[Economic Evaluation of Integrated Care Systems - Scientific Standard Specifications, Challenges, Best Practice Model]. / Ökonomische Erfolgsmessung von integrierten Versorgungsnetzen - Gütekriterien, Herausforderungen, Best-Practice-Modell.

PURPOSE: Transparency of economic performance of integrated care systems (IV) is a basic requirement for the acceptance and further development of integrated care. Diverse evaluation methods are used but are seldom openly discussed because of the proprietary nature of the different business models. The aim of this article is to develop a generic model for measuring economic performance of IV interventions. METHODS: A catalogue of five quality criteria is used to discuss different evaluation methods -(uncontrolled before-after-studies, control group-based approaches, regression models). On this -basis a best practice model is proposed. RESULTS: A regression model based on the German morbidity-based risk structure equalisation scheme (MorbiRSA) has some benefits in comparison to the other methods mentioned. In particular it requires less resources to be implemented and offers advantages concerning the relia-bility and the transparency of the method (=important for acceptance). Also validity is sound. Although RCTs and - also to a lesser -extent - complex difference-in-difference matching approaches can lead to a higher validity of the results, their feasibility in real life settings is limited due to economic and practical reasons. That is why central criticisms of a MorbiRSA-based model were addressed, adaptions proposed and incorporated in a best practice model: Population-oriented morbidity adjusted margin improvement model (P-DBV(MRSA)). CONCLUSION: The P-DBV(MRSA) approach may be used as a standardised best practice model for the economic evaluation of IV. Parallel to the proposed approach for measuring economic performance a balanced, quality-oriented performance measurement system should be introduced. This should prevent incentivising IV-players to undertake short-term cost cutting at the expense of quality.

[Health economic evaluation based on administrative data from German health insurance]. / Gesundheitsökonomische Evaluation auf Grundlage von GKV-Routinedaten.

Although the quality of administrative data of German health insurance is relatively good, administrative data are rarely used for the purpose of health economic evaluations in Germany. Health economic evaluations in Germany have so far mainly been performed based on primary data while in other countries the use of secondary data is quite common. The objective of the article is to give an introduction into the possibilities of performing health economic evaluations based on administrative data. First, we show that German health insurance have data sets that allow the follow-up of patients across all sectors of health care. Subsequently, characteristics of primary data and administrative data of health insurance for the purpose of health economic evaluations are compared. Finally we present an overview of recently performed health economic evaluations based on administrative data in Germany and conclude with lessons from other countries on the use of administrative data and implications for Germany.

[Authorization and reimbursement of orphan drugs in an international comparison]. / Zulassung und Erstattung von Orphan Drugs im internationalen Vergleich.

BACKGROUND: This paper analyses schemes to promote the authorisation of and reimbursement for orphan drugs. METHODS: 8 countries - Australia, Canada, Germany, Great Britain, France, Netherlands, Switzerland, USA - were studied to compare specific regulations for orphan drugs regarding drug admission, health technology assessment (HTA), decision-making for reimbursement, and off-label and compassionate use. Information was obtained by reviewing published and grey literature. Expert interviews were also conducted. RESULTS: The comparison of orphan drug legislation reveals that the EU and the USA offer the greatest incentives for the development of orphan drugs, whereas there is a tendency for Australia and Switzerland to profit from incentives in other countries. Although not explicitly stated, economic evaluation of orphan drugs takes the special circumstances for orphan drugs into account. In addition to common reimbursement practices, special schemes or programmes for the reimbursement of high-priced orphan drugs exist in all countries that were analysed. Therefore access to orphan drugs seems to be warranted. However, due to co-payments of 5%, the USA may form an exception. CONCLUSION: On the one hand, the use of special criteria for drug admission, HTA, and reimbursement promotes R&D for orphan drugs. On the other hand, high opportunity costs arise, because huge efforts are made for a minority of patients. A solution for this moral dilemma may be the application of "rule of rescue" or of "no cure, no pay" programmes.

Performance of reimbursement schemes in valuation of technologies: the example of magnetic resonance imaging.

Different reimbursement schemes for health care providers have been developed worldwide. They have evolved over time and have been influenced by politics, costs, patient needs and technological progress. Different methods in the valuation of technologies and their reflection in outpatient reimbursement schemes are analyzed. Using Magnetic Resonance Imaging (MRI) as an example, five different reimbursement schemes from four countries are compared according to defined performance criteria. Major differences in the structure and valuation of internationally used reimbursement schemes are presented; Prices for Neurocranium MRI scans vary from euro98 to euro462 and large discrepancies can even be found within the same country. There are politically driven reimbursement schemes like the German Gebührenordnung für 'A'rzte, while others such as the Swiss TARMED are primarily based on actual costs.

Cost-effectiveness analysis of telemedical devices for pre-clinical traffic accident emergency rescue in Germany.

OBJECTIVES: The purpose of this study is to assess the cost-effectiveness (net costs per life year gained) of telemedical devices for pre-clinical traffic accident emergency rescue in Germany. METHODS: Two equipment versions of a telemedical device are compared from a societal perspective with the baseline in Germany, i.e. the non-application of telemedicine in emergency rescues. The analysis is based on retrospective statistical data covering a period of 10 years with discounted costs not adjusted for inflation. Due to the uncertainty of data, certain assumptions and estimates were necessary. The outcome is measured in terms of "life years gained" by reducing therapy-free intervals and improvements in first-aid provided by laypersons. RESULTS: The introduction of the basic equipment version, "Automatic Accident Alert", is associated with net costs per life year gained of euro 247,977 (at baseline assumptions). The full equipment version of the telemedical device would lead to estimated net costs of euro 239,524 per life year gained. Multi-way sensitivity-analysis with best and worst case scenarios suggests that decreasing system costs would disproportionately reduce total costs, and that rapid market penetration would largely increase the system's benefit, while simultaneously reducing costs. CONCLUSION: The net costs per life year gained in the application of the two versions of the telemedical device for pre-clinical emergency rescue of traffic accidents are estimated as quite high. However, the implementation of the device as part of a larger European co-ordinated initiative is more realistic.

Defining the "Health Benefit Basket" in nine European countries. Evidence from the European Union Health BASKET Project.

This article identifies and analyses a framework for "health baskets," the taxonomy of benefit catalogues for curative services, and the criteria for the in- or exclusion of benefits in nine EU member states (Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland and Spain). Focusing on services of curative care, it is found that the explicitness of benefit catalogues varies largely between the countries. In the absence of explicitly defined benefit catalogues, in- and outpatient remuneration schemes have the character of benefit catalogues. The criteria for the in- or exclusion into benefit catalogues are often not transparent and (cost-)effectiveness is applied only for certain sectors. An EU-wide harmonization of benefit baskets does not seem realistic in the short or medium term as the variation in criteria and the taxonomies of benefit catalogues are large but not insurmountable. There may be scope for a European core basket.

[Pharmaceutical reference pricing in Germany: definition of therapeutic groups, price setting through regression procedure and effects]. / Arzneimittelfestbeträge: Gruppenbildung, Preisberechnung mittels Regressionsverfahren und Wirkungen.

The German reference pricing system defines a reimbursement threshold for groups of pharmaceuticals. Pharmaceuticals are grouped according to certain criteria by the Federal Joint Committee. To make different active ingredients comparable, so called reference values are defined. Subsequently, the federal association of sickness funds sets reference prices using a regression procedure. However, the impact of the reference price system is limited. On the one hand there is a strong incentive for pharmaceutical companies to decrease prices to the reference price. On the other hand there is no incentive for further price reductions. Additionally, only one part of the pharmaceutical market is affected by reference pricing. Therefore the instrument has only managed to lower pharmaceutical expenditure in the short run. For sustainable long-term cost containment the use of other regulatory instruments is necessary. Nevertheless, compared to other instruments of price-regulation, reference pricing seems to be a good alternative to control pharmaceutical prices, since rationing is kept as little as possible.

[Justice in health care systems from an economic perspective]. / Gerechtigkeit in Gesundheitssystemen aus ökonomischer Perspektive.

Due to rising health care expenditures international comparisons of health care systems are recently gaining more importance. These benchmarks can provide interesting information for improving health care systems. Many of these comparisons implicitly assume that countries have a universal understanding of justice. But this assumption is rather questionable. With regard to the existing cultural differences in the understanding of justice the transferability of elements of health care systems is not always assured. A transfer usually requires a thorough examination of the judicial systems in each country. This article analyses the influence of different judicial systems applying to health care. In this context theories of justice by Rawls, Nozick and Confucius representing the possible understanding of justice in different cultures are described and analysed with regards to their influence on health care systems. The example of financing health care shows that the three theories of justice have very different consequences for designing health care systems especially concerning the role of governments.