state with 10.6 million inhabitants, one can currently choose between 10 specialization centers for heart diseases. In total, Germany counts 23 heart centers. Furthermore, Thelen [33] reported on the low operation numbers for many transplantation centers. Due to the high number of transplantation centers in Germany (47 centers), many do not reach the number of operations per year required by regulators. However, these centers still receive organs to perform operations. Consequently, several interviewees argued that the German health-care system is in urgent need of uniform regulation on specialization centers (I4, I6). The interviewees requested consistent and comprehensive regulation for special treatment facilities with a numerical limitation in accordance with needs. The interviewees suggested that this is in accordance with the German understanding of free choice of service providers if, in addition to the distribution of special treatment centers, transportation routes are ensured. A prominent example of an excellent transportation system can be found in

M. Pelster et al.

Scandinavia. Hospitals fulfill a gatekeeping-function,8 and excellent transportation to special treatment facilities is ensured (I6). In conclusion, interviewees as well as the literature highlight the importance of improvements in the planning area of the distribution of medical practices, hospitals, and special treatment centers. This planning must consider, not only the distribution of centers, but also transportation routes (I4). 3.3 Cooperation and Networks in Health Care Closely connected with the planning of inpatient care is the planning of outpatient care. The most widespread form of outpatient care in Germany is the single practice of one general practitioner or one specialist. For example, in 2014, 33,058 of 43,206 general practitioners were practicing in their own practice [34]. Many of our interviewees claimed that the most common form of medical practice in Germany, the traditional single practice, will not last (I1, I2, I3, I4, I6). Expert I4 stated, ‘‘It is not sufficient to have a single physician practice. […] It is urgently required that the physician is well connected.’’ Expert I6 added, ‘‘[…] who will understand how to break up the classic outpatient care, inpatient care and postdischarge care and instead ask what a patient with a specific disease needs to be treated consistently?’’ The experts from the survey also stated that the segmentation between inpatient and outpatient care should be abolished (M = 2.60, SD = 1.22). Experts working in research (M = 2.80, SD = 1.12) agreed on this matter significantly more strongly than experts who did not work in research (M = 2.27, SD = 1.31) (F(1/92) = 4.26, p \ 0.05, gp2 = 0.04). Additionally, Robert Bosch Stiftung [35, 36] called for enhanced cooperation between different service providers, especially between physicians and other service providers. Interviewees provided several arguments to support their claim. First, in cases with complicated diagnoses, physicians in joint practices can receive assistance from their colleagues within their own practices. Second, the interviewees argued that the mentality of the new generation of physicians has changed. Work-life balance has become increasingly important, meaning that physicians do not want to take on the workload necessary to run a practice single-handedly (I7). Third, the interviewees argued that more joint practices would contribute to solving the question of the supply reliability of medical support in depopulated areas (I1). 8

In praxis, the German system does not incorporate physicians as gate-keepers. In 2004, gate-keeping models were partially implemented in order to reduce non-coordinated or unnecessary visits, but these models offered limited success.

The survey results supported these statements; joint practices contribute to more reliable medical support in depopulated areas (M = 2.95, SD = 0.87). Finally, the cooperation of several physicians in a network can help significantly reduce information asymmetries. The main goal of such a network should be optimal health care and not the reduction of costs. The idea is that integrated care increases the quality of care through better-coordinated treatment processes (I7). Another interviewee (I1) noted that with regard to the aging population, the formation of regional networks is very important, especially to continue to integrate the elderly in the community. Although the reduction of costs is desirable, whether health-care networks contribute to lower costs in health care remains an open question (I7). Higher overheads due to additional management processes could even lead to a rise in costs. 3.4 New Job Profile Needed? Closely connected with the demand for more cooperation between service providers is the call for new job profiles in health care. Several interviewees argued that the German health-care system is in need of new professional profiles that are less tainted by prejudice. Expert I1 argued that many physicians dump work on nurses and do not value their performance. Hence, a clear definition is required: ‘‘which role which job profile has to fulfill has to be obvious and that this happens on the same level. This has to be integrated in education.’’ People who fulfill the new job profile are supposed to disrupt old structures and serve as interfaces in the system, such as a ‘‘medical guide’’ (I1, I2, I4, I6, [36]). Expert I6 stated, ‘‘We need a new form, a new job profile, a different competency, obviously, although I am not able to define what exactly this would be. […] that this person would have institutionally a more neutral function […].’’ Moreover, expert I6 suggested some type of supply manager to foster prevention and health management: ‘‘This could be a primary care physician or a case manager that is specifically trained.’’ Such a role could also be fulfilled by certain technological developments that enhance the communication between stakeholders involved in a certain treatment (e.g. physicians, pharmacists, and physiotherapists) to smooth the treatment process (see I2, I6). Expert I2 stated, ‘‘We are lacking this interlocked approach. The electronic health card could have been a step into this direction.’’ Similarly, some experts claimed that certain tasks that currently can only be fulfilled by doctors, could also be fulfilled by, for example, highly qualified nurses (‘‘family nurse’’) (I1, I2, I7, [37]). In addition, the survey results showed that experts agreed on a stronger delegation of


medical tasks to highly qualified care staff (M = 2.52, SD = 1.25). The health-care system in the Netherlands provides proof that this approach can work well. In the Netherlands, verplegkundige (nurses) perform activities that in Germany must be performed by physicians [38]. As part of medical networks, these family nurses could help to provide medical care in scarcely populated areas (see I5), assisting rural general practitioners (GPs). Expert I7 added, ‘‘If we simultaneously talk about making [the job of] care staff more attractive […], that would be an option—to make job profiles more attractive by giving them more responsibility.’’ Reflecting a significant change in the setup of German jobs in health care rather than a new job profile, two interviewees (I1, I4) suggested that care staff undergo academic training (see also [37]). This training would improve the reputation of staff and advance research in care. (Interviewee I1 stated, ‘‘There is another important group of players: research. We have comparatively little to offer in this regard, especially as far as the research in care is concerned.’’). One expert argued that ‘‘governmental statements like ‘everybody can take into care’ are simply counterproductive’’ and that we are not able to finance research on quality in care. Academic training for care staff is required in Switzerland, France, Sweden, UK, and the USA, to name a few [38–40]. However, the survey yielded different suggestions; academic training of care staff was rejected (M = 1.47, SD = 1.11). Finally, to ensure sufficient service providers in the future, Heinrich-Bo¨ll-Stiftung [18] demands free (and better) education for all health service-related jobs, including physical therapists [see also I1]. The experts from the survey agreed on this issue (M = 2.28, SD = 0.99). 3.5 Prevention and Inclusion of Service Recipients Most interviewees agreed on the need for additional efforts in prevention and on the additional involvement of service recipients in the health-care system. Several interviewees argued that the German health-care system has to improve prevention methods urgently (I1, I2, I3, I4, I6). Suggestions ranged from a more thorough integration of health interventions in the educational system (I1, I6) (that is, in schools and even kindergartens) to a more complex use of data sets to enhance the early identification of disease patterns to treat diseases before they actually emerge (I4, I6) (‘‘predictive analytics’’) [41]. Expert I6 stated, ‘‘[…] However, it would be useful if we were able to especially recognize diseases that break out subtly early and point the disease out to the individual. If he [the individual] demonstrates certain risk factors, he can choose to have

himself checked out or change his behavior. […] We have to move the beginning of the treatment pathway […] to the point before the disease breaks out.’’ In addition, the expert suggested implementing these methods on a voluntary basis so that each person can decide independently whether he or she wants to use such methods. In the survey, the experts agreed on a more thorough integration of health prevention interventions in schools (M = 2.88, SD = 0.86). Regarding the centralization of patients’ data sets for data mining to enhance quality und reduce costs, the views were diverse.9 Researchers agreed on this matter (M = 2.82, SD = 1.07), whereas experts who did not work in research rejected it (M = 1.88, SD = 1.34). The difference between the two groups was significant (F(1/92) = 13.78, p \ 0.001, gp2 = 0.13). Again, the findings from our interview and survey data were supported by an empirical study. The EHCI index ranks national European health-care systems on a basis of 48 indicators covering six essential areas. These areas are (1) patients’ rights and information, (2) accessibility of treatment (waiting times), (3) medical outcomes, (4) range and reach of services provided, (5) prevention, and (6) pharmaceuticals. Although Germany is ranked highest in the area of Pharmaceuticals, the score for prevention is low compared to other European countries. Previous initiatives also requested intensified codetermination by service recipients [18]. Teevs [42] reported on health-care networks in Kenya. He reported that not only do physicians of different specialties work together in a team to pursue the best possible supply of health care, but service recipients also form networks to support each other. This ‘‘Micro Insurance’’ allows for basic health-care coverage for all members. Fees are subject to income rather than health risk. The main advantage of these small networks is motivated prevention and public-health policy. Because service recipients know each other, the influence of moral hazard is significantly reduced (for moral hazard in health insurance, see, e.g. [43, 44]. Moreover, the health benefit is at the center of all incentives. Hence, all aspects of competition have increasing health benefits as the primary goal. Similar suggestions were also made by one of our interviewees (I3), who suggested the formation of communities of service recipients, which organize health-care support within the community. He argued that this increases the sense of responsibility of service recipients, decreases costs due to less moral hazard, and increases motivation for prevention. Similarly, one expert (I4) suggested a more active role for

9

Note that the German Bundestag passed a law in May 2015 to allow for more thorough retention of sickness data on the ‘‘Gesundheitskarte’’, a smart card specifically designed for SHIs.

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service recipients in health care with a stronger sense of responsibility among individuals for their own health. Additionally, interviewee I3 suggested that in addition to individuals, firms are primarily interested in their employees’ health. He argued that companies lose productivity due to unhealthy employees. According to the Fu¨rstenberg Performance-Index 2011, companies in Germany suffered losses of EUR364 billion due to unrealized production. Hence, employers have a financial incentive to propagate prevention among their employees and may also be willing to invest in methods of prevention. 3.6 Measurement of Quality in Health Care All aspects dealing with quality and the measurement of quality in health care first have to clarify the general understanding of quality in health care. Expert I4 stated, ‘‘We have to identify over and over again: what does quality mean? Quality is a variable good. To register and quantify quality – are we looking at process quality, structure quality, or result quality, and how do I measure that, how fast do I measure that, what kind of tools do I have? You have to develop or possess such instruments to be able to perform.’’ Possible indicators of high quality range from easily quantifiable measures such as life expectancy, mortality from certain diseases, or time to recover from certain diseases, to more intangible issues such as quality of life. Although it is relatively easy to measure the quality of the overall health care in a given country with regard to the initially mentioned quantifiable categories [45], the measurement of the quality of a treatment for an individual service recipient is a much more sophisticated task. This issue is even more relevant if intangible issues such as individuals’ quality of life are to be considered. In our study, we were primarily concerned with the assessment of quality of the individual by specific physicians. The importance of a quality measurement in health care is also underlined by the growing literature on health performance comparisons around the globe [46, 47]. For example, Veit et al [6] argued that many sub-areas of medical care do not use operationalized indicators of quality. Consequently, this area needs increased research attention with methodological development. The specific application in medicine makes it necessary to develop completely new measures of quality as cases often differ significantly from each other, making comparisons complicated. The authors predicted the growing importance of indication benchmarks (6, p11). In line with this thinking, several of our interviewees argued that performance measurement of health care is a significant problem that

requires more research (I1, I3) and more freedom in designing new schemes. Expert I4 stated, ‘‘I need degrees of freedom in the arrangement to be able to do that [to combine quality and efficiency].’’ The experts from our survey stated that the German health-care system is missing working methods/systems to measure the quality of patient treatment (M = 2.59, SD = 1.06). One of our interviewees suggested, among other recommendations, the introduction of a government-run examination committee to implement quality measurement methods (I4). The opinions from the experts in our survey differed significantly regarding this recommendation (F(1/92) = 4.05, p \ 0.05, gp2 = 0.04). Researchers agreed on implementing a government-run examination committee to evaluate quality standards to enhance the quality of patient treatment (M = 2.33, SD = 1.15), whereas experts who did not work in research rejected it (M = 1.82, SD = 1.21). In 2013, the German government declared its intention to found an independent quality institute [48]. In January 2015, the Institute for Quality Control and Transparency in Health Care (IQTIG) was founded and will begin to undertake its tasks in 2016. Moreover, the German system features the Institute for Quality and Efficiency in Health Care (IQWIG). However, Transparency International Germany demands the supply of more translucent information about quality and performance differences through IQWIG. Whether the recommendations by Transparency International will be fulfilled by IQTIG, remains to be seen. Other interviewees argued that the quality measurement of service performance is not a problem, and well-functioning methods are in place (I3, I6). Another approach to quality measurement is voluntary ratings completed by service recipients after treatment. For example, Telgheder [49] reports the growing number of internet evaluation portals covering the health-care system in Germany. The author argues that up to 33 % of service recipients take these evaluation portals into account when selecting physicians. However, these ratings suffer from selection bias and possible ignorance by service recipients, so they cannot be used to distribute funds subject to the rating. Finally, a popular example of linking quality measures with reward systems is pay-for-performance schemes. Indicators of performance include clinical domains as well as organizational domains such as records and information, practice management, and medicine management and patient experience domains such as length of consultations [50]. Currently, such schemes have been implemented in several countries. However, the example of Great Britain shows that these systems induce adverse effects, such as less patient-centered primary care [50].


3.7 Costs, Demographic Change, Change of Expectations Toward the Health-Care System

elderly in the overall population. The authors found that Germany’s health-care expenditures are normal in an international comparison. The Robert Koch-Institut [53] presents data that pensioners account for 49.9 % of healthcare expenditures of SHI, although the share of people aged 65 years and over made up only 20.3 % of the overall population in 2007.11 The contribution payments by the elderly account for 23.3 % of the overall contributions. In 2004, the health-care expenditures for people aged 65 years and over comprised 75.5 % of the overall healthcare expenditures, while this group made up 17.27 % of the overall population. However, other interviewees argued that the demographic development per se is not the reason for rising costs. Only in combination with medical-technical development and/or changes in expectations by service recipients and patients does the demographic development act as a driver of rising costs. Although innovations might decrease costs in the long run, ‘‘in the short run, innovations always increase costs’’ (I4). In line with our interviewees, expenditure levels in Germany are far above average. Other countries have a better relationship between money spent in health care and quality achieved [1]. As a result, the EHCI 2013 summary by the Health Consumer Powerhouse formulates the concerns by healthcare companies and patients, for whom the introduction of newer treatments is often delayed, as a way to contain costs. The line of argument is that newer treatments are often more expensive [7]. Only in the long run can innovative treatments lead to cheaper treatments (I6). Therefore, all costrelated issues should focus on the value-for-money relationship (I4).

The general consensus is that health-care systems around the globe face a common challenge: increasing costs of health care [12] and, consequently, the problem of sustainability [4]. The issue of sustainability must be considered from a general economic point of view and from a fiscal point of view. Economic sustainability is concerned with the growth in health spending in relation to gross domestic product (GDP) [4]. In Germany, health spending in relation to GDP increased from approximately 10.25 % in 1999 to approximately 11.25 % in 2012, with a spike in 2009, when, due to the Global Financial Crisis, health spending was more than 11.75 % of the national GDP. In contrast, fiscal sustainability refers to public expenditures on health care. Hence, a health system may be economically sustainable but not fiscally sustainable if public revenue cannot meet public expenditures [4]. Obviously, the ratio of health spending to national GDP is subject to the overall economic condition. Every economic slowdown is related to an increase in the ratio, as witnessed in 2009. As a result, governments try to ensure that cost pressures do not undermine values such as universal coverage and equitable financing and access. The German national health fund expects to realize a deficit of EUR2.5 billion in 2015 [51]. Not surprisingly, the primary reform principles in recent history aim to contain costs through expenditure control [5]. The issue of rising costs was mentioned in almost all interviews, with interviewees providing quite different views. Most argued that rising costs in health care are a major challenge that the German health-care system is currently facing.10 However, different reasons were provided for rising costs. Some interviewees argued that the demographic development of an aging population is the main driver of increasing health-care costs (I1). This statement was also affirmed in the survey; M = 2.43, SD = 1.13. In fact, the share of people aged 65 years and over increased from 15 % in 1993 to 18 % in 2003, with the share of people aged 80 years or over expected to increase. In 2010, 21 % of the population was between 60 and 80 years of age, and 5.3 % of the population was over 80 years of age (German Federal Statistical Office). Still, other interviewees argued that increased expectations of the health-care system (I3) and steadily growing innovations are the main drivers of rising costs (I6). This finding is supported by Niehaus and Finkensta¨dt [52] who related the costs of a health-care system to the proportion of

From the literature review, it is clear that the issue of competition is closely connected with costs in health care, and it is argued that increasing competition helps to reduce costs ([54]; the authors find that competition keeps healthcare cost low). In principle, a health-care system allows for three-sided competition: the relation between insurance companies and service recipients (insurance market or ‘‘Versicherungsmarkt’’), the relation between insurance companies and service providers (service market or ‘‘Leistungsmarkt’’), and the relation between service providers and service recipients (treatment market or ‘‘Behandlungsmarkt’’) [55, 56]. Several interviewees provided insights into competition within the health-care system or the lack thereof.

10

11

At the same time, interviewee I4 argued that rising costs do not pose a challenge to the German health-care system: ‘‘No, definitively not [does the overall increase of health care costs pose a challenge].’’

3.8 Competition in Health Care

Pensioners are normally aged 65 and over. However, due to a few exemptions, the group of pensioners may include a small number of individuals under 65.

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Interviewee I4 claimed that the German health-care system is subject to sufficient competition (‘‘We do have competition between SHICs’’), whereas others argued that the system lacks competition (I2, I7). Expert I2 stated, ‘‘On the one hand, we want competition between SHICs; on the other hand, we do not allow them enough leeway to engage in competition. […] Hence, we do not have any competition.’’ The survey results mirrored these discrepancies; experts who did not work in research agreed on the existence of missing possibilities for insurance companies for competition in quality (M = 2.69, SD = 1.25), whereas researchers rejected it (M = 1.68, SD = 1.10, F(1/ 2 54) = 9.01, p \ 0.01, gp = 0.14). The possibility to shape a competitive health-care system was also part of that discussion. Again, expert opinions seemed to be divided: whereas the interaction between insurance companies and service providers can be competitive, the interaction between service providers and patients cannot. The survey results showed consensus regarding the option that quality competition between SHI companies should be enhanced (M = 2.77, SD = 0.97). However, the competition between SHI companies does influence decision making by service recipients. Since January 1, 2009, the SHI premiums have been calculated using the following formula [57]:12 Contributionik ¼ 8:2 % max ðgross labor incomei ; contribution capt Þ þ add-on premiumk : The total premium adds up to 15.5 %, which is shared between employers (7.3 %) and employees (8.2 %). As a result, price competition between sickness funds was limited to the amount of the positive add-on premium charged. SHICs were not able to charge premiums lower than the minimum premium. While Schmitz and Ziebarth [57] argue that sickness funds compete mainly on the basis of price, we believe that even at a time when SHICs were not able to engage in unconstrained price competition, they competed via their services. A recent survey by SWIFinance shows that SHICs with a positive image gain members, whereas others lose members. In particular, the Techniker Krankenkasse, recognized as the ‘‘best SHIC,’’ gained the most (new) members in the first half of 2014. During the first seven months of 2014, the Techniker Krankenkasse gained 192,000 members—individuals who entered any SHI for the first time—corresponding to a share of 53.8 % of new members [58, 59]. Thus, even at a 12

Note that the formula from Schmitz and Ziebarth reads 0.5 9 15.5 % instead. However, this formula is not entirely correct because the distribution between employers and employees was not equally shared between 2009 and 2014. Instead, apart from a period from July 1, 2009 to December 2010, employers paid 7.3 % and employees 8.2 %.

time when no single SHI charged an additional premium (in 2014, not a single sickness fund chose to charge the add-on premium), there seems to be evidence of successful competition. At the same time, the study by Schmitz and Ziebarth [57] provides evidence that service recipients leave sickness funds that charge add-on premiums and switch to other funds. In this context, the fact that no sickness fund charged an add-on premium can be interpreted as evidence of too-strong price competition. At the beginning of 2015, the minimum premium was lowered from 15.5 to 14.6 %, shared equally between employers and employees. The expectation is that more sickness funds must charge an add-on premium at some point, which increases price competition. Overall, opinions about the need for competition in health care diverged strongly. On the one hand, participants argued that competition in health care contradicts the basic right for health-care supply to be guaranteed even in depopulated areas, where the provision of health-care service is not profitable and most likely related to financial loss (I7). Additionally, according to one expert, the risk balance is better with large collective bodies, (I3) and competition between insurance companies results in smaller collective bodies. On the other hand, arguments such as increased incentives for innovation, increased quality, lower costs, and more efficiency call for more competition in health care [60]. Thus, the logical consequence seems to be that competition in health care is associated with constant adjustments to overcome undesirable developments. Among others, Goetze et al. [56] provided evidence for such constant adjustments in Germany and the Netherlands. The authors compared the two health systems and found that the implementation of reforms to increase competition involves self-reinforcing tendencies that call for reregulation and more competition. This line of argument is supported by Go¨pffarth [1], who stated that a balance between competition and cooperation is needed in health care. He reasoned that ‘‘[f]ree competition will not work in health care’’ because it leads to market failure and fragmentation, whereas a single-payer system would lead to a loss in quality and procrastination [1]. 3.9 The Coexistence of Statutory and Private Health Insurance in the German Health-Care System Perhaps the most disagreement involved the specific health-care system in Germany, where approximately 10 % of the population opt out of SHI and purchase private insurance at 1 of the 42 private insurance companies [61] instead.13 This option is income related and only applicable 13

Statutory health care consists of 123 statutory health insurance companies in 2014, which is a significant decrease from 1815 companies in 1970, and 420 companies in 2000 [62].


to people with a higher income. Similar to the general public discussion, our analyses of the expert interviews showed diverging results. Some interviewees suggested that the abolition of the split insurance system is the best way for the German health-care system to meet future challenges (I2, I7). Similarly, some argued that the existence of private insurance is not system relevant (I4); instead, consumer choice should be the distinguishing element (I6). At the same time, interviewees suggested that the split system per se is not a challenge to the German health-care system (I6). This large disagreement was also visible in the survey. The experts’ answers varied strongly over all scale points from 0 to 4 (a large standard deviation) regarding the statement that the coexistence of statutory and private health insurance is a problem for the German health-care system (M = 2.06, SD = 1.37). Not surprisingly, the solution to abolish the coexistence of the two systems was also assessed very diversely (M = 1.95, SD = 1.46). Moreover, interviewees criticized regulators for forcing the SHI system to integrate aspects of private insurance while the private insurance had to include aspects of a social care system (I2, I6, see also I3). One interviewee (I4) suggested that this step introduced unsuitable aspects in both systems. The interviewee argued that, for example, providers of SHI are encouraged to negotiate selective agreements with specific service providers that are supposed to ensure a certain quality standard and reduce costs. However, due to the existing collective agreement, SHIs must address service providers that are not part of a selective agreement as well (I4), which means that every service provider can choose to engage in some selective agreement but does not have to because he/she is part of the collective agreement (I7). ‘‘[…], especially the collective agreement, the actual problem’’). At the same time, expert I3 noted that the service agreement of services covered by SHI providers covers many services that are not covered by comparable systems in other countries as a result of the split system. People who can opt out of SHI put pressure on the statutory health care providers to deliver a good service agreement because they can opt out of the SHI and choose to purchase private insurance instead (I3). Hence, the competition between SHI and private insurance for clients who are free to opt out of SHI seems to result in better service agreements for all clients within the SHI. This is supported by Tenbensel et al [63], who compared health policies across eleven countries to analyze whether the way in which health systems are financed, influences the degree to which policymakers are interested in accessible and equitable health services. The authors found significant differences among the goals of differently financed health systems. For example, improving population health outcomes is more

likely to be on the agenda under tax-based systems, whereas health systems funded through social insurance are more focused on efficiency and cost containment. Nevertheless, the coexistence of statutory and private health insurance in a single system in Germany involves significant conflict. One interviewee argued that this combination is a root cause of social division in Germany (I1). Similarly, the literature suggests that this division induces conflict between insurance companies [64] and physicians [65, 66] stated that unified billing procedures would create a base for insurance companies and physicians to collaborate. In the survey, the current division of the billing system for statutory and private health insurances was seen as a cause of current problems in the German health-care system (M = 2.64, SD = 1.10).14 However, the solution to merge the two billing systems into a unified billing procedure was more strongly supported by researchers (M = 2.52, SD = 0.94) than by experts not working in research (M = 2.00, SD = 1.52, F(1/92) = 4.26, p \ 0.05, gp2 = 0.04). Consequently, a large body of literature addresses alternatives to the present German system [3, 26, 67]. Siadat and Stolpe [3] concluded that an entirely new system has to be implemented. One expert supported this notion by suggesting the extension of alternatives to the classical insurance system and pointing out the need to create a regulatory environment to allow for such alternative systems (I3). The grey literature also provides some suggestions on options to unify mandatory and private insurance [68]. However, the majority of interviewees argued that too many powerful advocacy groups protect the current system (I1, I3, I4, I6). One interviewee had particular concerns about officials and pensioners. He had doubts that a change in the system would occur as long as no solution for officials and pensioners is in sight (I4).

4 Discussion In this paper, we attempted to identify the key challenges for the German health-care system and health insurance system in the medium- and long-term future. In particular, we were interested in those challenges that call for urgent action. We conducted interviews and a survey to identify possible solutions for putting the German health-care system in a better position to face these challenges. Many studies recognize access to care, quality of care, and affordability of care as the main goals of successful health policy [1]. In general, three goals must be combined 14

Within the German system, physicians are able to charge a fee approximately twice as high when treating private patients rather than patients with social health insurance. Specifically, depending on the particularities of the treatment, physicians can charge between 2.3 and 3.5 times the regular rate.

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when trying to improve the German health-care system: an improvement in the overall health of the population, an improvement in access to health-care services, and a reduction in costs for health-care provision. Our results point in the same direction. First, we discuss our first and third research questions concerning key challenges and possible solutions. There was consensus among experts regarding challenges and possible solutions concerning the German health-care system in some aspects, and many disagreements in other aspects. For example, experts from the interviews and the survey identified ways to increase innovation, better hospital planning, and the regulation of special treatment centers as key challenges for the German health-care system. Additionally, all experts agreed on the need for networks, increased cooperation between service providers, and enhanced prevention. However, we observed some disagreement about the specifics in these latter areas. In contrast, we were able to identify strong disagreements concerning competition in the health-care system, methods to measure and ensure quality in the system, and the special set-up of the German health-care system. We identified several aspects that could help to strengthen the German Health-care system with regard to future requirements and challenges. First and foremost incentives to increase innovation must be strengthened, and innovation in health care must be encouraged. Note that this specifically addresses administrative innovation. Many other aspects of our study can be summarized under the concept of administrative innovation. Hence, innovation also includes some process optimization toward service recipients’ needs; an adaption toward a more patient-oriented system was presented as a step in the right direction by many experts. This includes ensuring a needs-oriented distribution of physicians, hospitals, and special treatment centers [69]. Additionally, we highlight the importance of establishing sufficient quality standards and quality controls, as well as adjusting misaligned incentives. Measuring the quality of an individual treatment in medicine is difficult because of an asymmetry of information between service recipients, service providers, and insurance companies, as well as a lack of knowledge among service recipients. More often than not, the service recipient must rely on the information provided by the service provider and is not able to validate the information.15 Thus, more innovation (and research) is 15

Moral hazard issues also come into play. The service recipient might not have the motivation to verify the additional benefits or costs of a proposed treatment because he does not have to cover the costs personally. Furthermore, asymmetric information between service recipients and insurance companies might lead to adverse selection issues. Interviewee I2 suggested increased offering of medical service telephones by insurance companies to allow patients to obtain a second opinion more easily.

needed to enable us to adequately quantify individual health-care quality. Transparency with regard to service quality is difficult to establish, and quantifying the quality of one individual treatment is even more so. However, it is possible to measure the quality of the average individual treatment. To be able to adequately quantify health-care quality (on average), a sufficiently large database must be present. This point emphasizes that the key for all quality improvements is data, which must come from the service recipients. In this spirit, Go¨pffarth [1] requests a ‘‘culture of sharing data.’’ This is only possible with the consent of physicians, who are currently anxious that insurance companies will use the collected data against them [70]. Moreover, service recipients fear that insurance companies will use the data to select among policyholders and provide no coverage for at-risk patients [41, 70]. Interviewee I2 stated, ‘‘Data privacy is the worst knockout argument that we use in the last decades time and time again.’’ Due to privacy protection laws, insurance companies are not allowed to interchange data. Additionally, data must be deleted after five years ([9], §304), and secondary exploitation is prohibited. Hence, only large insurance companies are able to maintain a sufficiently large data set. As long as people are not willing to share their data and sacrifice at least part of their privacy, any improvements in health care will be made under difficult conditions. Additionally, more liberal use of the available data enables interested service recipients to engage in proactive prevention [71, 72]. Although it is not clear whether prevention and expanded medical health check-ups reduce healthcare costs over the life cycle [73–75], they most likely increase quality of life. Note, however, that assessing the quality of life on a financial scale is difficult [76–79]. Thus, the balance of a cost-benefit analysis in this area is burdensome. Finally, it should be noted that reaching a consensus on the data that are relevant and accurate for the patient, service provider, and insurer poses a main obstacle, given the difficulty of quantifying individual health-care quality.16 Several interviewees (I1 and I2) and studies [28, 80] suggest that the transfer of more decision-making responsibilities to the regional level could be an important step in adapting the system to its needs. They argue that decision makers at the regional level have more insights into on-site needs and a greater ability to meet the population’s concerns. Although we agree with this opinion, we also would like to note that decision making at the regional level gives rise to fragmentation and, as a result, possibly inefficient outcomes. In addition, we note the discrepancy between the decision-making process and the responsibility to finance 16

We thank one anonymous reviewer for bringing our attention to this issue.


decisions. Thus, whereas popular suggestions demand a more regional decision-making approach to be able to meet the needs of the local population, we refer to the misplaced distribution of special treatment centers mentioned above and the inappropriate financial support of some local hospitals implemented by local politicians to win voters’ confidence (I1 and I4, [81]). Moreover, although many decisions can be made at the regional level, the responsibility for financing these decisions lies at a supra-regional level. Hence, we advocate for a more supra-regional approach to planning that takes into account logistic concerns and local decision-makers’ advice. We suggest implementing the planning of the distribution of hospitals and special treatment facilities at a supra-regional level with the involvement of regional decision makers. We also appeal to regional decision makers to be ready to accept compromises. We argue that a comprehensive approach to planning the distribution of hospitals helps to improve several key challenges at once. First, this guarantees access to care, even in remote areas. Second, a comprehensive planning approach would help to monitor costs because it prevents the use of public funds to finance hospitals that are not systemically relevant. Third, unified regulation would help to ensure the quality of care. Finally, we also support the opinion that cost-related issues should always consider the value-for-money relationship. However, although cost containment is an important issue, it does not ensure a sustainable health-care system in itself. Hence, engaging in discourse about what we expect from our health-care system and what we are willing to pay for it may be useful. Turning to our second research question on unbalanced incentive systems, we find evidence that unbalanced incentive systems contribute to the challenges the German health-care system faces. To be specific, we find a lack of incentives or even obstructions to contribute administrative or process) innovation to the German health-care system. Moreover, we find evidence that concerns that do not necessarily focus on outcomes, health-care quality, or the cost-efficiency relationship influence the decision making of decision makers, especially for the planning of the distribution of hospitals and special treatment centers. Each of the different sectors involved in the German health-care system focuses primarily on optimizing its individual benefits instead of pursuing the best solutions for patients or society. In other words, misaligned incentive systems and perhaps also prejudices between different sectors involved in the German health-care system are likely to obstruct efficient cooperation between the sectors or the beneficial referral to another sector from our point of view.

4.1 Policy Implications As a result of our findings, we urge policy makers to allow for more degrees of freedom for SHIs to promote innovation in health care. The implementation of an innovation fund through the Care Provision Strengthening Act to promote innovative forms of care with EUR300 million per annum from 2016 to 2019 is a first step in the right direction, although it should be accompanied by additional degrees of freedom to implement administrative innovation. Another possibility is increasing competition. Obviously, all discussions about competition in health care in Germany have to address the unique set-up of the German health-care system, which integrates statutory health insurance with the opportunity to opt out for individuals with high income. However, competitive models must always be accompanied by a risk-compensation structure to avoid risk-selection issues. As a result, a health-care system needs balance between competition and cooperation. This aspect is closely connected to methods to quantify the quality of individual health care. The need for more structured and needs-oriented planning of the distribution of hospitals, physicians, and special treatment centers also has implications for regulation policy. Of course, every regulatory initiative must consider the cultural background. Successful health policy cannot ignore cultural implications. Even concepts with the best figures cannot be realized if the cultural background hinders the acceptance of these concepts. With regard to Germany, this issue especially concerns the free choice of insurers and service providers for patients. Nevertheless, we emphasize the danger of fragmentation and inefficient outcomes due to a more regional decision-making process. Hence, we suggest a supra-regional implementation of hospital planning but also highlight the need for further research in this area to support this process. Finally, policy makers should agree on a compromise that allows the use of (anonymized) data to enhance quality control and prevention methods while respecting the privacy of the data. The EHCI index shows that the score for prevention in Germany is really low compared to other European countries. In addition, the interview experts recommended a more thorough integration of health interventions in the educational system, such as in schools and even in kindergartens. Additionally, firms could and should invest in methods of prevention for their employees to strengthen their well-being and health and thus the overall workforce. To summarize, the most urgent, and at the same time manageable, aspects are more innovation, hospital planning, prevention, and analytical quality assurance.

M. Pelster et al. Acknowledgments We thank the two anonymous reviewers and the editor for their thorough review. We greatly appreciate their comments and suggestions, which significantly contributed to improving the quality of the publication. Financial support by the Mercator Research Center Ruhr is gratefully acknowledged. Author contributions The manuscript was prepared by MP, with contributions from VH and FLU. Interviews were conducted by MP and FLU, with contributions from VH. The online survey was conducted by VH, with contributions from MP and FLU. MP, VH, and FLU acted as guarantors for the overall content.

Compliance with Ethical Standards This study was funded by the Mercator Research Center Ruhr. MP, VH, and FLU have no conflicts of interest.

Appendix: Interview Guideline for the SemiStructured Expert Interviews 1.

Introduction of the interviewer and the context of the research. (b) Introduction of the interviewee.

We are especially interested in your appraisal of the challenges for the German health insurance system. 1. 2. 3.

Which aspects pose major challenges? Which aspects are from your point of view of high relevance? Where do you see the need for changes or reforms?

Generic follow-up questions: • • • •

Solutions From your point of view, what are possible solutions or first steps towards a solution to successfully face these challenges? (b) We are also interested in aspects of health insurance systems from around the world.

P1

The dualism of statutory and private health insurance funds is a problem in the German health-care system

P2

The reason for the dualism of statutory and private health insurance funds becoming a problem lies within the increasing privatization of statutory insurance funds and the growing socialization of private health insurance funds

P3

The reason for the dualism of statutory and private health insurance funds becoming a problem lies within the scale of fees for medical treatment separating between the scale of ¨ ) and the Doctors’ Fee Scale within fees for physicians (GOA the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM)

P4

The German health-care system offers too few options (e.g. lack of degrees of freedom) for health insurance providers to create innovations and process innovations

P5

The German health-care system offers too few incentives (e.g. profit gain) for health insurance funds to create innovations and process innovations

P6

A missing ‘‘protection of patents’’ reduces the incentive for health insurance funds to aim for innovations

P7

The German health insurance funds system offers no opportunities for competition

P8

The German health insurance funds system offers no opportunities for competition on pricing

P9

The German health insurance funds system offers no opportunities for competition on quality

P10

The German health-care system is not patient centered

P11

The German health-care system lacks working, quality measurement systems

P12

In the German health-care system, there is insufficient hospital planning taking place (e.g. it is possible that unprofitable but structurally relevant hospitals are being closed)

P13

One of the fundamental problems of the German health-care system is rising health-care costs

P14

The process of demographic change is an essential cost factor for the German health-care system

P15

Medical and technological advances are an essential cost factor for the German health-care system

P16

Changing patient needs are an essential cost factor for the German health-care system

P17

Please indicate here which other causes/challenges the German health-care system is currently facing from your point of view

(a)

1. 2.

Are there countries that would be of interest to us in terms of their health insurance systems? What would we need to consider when applying such ideas to the German healthcare system?

Could you give me some examples? What examples do you have in mind? What is the reason for that? What has changed since then?

Items questionnaire

(a)

4.

Conclusion/End of interview Is there an aspect upon which you would like to elaborate? (b) Is there anything else you would like to add?

Causes Wherein lay the fundamental causes for those processes/challenges from your point of view? (b) Which role do faulty incentives have in this?

How about the transferability of such ideas to Germany?

(a)

Challenges (a)

3.

5.

Introduction (a)

2.

3.


L1 L2 L3 L4 L5 L6

L7 L8

L9

L10 L11

L12 L13

L14

L15 L16 L17 L18 L19

L20 L21 L22

Creating clear structures with regard to competition within the health insurance funds system is a necessity Opportunities for competition on pricing between health insurance funds have to be provided more frequently Opportunities for competition on quality between health insurance funds have to be provided more frequently To meet the challenges the health-care system is facing, only collective agreements should be provided without exception To meet the challenges the health-care system is facing, selective agreements should be encouraged ¨ ) and the Doctors’ Fee The scale of fees for physicians (GOA Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) should be combined to create one unified scale of fees The dualism of statutory and private health insurance funds should be dis-established A reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the quality of health care A reinforced authorization of regional policy making in the health-care system to make more tailored decisions offers the opportunity to improve the efficiency of health care The creation of networks adds to improved health care in rural areas Integrated care as an example for effective networks helps to ensure a more efficient functioning of the health-care system in urban regions The segmentation between outpatient and inpatient care has to be overcome Creating networks also on a patient level (e.g. using relief funds, using company welfare schemes, or on a regional level) will result in reinforced health consciousness and prevention Centralizing patient data (using, for example, an electronic health card) to create a database (‘‘data mining’’) can be an important factor towards increasing quality and reducing costs Patient-centered care should become more prominent in the health-care system There is a need for consistent standards to build and run specialized medical centers Using consistent standards for specialized medical centers can reduce costs Using consistent standards for specialized medical centers can increase the quality of patient care It is essential to create a unified (government-regulated) institution to control the quality standards set within the German health-care system and thereby increase the quality of patient care A more active role within the health-care system should be attributed to patients and policyholders (insured persons) There is a need for increased integration of measures aimed at health prevention in schools Possible solutions to meet the various challenges the German health-care system is facing are… 1. … the creation of new professional fields 2. … improved education of all health-related professions 3. … increased academic training and professionalization of nursing professions 4. … increased delegation of medical care and treatment provided by physicians to specialized and trained medical personnel

Area of expertise

Age Sex

Where do you work? 0 = research 1 = private health insurance fund 2 = statutory health insurance fund 3 = policies 4 = medical field 5 = administration Please provide details of your age in natural numbers, e.g. 43 Which gender are you?

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