[The Future of EU Finances After COVID-19]. / Zur Zukunft der EU-Finanzen nach Corona.

The impact of COVID-19 led to changes in EU financing that pose questions about the shape of the future EU "fiscal constitution". The additional Recovery Fund, with the volume of three-fourths of the new seven year budget, will be financed by the first EU borrowing ever. Is this unprecedented fiscal magnitude necessary to compete with China? Or does the EU need to downsize in two directions: (1) in the volume and differentiation of its various tasks and (2) in the equal rights among its 27 member states (01.01.2021). In any case, the COVID-19 shakeup should be incentive for a major reform of the EU finances.

The German Central Health Fund-recent developments in health care financing in Germany.

In 2009, Germany's Statutory Health Insurance System underwent a major financing reform. A uniform contribution rate set by government was introduced. Sickness funds retain only limited autonomy in charging additional premiums. A dynamic subsidy from general revenue was introduced. The aims of the reform were: (1) intensifying competition, (2) gearing competition towards quality and efficiency, and (3) increasing financial sustainability. This article describes the reform, presents the experiences made, and evaluates whether the policy aims have been met. Experiences have been mixed: on the one hand, the new arrangement showed a high level of flexibility in dealing with the severe recession in 2009. On the other hand, the new system of price differentiation has proven to be dysfunctional. Payments to sickness funds are based on predictions. But predictions have been of limited accuracy, and this has led to an accumulation of liquidity in the system. Price competition has been effectively eliminated. The intended surge in quality and product competition failed to appear, as sickness funds remain concerned mainly with their short term financial outlook. SHI finance has become more linked to the federal budget, leading to a higher level of political interventions. These arrangements will need a new reform - probably after the next general election in autumn 2013.

Access and choice--competition under the roof of solidarity in German health care: an analysis of health policy reforms since 2004.

This paper analyses the influence of recent German health care reforms, the Statutory Health Insurance Modernization Act 2004 and the Statutory Health Insurance Competition Strengthening Act 2007, on different dimensions of access and choice. More specifically, we look at and discuss the effects of these policies on the availability, reachability and affordability of health care as well as on their impact on consumers' choice of insurers and providers. Generally, patients in Germany enjoy a high degree of free access and a lot of freedom to choose, partly leading to over- and misuse of health services. Concerning choice of insurers, one result of our analysis is that in the statutory health insurance system, the introduction of a greater variety of benefit packages will develop into an additional parameter of choice. In contrast to that, insurees more and more accept certain restrictions of choice and direct access to providers by enrolling into new forms of care (such as gatekeeping-, disease management- and integrated care programmes). However, they might benefit from better quality of care and more options for products and services that best fit their needs.

[External and internal financing in health care]. / Mittelaufbringung und Mittelverwendung im Gesundheitswesen.

The objective of this contribution is to characterize the functional and institutional features of the German health-care system. This takes place after a short introduction and examination of the ongoing debate on health care in Germany. External funding describes the form of revenue generation. Regarding external funding of the German health care system, one of the favored alternatives in the current debate is the possibility of introducing per capita payments. After a short introduction to the capitation option, focus is on the so-called health fund that is currently debated on and being made ready for implementation in Germany, actually a mixed system of capitation and contributions based on income. On the other hand, internal funding is the method of how different health-care services are purchased or reimbursed. This becomes a rather hot topic in light of new trends for integrated and networked care to patients and different types of budgeting. Another dominating question in the German health-care system is the liberalization of the contractual law, with its "joint and uniform" regulations that have to be loosened for competition gains. After a discussion of the consequences of diagnosis-related groups (DRGs) in Germany, the article is concluded by a note on the political rationality of the current health-care reform for increased competition within the Statutory Health Insurance and its players as exemplified by the health fund. To sum up, it has to be said that the complexity and specific features of how the German system is financed seem to require ongoing reform considerations even after realization of the currently debated health-care reform law which, unfortunately, is dominated by political rationalities rather than objective thoughts.

Regulation of pharmaceutical markets in Germany: improving efficiency and controlling expenditures?

Rising pharmaceutical expenditure has become a major concern for policy makers in Germany over recent years. Therefore, the pharmaceutical market has been increasingly targeted by different kinds of regulation, focussing on both the supply and the demand side, using price, volume and spending controls. Specific regulations include price reductions, reference pricing, pharmacy rebates for sickness funds, increasing co-payments, an 'autidem' substitution, parallel imports, a negative list, directives, 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. In spite of being opposed by 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 detrimental.

The costs of atopy and asthma in children: assessment of direct costs and their determinants in a birth cohort.

The aim of this study was to estimate costs accrued by the health care of children with asthma in comparison to children with atopic eczema and seasonal rhinitis and to investigate cost determinants. From the multicenter cohort study (MAS-90), we selected children with an asthma, atopic eczema and/or seasonal rhinitis diagnosis during the first 8 years of life, and overall 8-year health care utilization was estimated retrospectively by reviewing medical records. Asthma treatment (n = 76) incurs an average cost of 627 US dollars per year, 44% due to hospital stays. Atopic eczema treatment (n = 91) cost on average 219 US dollars and seasonal rhinitis (n = 69) 57 US dollars per year. In asthma and atopic eczema, costs increase significantly with disease severity. Allergy diagnostics use accounts for only 1% of total costs. Costs for asthma and atopic eczema treatment are highest in those years when topical steroids are used for the first time, but decrease with every further year of steroid use. A remarkable 25% of asthmatic children with severe symptoms were not treated according to national guidelines, so that most steroid treatment was initiated during the first hospital stay. In the case of asthma, total direct costs increased until the 3rd year of the disease, and then decreased with further years of diagnosis, while steroid use continued to increase. These results indicate a 'learning effect' in the treatment of asthma and atopic eczema for each patient as well as considerable cost-saving potential by preventing severe asthma. Moreover, the importance of considering cost-driving factors and using cohort or longitudinal designs in cost-of-illness approaches is emphasized.