Completed Projects
International comparison of outpatient remuneration
By international standards, Germany spends a high proportion of its economic output on financing its healthcare system. At the same time, however, the German healthcare system is characterized by an above-average utilization of medical services. Against this background, it is reasonable to assume that the high level of health expenditure is due less to high prices than to the high volume of medical services billed. Analyses of the inpatient sector, which show a price level for inpatient services in Germany that is 12% below the OECD average, support this theory. However, it is unclear how German prices for outpatient services compare internationally.
The Zentralinstitut für die kassenärztliche Versorgung (Zi) therefore commissioned the Hamburg Center for Health Economics (hche) at the University of Hamburg to conduct an international price comparison of selected outpatient services. The results show considerable differences in the billing of medical services. These discrepancies can be attributed to a variety of factors, such as the different structures of national healthcare systems and insurance models, as well as other legal frameworks. The different billing systems make comparisons difficult, but overall this study shows that it is possible to compare prices despite the complexity. For the services considered, the prices of medical services in Germany tend to be in the middle of the comparison countries. However, contextual differences such as the cost of living and differences in purchasing power need to be taken into account in order to assess the differences.
Developing a Cost Function for Medical Practices
While extensive research has been conducted on the cost function of inpatient care, there have been very few analyses of outpatient care. In order to also identify significant cost factors for outpatient care, this research project develops cost functions for outpatient care and estimates them using regressions. In the cost functions of a practice, the costs of the practice (n = 5,000) are used as a target in the regressions to be estimated. In doing so, a number of organizational characteristics are controlled in order to generate a cost estimate that is as exact as possible, for example, number of patients treated, location, group of specialist doctors, and differences in patient structure. The practice cost function should provide answers to various research questions, such as whether group practices are more productive than individual practices, and whether specialized medical practices are more productive than general practices. The project is carried out in cooperation with the Zentralinstitut für die kassenärztlichen Versorgung (ZI, a research institute for ambulatory health care).
Developing a Quality Index for Hospitals
In contrast to many other countries, in Germany, there is little meaningful information on the quality of hospital care. Quality reports include extensive information, but many people consider these to be too susceptible to manipulation and therefore of only limited use. To assess the quality of hospitals, other countries use more robust and less vulnerable data on mortality after hospitalizations and on re-hospitalizations for selected indications, and then compress this into a quality index for each individual hospital. The aim of this study is to follow a similar approach for Germany and to establish a quality index for hospitals in Germany on the basis of data (section 301) provided by Barmer GEK (German health insurance company). As a first step, the data will be used to establish an index for the area of cardiovascular care. Using routine data provided by Barmer GEK, both the rate of re-hospitalizations and mortality after hospitalizations are determined for various periods of time (30 days up to 1 year). Then, a risk adjustment of the indicators is made using the Elixhauser index and other specific cardiovascular indexes. This is followed by an aggregation of the results for the individual indications using a self-developed method based on a seemingly unrelated regression (SUR). The result is a cardiovascular quality index for each hospital that evaluates the quality of hospitals on a scale of 1–10.
Impact of Privatizing Hospitals on Efficiency and Quality of Care
A number of hospitals have been privatized in the last few years. The impact of this development has not yet been examined. This project examines the impact that privatization has on the efficiency and quality of care provided by hospitals. In this project, the impact of privatization is examined using an extensive data set provided by the Federal Statistical Office (1998–2007) for all German hospitals; this also gives insight into the organization of the individual hospitals. Methodologically, a two-stage process that includes data envelopment analysis and a difference-in-differences regression approach is used. A quality index is being created for each hospital that is integrated into the data envelopment analysis.
Developing Innovative Health Care Programs for Patients with Rare Diseases (Entwicklung innovativer Versorgungsprogramme für Patienten mit seltenen Erkrankungen, EIVE)
This project is funded by the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF) and is dedicated to developing innovative health care programs for patients with rare diseases. The main problem with rare diseases is that they are often diagnosed too late. Early diagnosis can frequently extend life and result in lower-than-expected expenditures for health insurance companies. Based on routine data from the Techniker Krankenkasse health insurance company, regression models are used to identify and generalize actual clinical pathways of patients with selected rare diseases up to diagnosis. Predictors of an early diagnosis of rare diseases, such as density of physicians and physician’s specialty, are also identified. Routine data is also used to identify the duration between first symptoms and confirmed diagnosis. The results of these analyses are incorporated into the design of health care programs developed with other partners of the joint project for the treatment of patients with rare diseases.
For more information, please see http://www.eive.de
Innovative Behavior of Surgeons in German and American University Hospitals
This project examines innovative behavior of physicians through the example of surgeons in German and American university hospitals. Using an empirical analysis, this project aims to evaluate factors that inhibit and promote innovation on the basis of which university hospitals can optimize their research performance. This international comparison makes it possible to derive, in addition to recommendations for management at university hospitals, an understanding of the implications of health and economic policy. The project is being carried out in cooperation with the Chair of Technology Management at Kiel University.
Competition and Regulation of the Pharmaceutical Market
The regulation of the pharmaceutical market will continue to change in order to limit statutory health insurance expenditures and due to special conditions. But state interventions in the pharmaceutical market usually take place without an evaluation of their impact.
This project has the following objectives:
1. To examine the impact of regulatory measures on the price of drug products, the utilization of health care services, and prescription volumes
2. To examine the effect of external reference pricing systems (cross-reference pricing)
3. To examine the success of various price and market entry strategies on the generic drug market
Productivity²: Productive innovation processes to increase the productivity of health care providers.
This research project focuses, by way of example, on the productivity of hospitals as a particularly important sector of the health care system. The main objective of the project is to develop and implement an instrument which hospitals can use to measure and control their productivity and the productivity of innovation processes. This is a joint project funded by the Federal Ministry for Education and Research (Bundesministerium für Bildung und Forschung, BMBF) and conducted in cooperation with the Chair for Technology Management at Kiel University, the Institute for Work and Technology, and the Deutsches Krankenhausinstitut (German hospital institute).
The subproject at Universität Hamburg titled “Development and Testing of Validated Instruments to Measure Productivity” that falls under the joint research project is designed to address the following aims:
1. Analysis, evaluation, and development of methodological tools to measure productivity in hospitals
2. Analysis of the correlation between the productivity of performance and the productivity of innovation processes
3. Evaluation of the impact of innovations in strategic management on the productivity of hospitals
4. Development of concepts to anchor productivity measurements and increases in hospital management, and the exemplary implementation of the concepts in selected hospitals
More information is available at www.produktivitaet2.de.
MedtecHTA: Developing HTA Methods for Medical Devices—A European Perspective
Health Technology Assessment (HTA) methods already play a key role in the evaluation of technologies in various European countries. However, with the existing methods it is not always possible to sufficiently meet the challenges of the various health technologies.
MedtecHTA aims to further develop the existing HTA methods for evaluating medical devices. This includes examining decisions by organizations to adopt medical technology devices. First, a systematic review is used to identify the organizational factors of the adoption. Then, a standardized questionnaire is developed to determine what the relevant organizational requirements are. This should also make it possible to analyze the influence of adoption decisions on existing processes and structures. The survey is being carried out in cooperation with the European Society of Cardiology (ESC). Finally, a statistical analysis of the data collected is conducted that, among other things, should examine relevant influencing factors on the introduction of cardiac innovations within and between different countries. For more information, see www.medtechta.eu or our brochure.
Quality information, transparency and competition - opportunities and risks for SHI-accredited health care
In recent years, developments in health policy show a significant increase in the importance of quality assurance and quality transparency. Both are increasingly linked to the establishment of competitive mechanisms. Their implementation is also achieved with the help of corresponding legislative projects, such as the new regulations of the Hospital Structure Act in the inpatient sector. Soon, corresponding competitive efforts could also extend to SHI-accredited physicians and psychotherapists in private practice, since an increase in competition-oriented structures in outpatient SHI-accredited care has been observed in recent years. The aim of the project is to first conduct a critical assessment of the framework for quality assurance and quality promotion in the outpatient SHI-accredited physician sector on the basis of existing structures. Subsequently, possibilities will be discussed as to how associations of SHI-Physicians (Kassenärztliche Bundesvereinigung) can sensibly design a system that further establishes quality information, quality transparency, and quality presentation, taking into account the care mandate of SHI-accredited physicians and psychotherapists. The preparation of the expert report is carried out in several steps and by several independent experts, including scientists from the Technical University of Berlin and the IGES Institute.
Evaluation of the project "Further development of inpatient services for people with dementia"
In Hamburg, there are currently about 16,000 people living in fully inpatient nursing care facilities and it is assumed that between 50% and 75% of these residents suffer from a form of dementia. Against this background, various nursing facilities have recognised the need to adapt their services to this group of residents. The project "Further development of inpatient services for people with dementia", initiated by the working group, aims to achieve the following goals: Improve the quality of life of the residents and increase job satisfaction of employees, as well as the satisfaction of relatives. The project is being evaluated by the HCHE. As part of this evaluation, surveys are being conducted before and after the project and an evaluation report will be drawn up to determine to what degree the various objectives have been achieved.
European Research Training Group: Improving the Quality of Care in Europe
The HCHE - Hamburg Center for Health Economics, together with partners from the University of York, Universidade de Lisboa, University of Southern Denmark, Bocconi University, Erasmus University Rotterdam and Abbott, has received EU funding for the establishment of a doctoral program. The doctoral programme is concerned with "Quality of Care", i.e. the quality of the health care system. The research results are intended to improve the quality and performance of European health care systems. One aim of the doctoral program is to produce highly qualified scientists and experts in the field of "Quality of Care". Thus opening up diverse career paths in health economics research and practice.
INVEST Billstedt/Horn – Hamburg Billstedt/Horn as prototype for integrated full health care in deprived metropolitan regions
In socially disadvantaged urban areas, there are fewer and fewer GP, specialist, dental and psychotherapeutic practices. At the same time, life and health prospects are worse than in wealthier urban districts due to socio-economic conditions. As a result, residents do not feel adequately cared for, emergency rooms are utilized more frequently, and health expenditure is rising continuously. INVEST Billstedt/Horn uses the East of Hamburg (Billstedt/Horn) as an example to test how the health status of the population in socially disadvantaged districts can be improved and how the use of available resources can be optimised. The care model comprises various elements and includes all areas, institutions and occupational groups involved in health care. To this end, innovative and patient-oriented care structures and processes are being established and new digital applications are being tested in order to improve communication both between doctors themselves and between doctors and patients. The aims of the interventions are to relieve the workload of physicians, to strengthen the provision of care close to home and to avoid overuse, underuse and misuse of physician services. One innovative focus will be the establishment of the health kiosk, a central and well-networked contact point where the insured can receive broad advice, support and training on all health issues in their native language. Further information can be found on the project website of INVEST Billstedt/Horn.
Accompanying research on the effects of the introduction of the flat-rate payment system for psychiatric and psychosomatic facilities pursuant to § 17d, paragraph 8 KHG
By means of section 17d, paragraph 1 of the Hospital Financing Act (KHG) the GKV-Spitzenverband (National Association of Statutory Health Insurance), the Verband der Privaten Krankenversicherung (Association of Private Health Insurance) and the Deutsche Krankenhausgesellschaft (German Hospital Federation) were required to introduce a "universal, performance-oriented and flat-rate remuneration system based on daily rates" for the remuneration of general hospital services provided by psychiatric and psychosomatic institutions. The accompanying research is designed to particularly examine changes in care structures and the quality of care, the effects on other areas of care, and the type and extent of shifts in services. In view of the changes in the hospital sector induced by the renumeration system, the intersections with the service areas surrounding the hospital are to be analysed, particularly with regard to the politically desired networking of the care structures. The accompanying research should also identify possible incentive effects or undesirable developments, and, finally, enhance transparency already initiated in the hospital sector.
The influence of price changes on hospital behaviour in Germany
The existing literature cannot systematically distinguish between the different reactions (admissions behaviour, treatment intensity, coding) of hospitals to price changes. Furthermore, the effects of the three different behavioural changes on the quality of care have not yet been investigated. The project analyses whether hospitals change their "extensive margin", i.e. their admissions behaviour, the "intensive margin", i.e. the intensity of treatment, or the coding in response to price changes from one year to the next. Different elasticities and cross-price elasticities of supply are estimated. Biases due to reversed causality or unobservable confounding variables are minimized by means of instrumental-variable methods, among others. Furthermore, it will be investigated whether any changes in admission or treatment behaviour have an impact on the quality of care. From a scientific point of view, the project contributes to quantifying the three possible behaviours (extensive margin, intensive margin, and coding behaviour) in order to better understand hospital behaviour. From a practical point of view, the project will contribute to uncovering inappropriate incentives for overuse, underuse and misuse of the DRG reimbursement system and to identifying solutions.
Promotion of health-related personal responsibility
In the coming years, a substantial disparity between income and expenditure in the statutory health insurance system is expected. Rising contribution rates are becoming apparent for the coming years. As a result, politicians will look for alternative forms of financing, and/or instruments to strengthen individual accountability, that are economically effective on the one hand, but also legally, ethically justifiable, and consensual on the other. The aim of the subproject is to develop and analyse instruments to strengthen individual accountability, which from an economic perspective will enhance social welfare.