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Background: The German Prevention Act aims to strengthen health promotion and disease prevention. The law makes changes to the so-called "§20 measures". Target values were newly given for the expenditures of the health insurance funds in this area. The objective here was to examine how the prevention expenditures of the statutory health insurance developed in the period from 2012 to 2017, and whether the requirements of the Prevention Act were met., Methods: The accounting results of the statutory health insurance funds were evaluated for the period 2012-2017. The expenditures per insured person were calculated and the changes in expenditures were analysed. The effect of the prevention law was highlighted by differentiation of the time periods 2012-2014 and 2014-2017., Results: In 2017, about 2.5% of the total expenditure of the German statutory health insurance, around 5 billion euros, was accounted for in the reported prevention areas. Nearly 60% of these prevention expenditures were on early detection and vaccinations. Expenditure on "§20 measures" amounted to € 7.17 per insured person and thus reached the statutory guideline but accounted for less than 10% of all prevention expenditure. Although prevention expenditure per insured person increased over the period, the proportion of money spent on prevention measures as a whole had decreased since 2015. Expenditure on prevention measures that were directly aimed at the insured (individual approach, bonus programmes) and the setting approach (non-occupational settings, worksite health promotion) had hardly increased overall since the Prevention Act came into force. This effect is due to the equally strong decrease in bonuses for health-conscious behaviour among insured persons, despite the sharp increase in expenditure on company and noncompany settings., Conclusion: The proportion of money spent on disease prevention in total expenditure is still decreasing. The targets set by the Prevention Act, however, have been reached. Thus, target values have apparently proved to be an effective instrument for regulating prevention expenditure and have led to an increase in expenditure in the setting approach. Overall, there has been no expenditure effect in the area of disease prevention since the Prevention Act was enacted, as compensation was made at the expense of the non-setting measures without target values., Competing Interests: Die Autoren bestätigen, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking., Objectives: To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES., Materials and Methods: The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication., Results: There was no significant functional association between SES and healthcare costs for any of the analysed cost types., Conclusions: In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

Dementia is one of the most frequent diseases of people aged 65 and older. As a result of the upcoming demographic transition, a significant increase is expected to the current number of around 1.7 million dementia patients. A precise estimate of this increase is especially important for decision-makers and payers to the health-care system. This study examined the effects of different assumptions on the future frequency of disease using a time-discrete Markov model with population-related and disease-specific components. Based on health insurers' administrative data from AOK Baden-Württemberg, we determined age- and gender-specific prevalence rates, incidence rates, and mortality differences of dementia patients and combined them with demographic components from German population statistics. As a result, our Markov model showed a 20 to 25% higher number of dementia patients in 2030, compared to the results of the status quo projection applied in most previous studies, with the assumption of constant prevalence rates over time. Hence, our results indicate that even in the medium term payers will have to face significant increases in dementia-related health expenditures. By 2060, the number of dementia patients in Germany would rise to 3.3 million assuming a further increase to life expectancy and constant incidence rates over time. The assumption of a compression of the morbidity would reduce this number to 2.6 million.

Background: Little is known about the utilization of individual health services performed by a physician (IGeL) and the services and supplements provided outside a doctor's office (MuPaP) for osteoarthritis patients., Objectives: The aims of this study are to analyze the use of osteoarthritis-specific IGeL and MuPaP as well as predictors for their utilization., Materials and Methods: For this cross-sectional study, claims data was used to identify all persons with hip, knee, or polyarticular osteoarthritis in 2014 (n = 657,807). A random sample (n = 8995) was sent a questionnaire about their usage of IGeL and MuPaP. Furthermore, the type of physicians conducting or recommending services was evaluated. Applying multivariable logistic regression, predictors associated with the utilization of IGeL, MuPaP, and overall individual health services were analyzed., Results: After validating the data and osteoarthritis diagnosis, 2363 persons were enrolled (mean age: 65.5 years, 72% female). In the last 12 months, 39% of patients had used at least one IGeL (MuPaP: 76%), with 86% being primarily performed by orthopedists (MuPaP: 88% patient self-motivated). Knee osteoarthritis was associated with increased utilization of IGeL. Having female gender, higher income, residence in Western Germany, higher disease burden, and lower satisfaction with the healthcare system were influences on the use of overall individual health services., Conclusions: Since patients with high disease burden in particular tend to use these therapies with varying treatment success, detailed information, especially about the risks and existing evidence, should be a prerequisite for trustworthy doctor-patient relationships.

Give the due value to the end of life: the systematic underfunding of specialised palliative care in the Swiss DRG system Abstract. Palliative care is an integral part of modern medicine, improving quality of life, treatment satisfaction, and reducing the costs of care in severe disease. Patients' access should be early, regardless of age, diagnosis and setting, when incurable or advanced disease has been diagnosed. The public expenditure for specialised palliative care units in hospitals can be seen as yardstick for an appropriate palliative care supply, but in Switzerland only a mere fraction of revenues is dedicated to the palliative care units. Every year, 66'000 patients die in Switzerland, 38 % of them in a hospital. Health care costs for the last year of life account for 1.9 billion Swiss francs, but palliative care units receive only estimated 51 million Swiss francs per year. Reasons are a too little number of palliative care units, a systemic underfunding of their services and a fragmentary supply chain for severely ill or dying patients. This leads to ethically conflicting situations for clinicians. They have to deal with shortage of supply and, due to economic reasons, are forced to transfer severely ill or dying patients into inadequate settings. Based on international recommendations, Switzerland is in need of further 500 beds for specialised palliative care (actually 335), and at least 11'000 patients per year need access to a specialised palliative care service (actually about 3'500). Under the actual tariffing system, units for palliative care in hospitals are endangered in their existence. Corrections of the remuneration system are urgently warranted. On the long run, a national legal basis should be elaborated to safeguard adequate palliative care supply for all patients in need and as a base for monitoring, formation and research in palliative care.

New patients in the secondary respiratory care require more time for the first consultation and place a higher diagnostic and therapeutic demand if compared to patients already in chronic care. More diagnostic procedures and patient's education by the team are required. No such burden is observed regarding differential degrees of severity of respiratory diseases, e. g. COPD. The overall demands add up to twice the demands of patients already in care. Thus the time required for the treatment of 50 new patients allows consultations for 100 patients already known in the office.As additional time and effort for new patients is not adequately represented in the German medical tax (EBM) a trend to risk selection and a preference for control patients is observed. In contrast incentives to foster treatment of new patients could be an effective measure to dramatically reduce waiting time for visits with pulmonologists. This should be achieved by changes in the German medical tax (EBM)., Competing Interests: A. Hellmann ist Vorsitzender des Bundesverbandes der Pneumologen, Schlaf- und Beatmungsmediziner (BdP); Vorträge für Novartis und Allergopharma.T. Hering ist stellv. Vorsitzender des BdP.J. Andres ist Geschäftsführer der medWIss GmbH, Auftragnehmer des BdP., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Elderly people with a non-German background are a fast growing population in Germany., Objectives: Is administrative prevalence of dementia and uptake of nursing-home care similar in the German and non-German insured?, Materials and Methods: Based on routine data, administrative prevalence rates for dementia were calculated for 2013 from a full census of data from one large sickness fund. Patients with dementia (PWD) were identified via ICD-10 codes (F00; F01; F03; F05; G30)., Results: Administrative prevalence of dementia was 2.67% in the study population; 3.06% in Germans, and 0.96% in non-Germans (p value <0.001). Age and sex adjusted prevalence was comparable in the insured with and without German citizenship, except in women aged 80-84 (17.2 vs. 15.4) and for men in the age groups 80-84 (16.5 vs. 14.2), 85-89 years (23.4 vs. 21.5), and above 90 years of age (32.3 vs. 26.3). Standardized to the population of all investigated insured, 31.4% of all Germans with dementia had no longterm care entitlement vs. 35.5% of all patients without German citizenship. Of German patients, 55.1% were institutionalized vs. 39.5% of all patients without German citizenship., Conclusions: There was a higher prevalence of dementia in the very old insured without German citizenship compared to those with German citizenship, especially in men. Non-Germans showed lower uptake of nursing home care compared to Germans. Additionally, Germans had slightly higher nursing care entitlements. It should be investigated further how much of the difference is due to underdiagnosis, cultural differences, or lack of adequate diagnostic work-up.

The development of healthcare expenditures and the impact of demographic change are the subject of a controversial debate. Yearly healthcare expenditures have more than doubled between 1992 and 2015 and are often justified by the aging demographic. The majority of expenses are paid by the statutory health insurance (SHI). The aim of the current study was to evaluate the contribution of the demographic change to increasing total per capita expenditures in the SHI as well as to analyze the development and the impact in individual areas of spending.We calculated average per capita expenditures from 2004 to 2015 based on data from the German Federal (Social) Insurance Office. Information on the age distribution in SHI was derived from official statistics of the Federal Ministry of Health. To determine the impact of demographic change on per capita expenditures, age distribution was standardized based on 2004 data. Additionally, the impact of inflation and other factors was determined.The results show an increase in per capita expenditures from €1722 in 2004 to €2656 in 2015 (+54.2%). Assuming a constant age distribution at the 2004 level, average per capita expenditures would have increased by 44.9%. The relative share of demographic change is only 17.3%; 32.2% could be explained by inflation and 50.5% are based on other factors. We observed large differences in the increase for the individual areas of spending, which can partly be explained by the impact of demographic change.This analysis illustrates that the demographic change is not the frequently claimed cost driver in healthcare. Other factors have a substantially greater impact on healthcare expenditures.

Background and Objectives: The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB., Materials and Methods: To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany., Results: On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB., Conclusions: Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Cost-effectiveness of shoulder arthroscopy was analyzed and assessed by the days off work as part of the indirect costs. We retrospectively evaluated a group of 266 inpatients on sick leave after arthroscopic shoulder surgery. Mean duration till return to full duty was 9.5 days, the mean sick leave benefit was € 485. There was a statistically significant difference in the mean time to return to work between the older (age >50) and the younger group (age under 50). Secondary data analysis of sick leave and sickness benefits as indirect costs of medical treatment seems to be well suited to provide essentiell information to health care policy makers and those charged with distributing disability funds., Competing Interests: Interessenkonflikt:: Es besteht kein Interessenkonflikt. Die korrespondierende Autorin versichert, dass keine Verbindung mit einer Firma besteht. Die Präsentation des Themas ist unabhängig und die Darstellung der Inhalte produktneutral., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In Germany, out-of-pocket payments (OOPP) account for a large proportion of total health expenditure. However, there are only few investigations on how morbidity-related, sociodemographic and lifestyle factors affect OOPP particularly in the older population. The aim of this study was to identify factors affecting OOPP for health care services among elderly Germans in a longitudinal setting. Methods: This longitudinal study used data from 2 follow-up waves (3-year interval) from a population-based prospective cohort study (ESTHER study) collected in Saarland, Germany. At the first follow-up wave, subjects were between 57 and 84 years old. Participants provided comprehensive data including individual OOPP for the preceding 3 months. Fixed effects (FE) regressions were used to determine factors affecting OOPP. Results: Mean individual OOPP (3-month period) rose from € 119 (first wave) to € 136 (second wave). Longitudinal regressions showed that higher morbidity did not affect OOPP. Moreover, changes in sociodemographic as well as lifestyle factors were not related to changes in OOPP. Solely, exemption of OOPP reduced the dependent variable significantly. Conclusion: In contrast to cross-sectional findings for Germany, OOPP are not related to morbidity and income in this study. This underlines the complex nature of OOPP in old age and the need for longitudinal studies to gain some insight into the underlying causal factors., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Prostate cancer (PCa) is the most common cancer in men. For medical treatment of PCa, a number of therapies are available. The economic consequences associated with these individual treatment options in routine care in Germany are unclear so far., Methods: The present analysis was based on the Germany-wide HAROW observational study, which was conducted from 2008-2013. During this study, all participating physicians and involved patients reported and documented individual health care resource consumption. These data were evaluated in monetary terms stratified by treatment regime (hormone therapy, HT; active surveillance, AS; radiotherapy, RT; radical prostatectomy, RP; watchful waiting, WW)., Results: Overall, the data of 2672 patients were available for analysis. Based on the observational study design, the included patient groups were heterogeneous in their baseline characteristics. The annual total costs from the societal perspective were the largest for patient undergoing RP (9254 €; 95 % CI 8353-10,154), mainly driven by the costs for the initial hospital stay for surgery. HT, AS, RT, and WW seem to be comparable in terms of direct costs, ranging from 805 € (95 % CI 154-1455) for WW up to 1115 € (95 % CI 826-1405) for RT. The highest indirect costs were observed for patients receiving RT (3928 €; 95 % CI 0-10,675), which can be justified by the frequent incapacity to work in this patient group., Conclusion: The treatment of prostate cancer can lead to significant economic follow-up costs which vary greatly depending on the type of treatment. The analysis indicates a need for the implementation of a long-term health economic study in the future, which will be more suitable to show treatment-specific differences in the temporal occurrence of costs.

Background: The Parkinsonian syndromes (PS) belong to the frequent chronic neurological disorders that, due to their progressive character and complex therapeutic options, pose a large economic burden., Material and Methods: In a retrospective health economic study on the treatment of Parkinson's disease, various socioeconomic and clinical parameters were examined. In the years 2011-2012, a total of 29 patients with the diagnosis of a Parkinsonian syndrome who underwent an inpatient rehabilitation in the Department of Neurology of the Rehabilitation MediClin Center Bad Orb were recruited. For this group of patients, we calculated the direct treatment cost and also analyzed the treatment cost based on the German diagnosis-related groups (G-DRG, version 2012)., Results: The direct medical costs amounted to € 113.47±13.10 per patient per day. Furthermore, cost simulation and comparison revealed significantly higher cost per day for those patients insured via the German statutory health insurance who undergo inpatient care service based on the DRG-based payment (€ 241.77 vs. 171.74; p≤0.015)., Conclusion: This study contributes to the achievement of transparency of the direct medical costs of Parkinson's disease treatment in the inpatient setting and emphasizes the cost differences compared to the G-DRG-based payment., (© Georg Thieme Verlag KG Stuttgart · New York.)

Demographic development in Germany will lead to increasing health care costs. Telemedicine is believed to have the potential to generate cost savings and therefore to reduce the expected increase in health care costs. This publication reviews the relevant literature, presenting the results of available studies, describing the problems involved in performing appropriate studies, and examining solutions.

Purpose: Innovative care models shall reduce the frictional losses in health-care. The successful implementation of care networks requires the acceptance by the health care providers, by the patients and citizens as well as by the payers. The consideration of preferences is an essential factor for success. The aim of this study is to analyse patient preferences., Methods: With the help of Discrete-Choice experiment 21 patient-relevant attributes of innovative healthcare programmes were examined. On the basis of a balanced overlapping design (sawtooth) a total of 140 choice sets with the highest possible D efficiency was generated. The 21 attributes were divided into 4 thematic priorities for analysis. The cost attribute was integrated as a uniform comparator. The evaluation was done by a random effects logit estimation (STATA)., Results: The representative samples (N=1 322) revealed that in all 4 DCE blocks the attribute "additional costs" had the strongest influence on the patients choice (1: coeff.; 1.047; 2: coeff.: 1.105; 3.: coeff.: 0.956; 4.: coeff.: 0.954). This was followed by "medical apparatus and facilities", "waiting time for an appointment", "professional experience", "travelling time to treatment site", and "exchange of clinical information". "Transfer management" and "consideration of individual circumstances" for example, had a small influence on patient choice., Conclusion: In order to increase the acceptance of innovative health-care programmes preferences must be known and integrated into the design of the services. The present study has attempted to depict the patients' perspectives towards the new care systems. The individual selection decisions were not, as would be expected, influenced by the innovative approaches such as case management or shared decision making but rather by the quality of the infrastructure, the waiting times and professional experience., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Due to demographic trends towards an ageing population resource use of health care will increase. By collecting health-related costs via questionnaires, the impact of socio-economic variables and other medical factors can be examined. In addition, only patient reported resource use accounts for out-of-pocket payments. Thus, it is necessary to develop an appropriate tool to collect the health-related resource use in an elderly population., Methods: The development of the FIMA (questionnaire for the use of medical and non-medical services in old age) was carried out in 6 steps. These included the determination of necessary questionnaire contents based on a literature review and the wording and layout were defined. Finally the questionnaire was tested in a pilot study and was modified., Results: All direct medical and non-medical resource use excluding transportation and time costs were recorded. Productivity losses were not included. The recall time frames differed according to resource categories (7 days, 3 months, 12 months). For the pilot study, 63 questionnaires were analysed. The response rate was 69%. The questionnaire took an average of 21 min to complete. Three quarters of respondents completed the questionnaire without help and 90% rated the difficulty as easy or even very simple. There was good agreement between self-reported health-related quality of life and the resource use of nursing and domestic help (phi coefficient values between 0.52 and 0.58)., Conclusion: The FIMA is a generic questionnaire which collects the health-related resource use within the older population groups., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim and Methods: A common justification of the failure to perform scientific evaluations of integrated care programs (in accordance with Sect. 140 SGB V) is the high level of expenditure which is strongly influenced by the conditions of the particular program. Two practical examples will be used to outline frameworks of integrated care programs that may create obstacles to evaluation. If possible, appropriate solutions that may help to avoid or at least reduce these obstacles will be presented., Results: In many programs target groups and program objectives are inaccurately defined. Especially disease-specific programs bear the risk of having too small a sample size to exclude random effects. Only a few integrated care programs include evaluations that have been proactively planned from the outdet., Conclusion: In particular, early planning of evaluations plays an important role in avoiding distortions of results and additional expenses. It may also have a positive influence on all other frameworks., (Copyright © 2015. Published by Elsevier GmbH.)

Background: Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department., Objectives: This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery., Materials and Methods: Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery., Results: A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case., Conclusion: The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

Headaches are an enormous burden both for the individual sufferer and for society. The WHO lists migraine among the 10 diseases with the highest impact on the quality of life and functionality of the sufferers. The treatment of headache patients in Germany is relatively poor compared to other European countries. Only a minority of patients receives a treatment according to published guidelines, although sufficient care can be provided on all levels of the health care system. The total costs caused by headaches in Germany are approximately 27 bio € per year with 17 bio € caused by migraine. With respect to the individual annual costs of a headache, the highest costs are caused by medication overuse headache with 3600 € followed by migraine with 1200 €.

Objective: To analyze direct costs and cost determinants in psychotic patients with persistent positive symptoms (PPS)., Methods: A total of 330 patients with PPS were recruited via 6 university clinics and interviewed about service utilization in the previous 3 months. After monetary valuation, costs were analyzed via generalized linear mixed models with gamma distribution and log-link function to identify determinants of direct costs., Results: The mean costs were 7,065 € and resulted predominantly from psychiatric hospital care (63 %), assisted living (17 %) and complementary services (8 %). We found statistically significant associations between direct costs and an increasing score of the negative subscale of the Positive and Negative Syndrome Scale (+ 2,484 € per point, p < 0.001) and experiencing less than one social contact per week (- 2,272 €, p = 0.003)., Conclusion: PPS incurred substantial direct costs which primarily resulted from hospital treatment, and were strongly associated with symptom severity., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Eye diseases that are relevant regarding their macroeconomic costs and their impact on society include cataract, diabetic retinopathy, age-related maculopathy, glaucoma and refractive errors., Objectives: The aim of this article is to provide a comprehensive overview of direct and indirect costs for major eye disease categories for Germany, based on existing literature and data sources., Methods: A semi-structured literature search was performed in the databases Medline and Embase and in the search machine Google for relevant original papers and reviews on costs of eye diseases with relevance for or transferability to Germany (last research date October 2013). In addition, manual searching was performed in important national databases and information sources, such as the Federal Office of Statistics and scientific societies., Results: The direct costs for these diseases add up to approximately 2.6 billion Euros yearly for the Federal Republic of Germany, including out of the pocket payments from patients but excluding optical aids (e.g. glasses). In addition to those direct costs there are also indirect costs which are caused e.g. by loss of employment or productivity or by a reduction in health-related quality of life. These indirect costs can only be roughly estimated. Including the indirect costs for the eye diseases investigated, a total yearly macroeconomic cost ranging between 4 and 12 billion Euros is estimated for Germany., Conclusion: The costs for the eye diseases cataract, diabetic retinopathy, age-related maculopathy, glaucoma and refractive errors have a macroeconomic relevant dimension. Based on the predicted demographic changes with an ageing society an increase of the prevalence and thus also an increase of costs for eye diseases is expected in the future.

Background: Cancer screening tests such as ultrasound scans, extensive skin cancer screening, or the prostate-specific antigen (PSA) test are among the most commonly used individual out-of-pocket health services (in German: Individuelle Gesundheitsleistungen, or IGeL) among people who have statutory health insurance in Germany. They are usually offered as an add-on to the services that are covered by statutory insurers., Questions and Methods: There are a number of reasons why cancer screening tests might not be covered by insurers. The main reasons are because the test does not have any clear benefits, and because the harms outweigh the benefits. This article describes the fundamental difficulties of, and the requirements imposed on, benefit assessments of cancer screening tests., Results: Cancer screening tests that are available as individual out-of-pocket health services are always potentially harmful, while their benefit is either not clear or contested, or there is clearly no benefit., Discussion: Health-care providers who offer cancer screening tests are required to provide interested people with relevant information on the related benefits, harms, and uncertainties of the tests, so as to enable an informed decision. This is especially important when it comes to "IGeL" services.

Background: Chronic pain in children and adolescents causes a high utilization of the health care system and thereby significant costs. The aim of the present study is to describe the economic effects of pediatric chronic pain from the family's perspective., Material and Methods: Six months before and 6 and 12 months after a 3-week inpatient-based intensive interdisciplinary pain treatment, the parents of 101 children with chronic pain filled in a standardized cost questionnaire containing the following parameters: (1) child's utilization of medical and social services, (2) subjective financial burden, and (3) type and extent of direct costs., Results: During the 6 months before inpatient-based intensive interdisciplinary pain treatment, children used a median of four different services. After inpatient pain treatment, service utilization has been reduced significantly (p < 0.001). One fifth of the families report a high or very high financial burden before treatment. Family's direct costs are most often caused by travelling (86 %) and drugs (60 %). After inpatient pain treatment, family's financial burden decreased significantly (p < 0.001). The frequency of additional expenditures is also reduced after treatment: parents report less additional costs due to travelling and drugs (p < 0.001, respectively)., Conclusion: The present study emphasizes the pronounced utilization of health and social care due to pediatric chronic pain. In the future, the use of appropriate diagnostic and therapeutic standards that contribute to avoiding unnecessary and expensive interventions is preferred.

As healthcare expenditure typically rises during a person's lifetime, there are widespread fears that the ageing of the German population together with technical progress in medicine will be a serious threat to future healthcare financing. The relationship between ageing and growth of healthcare expenditure has been intensively studied over the past 15 years both theoretically and empirically. In this article it will be demonstrated that the highest expenditure is not due to age per se but rather to proximity to death. However, even taking this effect into account simulations show that the increase in life expectancy as well as medical progress will contribute to the growth of per capita expenditure in the German healthcare insurance system.

The dynamics of one of the most innovative segments of health care and its impact on pharmaceutical expenditure of private health insurance (PHI) is examined on the basis of drug prescription data from private health insurance companies. The study shows that the increase in pharmaceutical expenditure can be explained partly by the new treatment possibilities available with monoclonal antibodies. The per capita expenditure on drugs with monoclonal antibodies increased by 255% from 2006 to 2010 in private health insurance, while the corresponding expenditure of all pharmaceuticals has risen by only 19% in the same period. In the coming years, growth on this scale will be a challenge for all payers in the health system.

Objectives: This paper analyses on the basis of data from over 2 400 nursing homes the relationship between remuneration rates and quality for Germany. Other factors influencing this relationship are taken into account.Data about nursing homes are taken from the nursing home data base PAULA, which includes about 11 500 nursing homes., Data and Methods: Data about quality of care in nursing homes are derived from the so-called transparency reports for residential long-term care (PVTS). In a linear regression framework the different quality measures are regressed on the average nursing home price. Control variables are inter alia ownership, size and location of the nursing homes., Results: The analyses show a statistically significant positive correlation between remuneration rates and quality. Better quality is reflected in higher remuneration rates., Conclusions: The results show a significant, but in actual size low relationship between quality and remunerations rates. The results cannot be interpreted as a causal relationship. Additionally, it is not possible to explain differences in nursing home prices over federal states with differences in quality., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The development of paediatrics is characterised by several changes in the past few years, concerning, in particular holistic treatments or preventive check-ups, but also the transfer of treatment from the inpatient to the outpatient sector. There are no reference values for assessing emerging health insurance expenses. The aim of this study was to obtain a frame of reference for the costs of the treatment for neonates, infants, and young children using the example of the expenditures of one health insurance fund., Methods: The individual health insurance expenditures were analysed for the first five years of life of children insured with the AOK PLUS in Saxony, Germany, in 2005. Costs of hospital treatment, ambulatory care, remedies, tools, medicines and care were included., Results: The costs per insured child and year amounted to approximately 1,277 Euro (N = 11,147), with the highest costs arising in the first two years. 858 Euro were spent annually for an "average" child; 5,691 Euro per year incurred for a child with special medical needs., Discussion: The present cost analysis describes both the height and structure of a health insurance's spendings on children within the first five years of their life in consideration of regional medical care offers. The question of whether this analysis provides valid reference values for other health insurances or other service areas will have to be answered by other analyses., (Copyright © 2013. Published by Elsevier GmbH.)

The impact of a longer life on future health care expenditures will be quite moderate because of the high costs of dying and the compression of mortality in old age. If not age per se but proximity to death determines the bulk of expenditures, a shift in the mortality risk to higher ages will not significantly affect lifetime health care expenditures, as death occurs only once in every life. A calculation of the demographic effect on health care expenditures in Germany up until 2050 that explicitly accounts for costs in the last years of life leads to a significantly lower demographic impact on per-capita expenditures than a calculation based on crude age-specific health expenditures.

The objective of this pilot study was to evaluate the annual direct costs of chronic non-specific low back pain in Austria in patients currently undergoing in-patient rehabilitation or out-patient treatment. 48 patients participated in the study. Average direct medical costs per patient year as paid by the sick funds were € 1443,-, in-patient rehabilitation was the single most expensive direct cost factor. Non-medical costs, that is, mainly household assistance and home adaptations, were € 394,-; deductibles and non-reimbursable medical costs were € 329. On average, patients had 2.7 co-morbidities (men: 2.2; women: 2.9).

The aim of this study was to calculate the direct costs of illness in patients with advanced osteoarthritis of the hip and knee. Costs were reported retrospectively by a self-administered questionnaire, covering the period of 12 months prior to joint replacement. Total direct costs amounted to 2747.- euros, medical costs were 1148.- euros, and non-medical costs were 1599.- euros. Late-stage osteoarthritis is expensive because of high costs mainly from personal care and household assistance caused by severe loss of function.

Background and Purpose: Drug treatment of cystic fibrosis (CF) is associated with significant costs. To help ensure sustainable care, this study assesses the costs associated with outpatient treatment of adult CF patients in Germany. It identifies main cost drivers, evaluates the potential for cost savings from "aut idem" substitution and presents a projection of lifelong medication costs., Methods: The analysis is based on a complete set of prescriptions for adult CF patients from the outpatient clinic of the university hospital of Frankfurt am Main during 2007 (n = 124 patients). Annual treatment costs were calculated on the basis of the "Rote Liste", while the potential for cost savings from "aut idem" drug substitution was obtained through ABDATA Pharma Data Service., Results: The annual outpatient drug costs for an adult patient with CF averages € 17,219 (n = 124), which increases to € 21,782 if i.v. therapies are included. With an average life expectancy at birth of 39.7 years, total lifetime drug treatment costs amount to € 824,159 (reference year 2007, inflation rate 2.7%, 3% discount rate). "Aut idem" substitution with cheaper drugs could reduce pharmaceutical expenditures by 4.1%., Conclusion: Our results confirm the costly nature of drug treatment for CF patients, both on an annual and in particular on a lifelong basis. At the same time, the potential for cost savings through "aut idem" substitution with cheaper drugs remains limited. The added transparency around a small set of costdriving drugs, which is offered in this study, represents a solid contribution to assess treatment choices and financing options to help secure adequate yet sustainable care for CF patients.

This article presents an overview of the recently published first two parts of the Memorandum III "Methods for Health Services Research" discussed and approved by the member societies of the German Network Health Services Research [Deutsches Netzwerk Versorgungsforschung e.V.]. Part one of this memorandum covers methodical principles and minimum standards for the subject areas of health services research "Epidemiological Methods for Health Services Research", "Methods for Organisational Health Services Research" and "Methods for Quality of Life Research", the second part the topics "Methods of Health Economic Evaluation" and "Registries for the Health Services Research". The Memorandum is addressed to health services researchers and to reviewers who are planning, conducting, publishing studies as well as evaluating research proposals and publications. Assurance of quality and increase of the health services research are the aims of the Memorandum III. According to the advanced knowledge in health services research the Memorandum needs regular updates. Therefore the Memorandum has to be understood as "work in progress".

Background: The risk compensation scheme (RCS) in the Statutory Health Insurance (SHI) was implemented in 1994 to discourage risk selection between sickness funds. However, several expertise papers have concluded since then that the sociodemographic risk adjusters in place could not adequately curb risk selection. To minimise incentives for risk selection in the Statutory Health Insurance (SHI) further, the RCS was refined in 2009 by adding 80 diseases as additional risk adjusters. In spite of the better compensation of differences in morbidity, however, incentives for risk selection may still persist. In this study, we investigated the association of indicators such as region (number of inhabitants in the city), income, level of education and family status (children in the household) with health care costs to determine if risk selection is still attractive for sickness funds under the refined RCS., Method: The analysis is based on a 2002 cross-section survey comprising 75,122 individuals. Health expenditures were estimated using self-documented utilisation data and were standardised for age, sex and diagnoses covered by the risk adjustment scheme. We included costs for inpatient care, outpatient care, pharmaceuticals, rehabilitation, and medical devices. To assess the effects of the above-mentioned individual characteristics on health-care expenditure, regression analyses and analyses of variances were performed., Results: Full documentation was available for 52,484 individuals (69.86%). From these the variables "family status (children in the household)", "higher educational level", and "higher income" were associated with lower costs for individuals without chronic conditions. For individuals with chronic conditions, results were mixed. "Family status", "education" and "income" showed no clear association with lower or higher costs and were not statistically significant. The variable "region" was neither significantly associated with chronically ill nor for healthy individuals., Discussion: With respect to age, sex, and morbidity, individuals with high income and education and without chronic diseases apparently cause lower costs. Thus, health status, income and education remain as possible selection criteria for sickness funds in Germany. However, the refined RCS compensates for the largest proportion of cost differences between insured with and without chronic disease. Possible causes of the small but remaining differences and whether improving preventive programmes or providing awareness campaigns may be appropriate strategies to tackle this issue should be investigated in future research., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: INTRODUCTION Based on the data of the Institut für das Entgeltsystem im Krankenhaus (InEK) cost and revenue data for deliveries in Germany can be compared. The InEK calculates the cost data for each individual diagnosis-related group (DRG) on the basis of those hospitals that deliver their individual cost data, so-called "Kalkulationshäuser". The InEK only publishes data for patients with standard lengths of stay. It does not deliver data for short- and long-stay patients. Beside these cost data, the InEK publishes the nationwide case volume for each DRG. Having a knowledge of the individual base rate (Landesbasisfallwert), which differs from province (Bundesland) to province and, in addition, the nationwide case weight for each DRG, the average revenues for deliveries in general, vaginal deliveries, and Cesarean sections can be calculated. These revenue data differ not only from province to province, but from hospital to hospital because of the individual hospital-specific base rates., Materials and Methods: The average costs for a delivery in general, a vaginal delivery, and a Cesarean section were calculated on the basis of the DRG Report Browsers 2005/2007-2007/2009 published by the InEK. The costs for short- and long-stay patients were estimated on the basis of a scenario technique. The revenues were calculated on the basis of the published DRG catalogues, which supply individual case weights, and the county-wide base rate. Short- and long-stay revenues again had to be estimated by a scenario technique. In every DRG the cost data create the basis for the case weight two years later., Results: In relation to the average base rate over all provinces the 2005 costs are higher than the revenues in each province. Even in Rhineland-Palatinate, the county with the highest base rate, costs and revenues are at par. Only the declining costs from 2005-2007 balance the costs and revenues nationwide. But in provinces with low base rates the revenues stay lower than costs. These data demonstrate the pressure of rationalisation on German perinatal medicine and their hospitals. Cost and revenue comparisons with other countries are of lesser interest. Most countries have totally different systems for financing hospitals. In Germany, the published data show only the running costs financed by public and private health-care insurances. Infrastructure costs are financed by the government. In other countries not only the running costs but also the investment costs must be financed by running revenues too., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The standardization of the profit in the public health system causes the question if obstetrical departments of different structures can work cost-coveringly and which services in the DRG-system operate in deficit or profitably. This problem mainly refers to the hospitals of obstetrical maximal care, namely the perinatal centre of level I., Material and Methods: Based on the body cost accounting according to InEK-Matrix the average actual costs of an obstetrical department level IV, a perinatal centre level I and university hospitals were found out for the obstetrical DRGs and compared with the profits calculated by InEK. An analysis of the costs was carried out concerning the cost relevance for different cost areas., Results: Spontaneous delivery was the service that turned out to be cost-covering in all structures. The real costs of caesarean sections, however, as well as those of some vaginal kinds of delivery, mainly pre-mature births and complicated diagnoses turned out to be not cost-covering. However, the perinatal centre was able to compensate the deficit by the high number of vaginal deliveries. The actual personel costs for physicians were higher in the perinatal center than the InEK-calculation for all obstetrical DRGs. The costs of nursery and the costs of the non-medical infrastructure were partly smaller than those of the InEK-calculation., Conclusion: A perinatal center level I can operate cost-coveringly on the basis of the DRG system. To achieve this it's not necessary to increase the number of caesarean sections, but what is needed instead is a high number of normal deliveries and an economical non-medical infrastructure and care., (© Georg Thieme Verlag KG Stuttgart · New York.)

The expenditure incurred in the German statutory health insurance (SHI) in relation to drugs, are characterized not only by the amount of drug prices, but also by their degree of efficient usage. The prevention of superfluous and inappropriate pharmaceutical supply leads to direct savings in expenditure, a drug-based guideline-oriented therapy, and prevention of diseases and deficiency symptoms leads to savings by avoiding hospitalizations, operations, and maintaining the ability to work. Prescriptions of new and expensive me-too drugs with no additional benefit bind financial resources of the SHI, which should be available for pharmaceutical therapeutic innovations.

Aim of the Study: In the past few years, the number of over-indebted private households in Germany has steadily increased and is currently estimated to have reached 3.13 million. Financial difficulties culminating in private insolvencies of the persons concerned may lead to a restrained usage of health-care services that require additional payment. For the first time ever this study has examined whether over-indebted individuals refrain from seeking medical treatment or from buying prescribed medicine because of their financial situation., Methods: The cross-sectional study covered over-indebted persons in Rhineland-Palatinate and was conducted between July 2006 and March 2007. In cooperation with 53 debt counselling agencies in Rhineland-Palatinate and in cooperation with the specialized debtor counselling centre of the Johannes Gutenberg-University of Mainz a singular, anonymous questionnaire-based survey in written form was conducted., Results: Altogether 666 persons (51% female) between 18 and 79 years old (mean value: 41,0 years, standard deviation: 11,2 years; median: 41 years) participated in this evaluation, which amounts to a participation rate of 35.5%. The majority of participants stated to refrain from buying prescribed medication (65.2%) as well as from seeking medical advice and paying euro 10.00 own contribution (60.8%) because of their financial situation. The multivariate, binary logistic end-model showed age, family situation, insolvency proceedings, medical conditions and the self-reported attitude towards health alertness to be relevant factors of influence for both target variables., Conclusion: The enacted own financial contribution when seeking health care or when receiving medication in Germany might cause a discrimination of indebted persons or households with regard to health care and medical treatment. Because of the obligation of additional payment, health services are not independent of an individual's financial resources, meaning that especially destitution in expenditure affects equal opportunities in the health care system., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

Objective: Within the last few years, a small number of German cost analyses of patients treated in community mental health care settings was presented. None of these studies, however, examined direct health care costs of the patients' close reference persons focusing on costs associated with providing informal care. Therefore, our study aimed to analyse health-related direct costs of severely ill patients suffering from affective or schizophrenic disorders, and of their informal carers during community mental health care; further, we examined if these costs differed between the diagnostic groups., Methods: 69 patients currently treated by community mental health services of the Dresden region and their closest reference person providing informal care were assessed twice within an interval of 3 months by use of the CSSRI- D. Thus, direct health care costs of patients and their informal carers covering a 6-months-period could be calculated., Results: 25.35% and 38.24%, respectively, of the closest reference persons' direct health care costs were caused by the situation of acting as informal carer. This was 9.12% and 22.74%, respectively, of the patients' direct health care costs assessed at the same time-points. Patients' costs did not differ between the diagnostic categories, but were influenced by the current severity of psychopathological symptoms. Reference persons' costs were influenced by the severity of the patient's psychopathological symptoms, but also by the social control behaviour of the reference persons themselves as well as by their sense of coherence., Conclusions: While a replication of our findings is urgently needed, they point at the economic significance of direct health-related costs caused by acting as informal carers. Further, therapeutic approaches adequate for minimizing these costs could be suggested, like emphasizing protective factors of mental well-being in psycho-educational programmes for relatives.

The purpose of this study was to evaluate the impact of demographic changes on future health care expenditure of the German social health insurances considering the expenditures of survivors and decedents by age. The study analysed data from 269,646 members up to the age of 99 years of the AOK - one of Germany's largest social health insurers - in the State of Hesse in 2000/2001. In order to determine future health care expenditures, per-capita expenditures by age for outpatient, inpatient, rehabilitation, and nursing services of survivors and decedents (death within the next 12 months) were multiplied by the estimated number of survivors and decedents by age in Germany in 2020, 2035 und 2050. Expenditures for all ages were summed together. The paper shows that demographic changes until 2050 will lead to an increase of health care expenditures by 20% in total or less than 1% annually. Considering the future re-duction in workforce, demographic changes until 2050 will result in an estimated increase in health care expenditures per employee by about 57% (undifferentiated model). Considering the cost of survivors and decedents separately, this increase will amount to 50%. Hence, undifferentiated models overestimate the impact of demographic changes by about 10%.

The incidence of cancer has been increasing throughout Europe for decades. In 2003 in Austria, 36,689 people developed malignant tumours, that is 26.7% more than in 1986. In total, every third person will have cancer during their life-time. However the total number of people dying from cancer remains more or less constant. This is due to advances in diagnosis and treatment, almost one-third of the fall in mortality in the period from 1995-2003 being attributable to the use of modern anti-cancer medications. The cost factor related to modern cancer treatment is increasingly a subject for discussion. The aim of this research was to analyse hospital treatment costs and expenditure on medication in the oncology sector in a broader context. The intention was to show the costs of oncology in-patient treatment in relation to the overall Austrian hospital costs and health expenditure. Only in this way it is possible to establish whether the proportion spent on oncology is really disproportionately high. This analysis shows that despite increasing hospital admissions and the associated increase in treatment no cost explosion has taken place. The analysis of costs based on malignant tumours in relation to overall costs has shown that these are not disproportionately high even when taking the number of patients into account. Only 12.21% of cancer treatment costs are used for anti-cancer medications (ATC-classes L01 and L02). The proportion of anti-cancer medications related to the total hospital expenditure is approximately 1.04%. The costs of anti-cancer medication in the hospital sector have a ratio of 0.46% of health expenditure and 3.66% of Austrian expenditure on medications. This shows that based on the low proportion of the overall expenditure anti-cancer medications are not pushing up costs.

Germany is one of those OECD-countries with the highest per-capita-expenses in public healthcare, but is lagging behind in life-expectancy compared to other countries like Japan, where life expectancy is highest at comparatively low costs. This article investigates reasons for this discrepancy in costs and outcome, and tries to form a hypothesis how this gap could be narrowed. One key finding was that Japan's life expectancy had not always been higher, but increase continuously over the past 40 years. While reasons for this development are plenty-fold, one relevant factor could be the early introduction of the "Nutritional Guidelines for the Japanese People", with which the Japanese Government started to implement a dedicated prevention policy. The positive developments in Japan provide an indication of how this can be achieved in other countries as well and to increase life expectancy without significantly increasing expenses.

Background and Purpose: Cost-benefit analyses are helpful in setting priorities for funding health-care programs. The authors studied the cost/benefit of treatment with radium-224 compared to the treatment without radium-224 in patients with ankylosing spondylitis (AS)., Material and Methods: The data of a 2-year retrospective observational study were used to estimate cost/benefit of [224Ra] therapy. Twelve patients treated with [224Ra], complete recruit in AOK Saxony, matched (age, gender, employment status) with twelve patients receiving conservative treatment without [224Ra], were compared for lost productivity and direct medical costs, such as doctor visits, medication and hospitalization, 1 year before and after treatment., Results: 1 year after the first i.v. injection of [224Ra], all cost factors in the case group were reduced compared to 1 year before treatment with [224Ra] (hospitalization 29.4%, doctor visits 23.5%, medication 9.4%, and lost productivity even 82.3%). The total costs decreased by an average of 3,870 Euros. Because of the small sample the differences showed a trend but were not significant., Conclusion: The use of [224Ra] in patients with AS seems to reduce lost productivity and direct medical costs, but additional studies based on more patients and long-term data are needed.

Aim: In the year 2005 the German DRG system underwent further differentiation in many areas compared to previous years. The effects of an improved coding quality by a specifically trained orthopaedic surgeon (KBFA) at an orthopaedic university department are analysed., Methods: In a closed sample of 1 277 cases the following parameters were documented after primary coding at discharge and after the final coding by the KBFA: main diagnosis, number of additional diagnoses and procedures, the resulting G-DRG, PCCL, cost weight and revenues. These data were analysed for statistically significant differences and correlations., Results: The final coding by the KBFA caused a significant (p<0.001) increase in the number of diagnoses and procedures. The intervention of the KBFA changed the DRG grouping in 34 % of the cases. The cost weight increased significantly and the case mix index raised by 0.26 in the complete sample, corresponding to an increased revenue of euro 62 per case and day., Conclusions: The establishment of a KBFA in an orthopaedic department improved the quality of revenue-relevant DRG coding and the reflection of the economic complexity level of the cases. Compared to other reports, an above-average increase of cost weight as well as specification depth for diagnoses and procedures was achieved.

Aim: We introduce a grouping system for clinical practice which allows the separation of DRG coding in specific orthopaedic groups based on anatomic regions, operative procedures, therapeutic interventions and morbidity equivalent diagnosis groups. With this, a differentiated aim-oriented analysis of illustrated internal DRG data becomes possible., Methods: The group-specific difference of the coding quality between the DRG groups following primary coding by the orthopaedic surgeon and final coding by the medical controlling is analysed. In a consecutive series of 1600 patients parallel documentation and group-specific comparison of the relevant DRG parameters were carried out in every case after primary and final coding., Results: Analysing the group-specific share in the additional CaseMix coding, the group "spine surgery" dominated, closely followed by the groups "arthroplasty" and "surgery due to infection, tumours, diabetes". Altogether, additional cost-weight-relevant coding was necessary most frequently in the latter group (84%), followed by group "spine surgery" (65%). In DRGs representing conservative orthopaedic treatment documented procedures had nearly no influence on the cost weight., Conclusions: The introduced system of case group analysis in internal DRG documentation can lead to the detection of specific problems in primary coding and cost-weight relevant changes of the case mix. As an instrument for internal process control in the orthopaedic field, it can serve as a communicative interface between an economically oriented classification of the hospital performance and a specific problem solution of the medical staff involved in the department management.

Background: A new measurement instrument was developed to combine common scores with the parameter of effort for rehabilitation, the latter being a control instrument for medical professionals and rehabilitational health organisations., Methods: The Neurological Rehabilitation Score (NRS) contains 61 items (including the ten from the Barthel Index) resulting in scores of 0 (worst patient condition) to 600 (best). The items are grouped into seven categories: activities of daily life (13), mobility (8), communication and social skills (7), arm and hand function (7), orientation and cognition skills (10), strength and pain (8), and coping and miscellaneous (8). We investigated 8,139 patients and determined reliability (kappa statistic) and responsivity (standardised response means). In 100 consecutive patients, we also measured the Functional Independence Measure (FIM) and Scandinavian Stroke Scale (SSS) to address validity., Results: With an average kappa value of 0.86 (range 0.62-0.98), the NRS showed excellent inter-rater reliability. There was a good correlation between NRS, FIM, and SSS. Response was good at 0.84. The ceiling effect was also less than 1%, compared to 17% in the Barthel Index., Conclusion: The NRS was shown to be effective for evaluation of outcome and expenditure in neurological rehabilitation.

Idiopathic Parkinson's disease is a chronic progressive neurodegenerative disorder that remains refractory to curative treatment. Most patients are afflicted for many years, and the disease frequently results in severe physical handicap. Statements on the considerable cost of treatment are largely based on estimates and retrospective studies. To obtain more substantial data, we conducted a 3-year study of the economic aspects. Direct and indirect costs incurred by 117 patients (78 male, mean age 67.5 years) at the Deutsche Klinik für Diagnostik in Wiesbaden, Germany, were prospectively followed. The average cost per patient and month ran to 1007.55. Of that, direct costs amounted to 603.33 (55.9%), with drugs taking up the major share at 480.23. Indirect costs were 404.22 per patient and month, with 76% thereof related to nursing care and the incapacity to earn a living. Cost increased in proportion to Hoehn and Yahr stage, declining again with stages 4 and 5. The data we gathered confirm that Parkinsonism is responsible for sizeable expenses for not only the treating unit but the national economy as a whole.