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Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?

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Abstract

Preventable chronic diseases account for the greatest burden in the German health system and statutory health insurance (SHI) funds play a crucial role in implementing and financing prevention strategies. On the contrary, the morbidity-based scheme to distribute financial resources from the Central Reallocation Pool among the different sickness funds may counteract efforts of effective prevention from an economic perspective. We assessed financial impacts of prevention from a sickness funds perspective in a retrospective controlled study. Claims data of 6,247,275 persons were analyzed and outcomes between two propensity-matched groups (n = 852,048) of prevention users and non-users were compared in a 4-year follow-up. Using a difference-in-differences approach, we analyzed healthcare expenditures, the development of morbidity, financial transfers from the Central Reallocation Pool, and contribution margins. The group of prevention users develops less morbidity (incidences and disease aggravations) compared to the control group. Healthcare expenditures increase in both groups within 4 years, whereas the increase is lower for prevention users compared to non-users (€568.04 vs. €640.60, p < 0.0001). Taking morbidity-based financial transfers into account, the decrease in contribution margins is stronger for prevention users (− €188.44 vs. − €138.73, p < 0.0001). This study demonstrates an economic disincentive from a sickness funds’ perspective. In the semi-competitive SHI market, sickness funds will be discouraged from effective prevention strategies if investments are not worth it financially. Their efforts and knowledge are, however, crucial for joint action to foster prevention over cure in the health system.

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Notes

  1. Including strengthening of health competence and patient sovereignty, establishment of healthy environments that fit peoples’ living and working conditions, prevention of work-related health hazards, self-help promotion, vaccination, prevention of dental diseases, contraception, vasectomy, and abortion.

  2. Including early diagnosis of cancer and preventive checkups for children and adolescents.

  3. Insurance days per year are used for the weighting to devalue the econometric relevance of people with short insurance times.

  4. Health policy recently increased the benchmark for SHI prevention investment per insurant. From 2016 sickness funds are required to invest 7 € per person in approaches to enhance healthy environments and working conditions and prevent work-related health risks (§ 20 Sect. (6) SGB V).

  5. With a total market share of 8%.

  6. i.e., compulsory member, dependent coverage (family insurance) or retired.

  7. Since the Morbi-RSA is a prospective model, we received the financial transfers 2011–2015.

  8. Assessed based on escalations in the Morbi-RSA hierarchies.

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Acknowledgements

WIG2 researchers are responsible for the development of the research idea, study design, data analysis, interpretation of the results, and publication strategy. The IKK e.V., which is the representation of craft guild sickness funds, provided the data for the research and supported in the preparation of the manuscript.

Funding

The study was supported financially by the IKK e.V..

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Authors and Affiliations

  1. WIG2 Scientific Institute for Health Economics and Health System Research, Leipzig, Germany

    Ines Weinhold, Christian Schindler, Nils Kossack, Benjamin Berndt & Dennis Häckl

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  1. Ines Weinhold
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  2. Christian Schindler
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  3. Nils Kossack
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  4. Benjamin Berndt
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  5. Dennis Häckl
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Corresponding author

Correspondence to Christian Schindler.

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The author BB was an employee of the IKK e.V., which supported the research financially. There are no other relationships or potential conflict of interest to declare.

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Appendix

Appendix

Potential aggravation of type 2 diabetes without complications

 Diabetes with other complications

 Diabetes with peripheral circulatory manifestations or ketoacidosis

 Diabetes with renal or multiple complications


Potential aggravation of COPD

 COPD or emphysema with permanent medication, bronchiectasis, other interstitial lung disease without permanent medication


Potential aggravation of Hypertension

 Coronary heart disease/other chronic ischemic diseases of the heart

 Angina pectoris

 Acute myocardial infarction/unstable angina pectoris and other acute ischemic heart diseases

 Hypertensive heart or kidney disease, encephalopathy or acute pulmonary edema

 Heart failure

 Pulmonary heart disease.

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Weinhold, I., Schindler, C., Kossack, N. et al. Economic impact of disease prevention in a morbidity-based financing system: does prevention pay off for a statutory health insurance fund in Germany?. Eur J Health Econ 20, 1181–1193 (2019). https://doi.org/10.1007/s10198-019-01086-7

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