Regional variations in vaccination against COVID-19 in Germany.

Vaccination willingness against COVID-19 is generally perceived as low. Moreover, there is large heterogeneity across and within countries. As a whole, Germany has average vaccination rates compared to other industrialized countries. However, vaccination rates in the 16 different German federal states differ by more than 20 percentage points. We describe variation in vaccination rates on the level of the 400 German counties using data on all vaccinations carried out until December 2022. Around 52-72% of that variation can be explained by regional differences in demographic characteristics, housing, education and political party preferences. We find indications that the remaining part may be due to differences in soft factors such as risk aversion, trust in the German government, trust in science, and beliefs in conspiracy theories regarding the origins of the Corona virus. We conclude that improving the trust in science and the fight against conspiracy theories may possibly be effective tools to improve vaccination rates and effectively fight pandemics.

Housing situations and local COVID-19 infection dynamics using small-area data.

Low socio-economic status is associated with higher SARS-CoV-2 incidences. In this paper we study whether this is a result of differences in (1) the frequency, (2) intensity, and/or (3) duration of local SARS-CoV-2 outbreaks depending on the local housing situations. So far, there is not clear evidence which of the three factors dominates. Using small-scale data from neighborhoods in the German city Essen and a flexible estimation approach which does not require prior knowledge about specific transmission characteristics of SARS-CoV-2, behavioral responses or other potential model parameters, we find evidence for the last of the three hypotheses. Outbreaks do not happen more often in less well-off areas or are more severe (in terms of the number of cases), but they last longer. This indicates that the socio-economic gradient in infection levels is at least in parts a result of a more sustained spread of infections in neighborhoods with worse housing conditions after local outbreaks and suggests that in case of an epidemic allocating scarce resources in containment measures to areas with poor housing conditions might have the greatest benefit.

Late-career unemployment and cognitive abilities.

We study the effect of unemployment on cognitive abilities among individuals aged between 50 and 65 in Europe. To this end, we exploit plant closures and use flexible event-study estimations together with an experimentally elicited measure of fluid intelligence, namely word recall. We find that, within a time period of around eight years after the event of unemployment, cognitive abilities only deteriorate marginally - the effects are insignificant both in statistical and economic terms. We do, however, find significant effects of late-career unemployment on the likelihood to leave the labor force, and short-term effects on mental health problems such as depression and sleep problems.

Determinants of nursing home choice: Does reported quality matter?

Quality report cards addressing information asymmetry in the health care market have become a popular strategy used by policymakers to improve the quality of care for older people. Using individual level data from the largest German sickness fund merged with institutional level data, we examine the relationship between reported nursing home quality, as measured by recently introduced report cards, nursing home prices, nursing home's location, and the individual choice of nursing homes. Report cards were stepwise introduced as of 2009, and we use a sample of 2010 that includes both homes that had been evaluated at that time and that had not yet been. Thus, we can distinguish between institutions with above and below average ratings as well as nonrated nursing homes. We find that the probability of choosing a nursing home decreases in distance and price. However, we find no economically significant effect of reported quality on individuals' choice of nursing homes.

New Evidence on Employment Effects of Informal Care Provision in Europe.

OBJECTIVE: To estimate how labor force participation is affected when adult children provide informal care to their parents. DATA SOURCE: Survey of Health, Ageing and Retirement in Europe from 2004 to 2013. STUDY DESIGN: To offset the problem of endogeneity, we exploit the availability of other potential caregivers within the family as predictors of the probability to provide care for a dependent parent. Contrary to most previous studies, the dataset covers the whole working-age population in the majority of European countries. Individuals explicitly had to opt for or against the provision of care to their care-dependent parents, which allows us to more precisely estimate the effect of caregiving on labor force participation. PRINCIPAL FINDINGS: Results reveal a negative causal effect that indicates that informal care provision reduces labor force participation by 14.0 percentage points (95 percent CI: -0.307, 0.026). Point estimates suggest that the effect is larger for men; however, this gender difference is not significantly different from zero at conventional levels. CONCLUSIONS: Results apply to individuals whose consideration in long-term care policy is highly relevant, that is, children whose willingness to provide informal care to their parents is altered by available alternatives of family caregivers.

Informal care and long-term labor market outcomes.

In this paper we estimate long-run effects of informal care provision on female caregivers' labor market outcomes up to eight years after care provision. We compare a static version, where average effects of care provision in a certain year on later labor market outcomes are estimated, to a partly dynamic version where the effects of up to three consecutive years of care provision are analyzed. Our results suggest that there are significant initial negative effects of informal care provision on the probability to work full-time. The reduction in the probability to work full-time by 4 percentage points (or 2.4-5.0 if we move from point to partial identification) is persistent over time. Short-run effects on hourly wages are zero but we find considerable long-run wage penalties.

On the interdependence of ambulatory and hospital care in the German health system.

For some considerable time now the interface between ambulatory and hospital care has been mooted as a cause of inefficiencies in the German health system and there have been calls for a softening of the strict separation between the two sectors. This debate emphasizes the need for detailed empirical information on the interdependence between the two sectors. Using extensive administrative data at the level of the 412 German counties for the years 2007 to 2009 and a simultaneous equation model which allows the numbers of ambulatory and hospital cases to be mutually interdependent, we examine the connection between ambulatory and hospital specialist care separately for ten medical specialties. The results show that the interdependence of ambulatory and hospital services is far from homogeneous. The relationship depends, on the one hand, on the specialty and, on the other, on the direction of the effect observed. This heterogeneity needs to be taken into account for cross-sector needs-based planning.

Health shocks and risk aversion.

We empirically assess whether a health shock influences individual risk aversion. We use grip strength data to obtain an objective health shock indicator. In order to account for the non-random nature of our data regression-adjusted matching is employed. Risk preferences are traditionally assumed to be constant. However, we find that a health shock increases individual risk aversion. The finding is robust to a series of sensitivity analyses and persists for at least four years after the shock. Income changes do not seem to be the driving mechanism.

Public reporting and the quality of care of German nursing homes.

OBJECTIVES: Since 2009, German nursing homes have been evaluated regularly by an external institution with quality report cards published online. We follow recent debates and argue that most of the information in the report cards does not reliably measure quality of care. However, a subset of up to seven measures does. Do these measures that reflect "risk factors" improve over time? METHOD: Using a sample of more than 3000 German nursing homes with information on two waves, we assume that the introduction of public reporting is an exogenous institutional change and apply before-after-estimations to obtain estimates for the relation between public reporting and quality. RESULTS: We find a significant improvement of the identified risk factors. Also, the two employed outcome quality indicators improve significantly. The improvements are driven by nursing homes with low quality in the first evaluation. CONCLUSION: To the extent that this can be interpreted as evidence that public reporting positively affects the (reported) quality in nursing homes, policy makers should carefully choose indicators reflecting care-sensitive quality.

Quantile treatment effects of job loss on health.

Studies on health effects of job loss mostly estimate mean effects. We argue that the effects might differ over the distribution of the health status and use quantile regression methods to provide a more complete picture. To take the potential endogeneity of job loss into account, we estimate quantile treatment effects where we rely on job loss due to plant closures. We find that the effect of job loss indeed varies across the mental and physical health distribution. Job loss due to plant closures affects physical health adversely for individuals in the middle and lower part of the health distribution while those in best physical condition do not seem to be affected. The results for mental health, though less distinct, point in the same direction. We find no effects on BMI.

Determinants of Regional Variation in Health Expenditures in Germany.

Health care expenditure in Germany shows clear regional differences. Such geographic variations are often seen as an indicator for inefficiency. With its homogeneous health care system, low co-payments and uniform prices, Germany is a particularly suited example to analyse regional variations. We use data for the year 2011 on expenditure, utilization of health services and state of health in Germany's statutory health insurance system. This data, which originate from a variety of administrative sources and cover about 90% of the population, are enriched with a wealth of socio-economic variables, data on pollutants, prices and individual preferences. State of health and demography explains 55% of the differences as measured by the standard deviation while all control variables account for a total of 72% of the differences at county level. With other measures of variation, we can account for an even greater proportion. A higher proportion of variation than usually supposed can thus be explained. Whilst this study cannot quantify inefficiencies, our results contradict the thesis that regional variations reflect inefficiency. Copyright © 2015 John Wiley & Sons, Ltd.

Short- and medium-term effects of informal care provision on female caregivers' health.

In this paper, we present estimates of the effect of informal care provision on female caregivers' health. We use data from the German Socio-Economic Panel and assess effects up to seven years after care provision. The results suggest that there is a considerable negative short-term effect of informal care provision on mental health which fades out over time. Five years after care provision the effect is still negative but smaller and insignificant. Both short- and medium-term effects on physical health are virtually zero throughout. A simulation analysis is used to assess the sensitivity of the results with respect to potential deviations from the conditional independence assumption in the regression adjusted matching approach.

Regional variation in the utilisation of ambulatory services in Germany.

We used an administrative dataset covering approximately 90% of all Germans to investigate the determinants of regional differences in the utilisation of ambulatory services in the year 2008. There are great regional differences in Germany, in GP, specialist and psychotherapist consultations. By means of a regression model taking account of the spatial dependencies of the error terms, we can explain a considerable part of the variation in terms of differences in demography, health status and socio-economic features. In addition, we made use of data on pollutants, the supply of services and the number of hospital cases as explanatory variables, which all have a significant influence on utilisation but contribute considerably less to explaining the differences. Overall, we are in a position to explain 29-40% of the regional differences in ambulatory case numbers at the level of the 413 counties and 55-70% at the level of the 16 German states (Länder) by observable differences.

Practice budgets and the patient mix of physicians - the effect of a remuneration system reform on health care utilisation.

This study analyses the effect of a change in the remuneration system for physicians on the treatment lengths as measured by the number of doctor visits using data from the German Socio-Economic Panel over the period 1995-2002. Specifically, I analyse the introduction of a remuneration cap (so called practice budgets) for physicians who treat publicly insured patients in 1997. I find evidence that the reform of 1997 did not change the extensive margin of doctor visits but strongly affected the intensive margin. The conditional number of doctor visits among publicly insured decreased while it increased among privately insured. This can be seen as evidence that physicians respond to the change in incentives induced by the reform by altering their patient mix.

What accounts for the regional differences in the utilisation of hospitals in Germany?

There are huge regional variations in the utilisation of hospital services in Germany. In 2007 and 2008 the states of Hamburg and Baden-Württemberg had on average just under 38 % fewer hospitalisations per capita than Saxony-Anhalt. We use data from the DRG statistics aggregated at the county level in combination with numerous other data sources (e.g. INKAR Database, accounting data from the National Association of Statutory Health Insurance Physicians (KBV), Federal Medical Registry, Germany Hospital Directory, population structure per county) to establish the proportion of the observed regional differences that can be explained at county and state levels. Overall we are able to account for 73 % of the variation at state level in terms of observable factors. By far the most important reason for the regional variation in the utilisation of in-patient services is differences in medical needs. Differences in the supply of medical services and the substitutability of outpatient and inpatient treatment are also relevant, but to a lesser extent.

Profit efficiency and ownership of German hospitals.

This paper investigates the cost and profit efficiency of German hospitals and their variation with ownership type. It is motivated by the empirical finding that private (for-profit) hospitals - having been shown to be less cost efficient in the past - on average earn higher profits than public hospitals. We conduct a Stochastic Frontier Analysis on a multifaceted administrative German data set combined with the balance sheets of 541 hospitals of the years 2002-2006. The results show no significant differences in cost efficiency but higher profit efficiency of private than of publicly owned hospitals.

What determines influenza vaccination take-up of elderly Europeans?

We analyse the determinants of influenza vaccination take-up of Europeans above the age of 50 years using the first two waves of the Survey of Health, Ageing, and Retirement (SHARE). Using quality-of-care indicators, special emphasis is put on the measurement and the impact of physician quality. We find that age, health status, lifestyle, labour-force status, and the family structure are important determinants of the decision to get a flu shot. Physician quality, as measured by four indicators, also positively affects the probability of getting a flu shot.