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Hintergrund: Diese Studie untersuchte die Bedeutung von Spillover-Effekten zwischen Krankenhäusern und anderen Determinanten für die Nutzung von medikamentenbeschichteten Koronarstents in Deutschland in einem Zeitraum, in dem die entsprechende medizinische Leitlinie deren Einsatz eindeutig gegenüber dem Einsatz von herkömmlichen Metallstents empfahl. Methodik: Wir nutzten administrative Daten von Krankenhauspatient:innen mit ST-Hebungs-Myokardinfarkt (STEMI) aus den Jahren 2012-2016, um räumliche Panelmodelle zu schätzen, die globale Spillover- Effekte berücksichtigen. Um die geografische Nähe zwischen benachbarten Krankenhäusern zu erfassen, verwendeten wir eine Matrix mit inversen Entfernungsgewichten, wobei weiter entfernten Nachbarn ein niedrigeres Gewicht zugeordnet wurde. Ergebnisse: Wir fanden eine signifikante positive räumliche Autokorrelation auf der Grundlage des globalen Moran's I-Tests und einen signifikanten, positiven Spatial Lag Parameter über alle Modellspezifikationen hinweg, was auf positive Spillover-Effekte zwischen benachbarten Krankenhäusern hindeutet. Zudem zeigte sich, dass private Trägerschaft und Krankenhauswettbewerb weitere signifikante Determinanten für die Nutzung von medikamentenbeschichteten Koronarstents sind. Schlussfolgerung: Unsere Ergebnisse zeigen die Bedeutung von Spillover-Effekten unter medizinischem Personal für die Diffusion von Medizintechnikprodukten trotz Vorliegen einer positiven Leitlinienempfehlung. Politische Entscheidungsträger könnten daher in Erwägung ziehen, verschiedene Formen des Austauschs und der Zusammenarbeit zwischen medizinischem Personal und Krankenhäusern zu fördern, um die angemessene Nutzung medizinischer Technologien zu gewährleisten und regionalen Unterschieden in der Nutzung entgegenzuwirken. Bei der Untersuchung von regionalen Unterschieden in der Versorgungsforschung sollten Spillover-Effekte zukünftig Berücksichtigung finden. Schlagwörter: Technologie, medizinische Geräte, Diffusion, Spillover-Effekte, medizinische Leitlinien, regionale Unterschiede, Inanspruchnahme, räumliche Paneldatenanalyse

Additional file 1: Table A1. Selected DRGs for procedure groups defined by ccs procedure.

Additional file 2: Distance Weighted Measure of Hospital Competition.

Additional file 1 : Appendix A [48, 49] provides further information on model fit statistics as a means to compare the zero-inflated negative binomial model to a traditional negative binomial model. Figure A: Graphical illustration of the residuals from the negative binomial model and zero-inflated negative binomial model. Figure A illustrates the residuals from the negative binomial model and zero-inflated negative binomial model.

Additional file 4 : Appendix D shows the results of our subgroup analysis on health-related characteristics.

Additional file 2 : Appendix B provides additional information on our interactions analyses. Figure B: Interaction effect between social prescription and visit due to psychological concerns on return visits. Figure B: illustrated the interaction effect between social prescription and visit due to psychological concerns on return visits.

Additional file 3 : Appendix C shows the results of our sensitivity analyses using observation periods of lengths other than 3 months.

This is the first study to specify a physician practice cost function with practice costs as the unit of analysis. Our study is based on the data of 3,706 physician practices for the years 2006 to 2008. We propose a model using physician practices as the unit of observation and considering the endogenous character of physician input. In doing so, we apply a translog functional form and include a comprehensive set of variables that have not been previously used in this context. A system of four equations using three-stage least squares is estimated. We find that a higher degree of specialisation and participation in disease management programs and gatekeeper models leads to a decrease in costs, whereas quality certification increases costs. Costs increase with the number of physicians, most likely because of the existence of indivisibilities of expensive technical equipment. Smaller practices might not reach the critical mass to invest in certain technologies, which leads to differences in the type of health care services provided by different practice types.

In this paper, we propose a methodological approach to measure the relationship between hospital costs and health outcomes. We propose to investigate the relationship for each condition or disease area using patient-level data. We suggest to examine health outcomes as a function of costs and other patientlevel variables: (1) using two-stage residual inclusion with Murphy-Topel adjustment to address costs being endogenous to health outcomes, (2) using random-effects models in both stages to correct for correlation between observation, and (3) using Cox proportional hazard models in the second stage to ensure the available information is exploited. To demonstrate its application, data on mortality following hospital treatment for acute myocardial infarction (AMI) from a large German sickness was used. Provider reimbursement was used as a proxy for treatment costs. We relied on the Ontario Acute Myocardial Infarction Mortality Prediction Rules as a disease-specific risk-adjustment instrument. 12,284 patients with a treatment for AMI in 2004-2006 were included. Results showed a reduction in hospital costs by 100 to increase the hazard of dying, i.e. mortality, by 0.43%. The negative association between costs and mortality confirms that increased resource input leads to better outcomes for treatment after AMI.

This paper studies the politico-economic reasons for the refusal of a proposed compulsory flood insurance scheme in Germany. It provides the rationale for such scheme and outlines the basic features of a market-orientated design. The main reasons for the political down-turn of this proposal were the (mis)perceived costs of a state guarantee, legal objections against a compulsory insurance, distributional conflicts between the federal government and the German states ("Länder") on the implied administrative costs and the well-known "samariter dilemma" of ad-hoc disaster relief. The focus on pure market solutions proved to be an ineffective strategy for policy advice in this field.

In many sectors of the health care system, prices at which providers are reimbursed by payers are not determined by the market mechanism, but rather by a defined administrative process. Depending on the sector, prices are set "politically" and are negotiated between different actors or are calculated according to a defined procedure, considering cost data from a sample of providers. The selected approach for price setting determines decisively, to which extent prices for certain services reflect the actual costs incurred for these services. A lack of reflection of actual costs can lead to unintended incentives for providers and therefore have implications on the allocative efficiency. Our analysis shows that in Germany's inpatient and outpatient sector, cost data is increasingly considered for price setting while in other sectors such as long-term care and rehabilitation, the use of cost data is still very limited. However, DRG-cost-weights in the inpatient sector insufficiently reflect actual costs incurred. Thus, decision makers in the German health care system rely more on cost data for price setting and improving the accuracy of cost calculations in order to increase allocative efficiency.

In all four countries health care expenditures grow while the revenue remains at the same level or even shrinks in many cases. Due to medical progress, ageing and many other factors the gap is widening over time. The pay-as-you-go approach is running against limits either with rising employer and employee contribution rates as is the case in the so-called Bismarck-Systems or with higher taxes in the so-called Beveridge-systems. There are differences regarding the solutions of each country to tackle the described challenge and they might be able to learn from each other if they are compared. Therefore the study compares the health care systems of France, Germany, Japan and the Netherlands. Due to the complexity of the different institutional settings it seems necessary to select certain criteria in order to make a comparison at all possible. The comparison is divided into three different sections. The institutional and organizational framework as first section compares the general organization of social health insurance in all four countries. It comprises the benefit structure, the enrolment, ownership issues and other criteria. The second section focuses on the funding of social health insurance comparing the different approaches according to criteria like contribution rates, contribution assessment bases, burden of contributions and others. The final section analyses different strategies in the provision and purchasing of health services in the four countries. Next to other hospital ownership infrastructure characteristics play an important role in this section. In the last part of the study certain lessons are drawn from the comparison of the four countries. Furthermore certain developments are described which can be anticipated for the future of social health insurance systems.

Rising costs in pharmaceutical expenditure have become a major concern for policy makers in Germany over the last years. Therefore the pharmaceutical market in Germany has been increasingly targeted by different kinds of regulations, focussing both on the supply and the demand side, using price, volume and spending controls. Specific regulations include price reductions, reference pricing, pharmacy rebate for sickness funds, increasing co-payments, an "aut-idem" substitution, parallel imports, negative list, guidelines, and finally spending caps for pharmaceutical expenditure per physicians' association. Although it is difficult to attribute certain effects to single measures, some measures like reference pricing and physician spending caps are more effective and long-lasting than others. Although highly disputed among physicians, the spending caps applied between 1993 and 2001 have limited pharmaceutical expenditure for an entire decade. However, while some measures do effectively control expenditures, their effect on allocative efficiency may be negative.

This thesis describes the status quo of the Taiwanese health care system in the year 2000, 5 years after the reforms, analyses the economic efficiency of single components of the new health care system and searches for possible solutions to solve uncovered problems. For a better understanding of the Taiwanese health care system, the economic, political and demographic environment is described first of all. Although the Taiwanese economy developed rapidly, the health care system was still looking like that of a underdeveloped country. To analyze the efficiency of the Taiwanese health care system it is necessary to have a general look at the possible composition of health care systems and their incentives on the actors of the system. A health care system can be divided in finance and reimbursement. After presenting basic models of financing a health care system, different methods of reimbursing in-patient, out-patient and pharmaceutical services are described.

Das Konzept der Medical Savings Accounts als Instrument zur Finanzierung von Gesundheitssystemen hat in den letzten Jahren international Aufmerksamkeit erregt. In Deutschland wurde ein ähnliches Konzept für die Gesetzliche Rentenversicherung im Rahmen der "Riester Rente" diskutiert. Länder wie Singapur, Südafrika, China und die USA haben diese neue Form der Finanzierung bereits eingeführt oder in Pilotprojekten erprobt. Dieser Beitrag gibt zunächst einen Überblick über Erfahrungen, die einzelne Länder bisher mit der Konzeption der Medical Savings Accounts gemacht haben. Außerdem wird anhand erster Ergebnisse aufgezeigt, dass die beschriebenen Länder überwiegend positive Erfahrungen mit diesem Konzept gemacht haben. Abschließend wird vorgeschlagen, dieses Konzept zur Lösung der Finanzierungsprobleme der Gesetzlichen Krankenversicherung auf Deutschland zu übertragen.

Die Debatte über eine Finanzierungsreform des deutschen Krankenversicherungssystems hat in der letzten Zeit viele Konzepte hervorgebracht. Die Vorschläge reichen von der Stabilisierung des Status quo in Form von Kopfpauschalen über die Einführung verschiedener Formen eines Teilkapitaldeckungsverfahrens bis hin zu einer kompletten Systemumstellung auf eine voll kapitalgedeckte Finanzierung. Zusätzlich wurde das Modell der Medical Savings Accounts in Singapur und Südafrika als internationales Konzept thematisiert. Der vorliegende Beitrag soll einerseits einen Überblick über die derzeit diskutierten Modelle geben. Andererseits wird der Versuch unternommen, die Konzepte anhand der Kategorien Beitragsbemessungsprinzip und Finanzierungsverfahren zu systematisieren und einer kurzen Beurteilung zu unterziehen. Dabei lag der Fokus der Arbeit auf den Vorschlägen zur Reform der Finanzierungsseite. Inwiefern sich eines der Modelle durchsetzen kann, wird nicht zuletzt von den politischen Konstellationen der nächsten Jahre abhängen. In dem korporatistischen deutschen Gesundheitswesen dürfte die Durchsetzung revolutionärer Ideen relativ unwahrscheinlich sein. Nach Einschätzung der Autoren ist eher eine evolutorische Weiterentwicklung des bestehenden Systems zu erwarten.

Krankenversicherungssysteme induzieren häufig Wohlfahrtsverluste aufgrund asymetrischer Informationen. Neben einem Anstieg der Gesundheitsausgaben bewirken diese eine ineffiziente Allokation von Ressourcen. Einige empirische Studien schätzen den Wohlfahrtsverlust sogar so gross, dass er den aus dem Pooling von Risiken resultierenden Nutzen einer Krankenversicherung überkompensiert. Da die Höhe des Wohlfahrtsverlustes von der Preiselastizität der Nachfrage abhängt, erscheint es sinnvoll, den Versicherungsumfang auf preisunelastische Gebiete der Nachfrage zu beschränken. Eine Differenzierung der Absicherung des Krankheitsrisikos nach der Preiselastizität verschiedener Nachfragebereiche könnte demnach die Wohlfahrtsverluste reduzieren. Singapur hat diesen Ansatz erfolgreich umgesetzt. Das dortige Finanzierungssystem setzt sich zusammen aus einer Hochrisikoversicherung, die unelastische Bereiche der Nachfrage abdeckt, out-of-pocket Zahlungen für elastische Bereiche und Gesundheitssparkonten (Medical Savings Accounts) für den Zwischenbereich.

Objectives: Despite the widespread use of Diagnosis-Related Groups (DRGs) for hospital reimbursement, little empirical evidence exists on the effect of DRG systems on hospital behavior and, ultimately, the quality of care. Additionally, an overview on the results of prior literature is missing so far. This study aims to provide a synthesis of existing research, including an overview of the data and methods used, the quality measures, the results, as well as the strengths and weaknesses of the studies. Method: DRG prices can be considered to be in-between individual hospital costs and external fixed prices, as they reflect the average costs of all or selected hospitals within an industry. Therefore, we included studies on hospital costs and prices, and positioned them on a continuum. In sum, 16 studies were identified and considered as high-quality studies by experts. Results: The majority of the studies review the impact of cost on quality of care, while three studies directly focused on the impact of price. The dominant study design was based on repeated cross-sections. Studies differ in the level of data used (hospital versus patient level) and measures of quality (e.g., treatment intensity, readmissions, mortality, and complications). The studies exhibit large heterogeneity in populations and methodology. Although most studies did not detect a significant relationship between hospital cost and quality of care, others suggest that there is a trade-off between them. For some conditions, e.g., Acute myocardial infarction and Pneumonia, authors rather find a trade-off while for others not. This also suggests that the relationship may depend on the condition investigated. Discussion: The synthesis allows to generate questions for further research as well as recommendations for the study design in researching the relationship between hospital cost, price and the quality of care. It also suggests that more research is needed to generate robust evidence on the relationship between cost/price, and quality of care. Additionally, results will inform policymakers about potentially adverse effects of price changes on hospital behavior and ultimately, the quality of care.

Objectives: Despite the widespread use of Diagnosis-Related Groups (DRGs) for hospital reimbursement, little empirical evidence exists on the effect of DRG systems on hospital behavior and, ultimately, the quality of care. Additionally, an overview on the results of prior literature is missing so far. This study aims to provide a synthesis of existing research, including an overview of the data and methods used, the quality measures, the results, as well as the strengths and weaknesses of the studies. Method: DRG prices can be considered to be in-between individual hospital costs and external fixed prices, as they reflect the average costs of all or selected hospitals within an industry. Therefore, we included studies on hospital costs and prices, and positioned them on a continuum. In sum, 16 studies were identified and considered as high-quality studies by experts. Results: The majority of the studies review the impact of cost on quality of care, while three studies directly focused on the impact of price. The dominant study design was based on repeated cross-sections. Studies differ in the level of data used (hospital versus patient level) and measures of quality (e.g., treatment intensity, readmissions, mortality, and complications). The studies exhibit large heterogeneity in populations and methodology. Although most studies did not detect a significant relationship between hospital cost and quality of care, others suggest that there is a trade-off between them. For some conditions, e.g., Acute myocardial infarction and Pneumonia, authors rather find a trade-off while for others not. This also suggests that the relationship may depend on the condition investigated. Discussion: The synthesis allows to generate questions for further research as well as recommendations for the study design in researching the relationship between hospital cost, price and the quality of care. It also suggests that more research is needed to generate robust evidence on the relationship between cost/price, and quality of care. Additionally, results will inform policymakers about potentially adverse effects of price changes on hospital behavior and ultimately, the quality of care.