Morbidity-based risk structure compensation

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

In January 2009, the existing risk structure compensation scheme between sickness funds has been expanded to include morbidity-oriented factors. The measure aims at preventing risk selection, improving care for patients with chronic diseases and equalizing starting points for competition between sickness funds. The introduction of morbidity-oriented risk structure compensation ("morbi-RSA") entails a major reorganization of financial flows which is highly controversial.

Purpose of health policy or idea

Reasons for risk structure compensation

The risk structure compensation scheme (Risikostrukturausgleich, RSA) between sickness funds was introduced in 1994 to strengthen solidarity in the health system and to create a framework for competition:

• For reason of solidarity, insurees pay income-related contributions, independent of their morbidity risk. Thus, the health status of insurees does not determine the revenue of sickness funds, while it does, however, affect their expenditure. The risk structure compensation scheme aims at compensating sickness funds for insurees with predictably high medical expenses by balancing differences in income-related contributions and differences in risk-related expenditure between sickness funds.
• Without risk structure compensation, sickness funds would try to acquire many "good risks" ("cream-skimming") instead of competing for quality and efficiency. By balancing structural differences in revenue and expenditure, risk structure compensation creates equal starting points for competition between sickness funds. The risk structure compensation scheme serves to prevent risk selection and to increase competition for quality and efficiency, not for healthy insurees.

Shortcomings of the original RSA 

The initial risk structure compensation scheme equalized differences in income-related contributions and differences in expenditure of sickness funds due to age, sex and invalidity. However, critics warned that

• socio-demographic risk adjusters which are only indirectly linked to morbidity would not sufficiently explain structural differences in expenditure levels of sickness funds
• unadjusted differences in morbidity levels would promote risk selection by sickness funds and hamper efforts of improving quality and efficiency

While the original RSA was later modified to include participation in a Disease Management Program (see below), it did not become truly morbidity-oriented.

The morbi-RSA: main objectives 

Since January 2009, morbidity-based categories complement the previous compensation mechanism. The morbidity-oriented risk structure compensation scheme (morbiditätsorientierter Risikostrukturausgleich, morbi-RSA) is aimed at more equitable distribution of funds, corresponding to morbidity-related expenditure of sickness funds. Objectives are to

• prevent risk selection by sickness funds
• improve care for patients with chronic and/or severe expensive diseases
• equalize starting points for competition between sickness funds

How the morbi-RSA works

The morbi-RSA balances differences in risk-related expenditure:

• For each insuree, sickness funds theoretically receive a uniform flat rate from the health fund. According to the risk structure of the individual insuree, there are deductions or increases. For a healthy 24-year-old woman, for example, there is a deduction due to her age and sex. If the 24-year-old is suffering from a disease included in the morbi-RSA, her sickness fund receives extra payments (fig. 1).
• The morbi-RSA comprises 80 diseases. As some of them are split according to different levels of severity, there are 106 hierarchical morbidity groups for classifying insurees.
• These 106 morbidity groups, together with 40 age/sex risk groups and 6 groups of people receiving invalidity benefits form the basis for calculating the individual risk structure of each insuree. (fig. 2). Additionally, sickness funds receive a flat rate for participants of disease management programs.
• The morbi-RSA follows a prospective model: Allocation of funds does not depend on current treatment expenses(i.e. those in the year of the original diagnosis), but on costs in the following year(s). The additional payment for an acute myocardial infarction, for example, is determined by the average additional costs of care in the subsequent year(e.g. due to medication, re-hospitalization, higher co-morbidity from diseases not included themselves in the morbid-RSA).

Main points

Main objectives

• prevent risk selection by sickness funds
• improve care for patients with chronic diseases
• equalize starting points for competition between sickness funds

Type of incentives

Additional payments to sickness funds for 80 defined diseases

Groups affected

sickness funds

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Degree of innovation: The introduction of morbidity-based categories constitutes an ambitious reform of the previous risk structure compensation scheme which merely adjusted for age, sex and invalidity among insurees.

Degree of controversy: While the Government, the Federal Social Insurance Authority and sickness funds with many chronically ill patients support the morbi-RSA, other stakeholders and sickness funds are strongly opposed.

Impact: The morbi-RSA entails a major reorganization of the financial flows between sickness funds: almost half of the 168 billion Euro pooled in the health fund will be redistributed according to the new morbidity-based categories.

Public Visibility: While the topic is very prominent among sickness funds and health policy experts, the general public has not been extensively informed about the morbi-RSA by the stakeholders and by the media.

Transferability: Risk structure compensation schemes exist in several countries (e.g. in the Netherlands or Switzerland). While acknowledging international differences in health system organisation, other countries could learn from German experiences to a certain extent.

Political and economic background

In January 2009, a financial reform of the social health insurance system, the final step of the Act to Strengthen Competition in Statutory Health Insurance passed in 2007,entered into force. The core elements are

• a uniform contribution rate, for the first time set by the government and not by each sickness funds individually (c.f. HPM reports "Health care reform in Germany: Not the big bang" and accompanying report 04/09),
• central pooling of contributions in a health fund,
• introduction of a morbidity-oriented risk structure compensation scheme for allocating payments from the health fund to the sickness funds acting as third-party payers. 

The morbi-RSA entails a major reorganization of the financial flows between sickness funds: almost half of the 168 billion Euro pooled in the health fund will be redistributed according to the new morbidity-based categories. At the same time, the morbi-RSA is part of a wider health system reorganisation.

In addition (but regulated separately), remuneration of providers has become morbidity-oriented as well; by means of diagnosis-related groups (DRGs) for hospitals (since 2004) and standard service volumes for physicians in the ambulatory sector. Increased morbidity-orientation grounds on the idea of structuring financial flows according to medical criteria, in order to achieve a more patient-centred and a more efficient health system.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

Since the introduction of risk structure compensation in 1994, the shortcomings of socio-demographic categories have been discussed. A scientific report, commissioned by the Federal Ministry of Health, concluded that unadjusted differences in morbidity levels would promote risk selection and hamper efforts of improving quality and efficiency in social health insurance (Jacobs et al, 2001). Other reports came to similar conclusions (e.g. Lauterbach & Wille, 2001).

Increasing evidence seemed to support morbidity-based risk structure compensation. At the same time, the range of data accessible to sickness funds expanded. In 1994, the choice of risk adjusters had been restricted by the availability of data: Age and sex became risk adjusters, as sickness funds could only collect socio-demographic data. Since 1999, however, sickness funds can access data on pharmaceutical prescriptions and inpatient diagnoses and, since 2004, data on outpatient diagnoses. The scientific community consented that direct morbidity-orientation in risk compensation was needed.

The Act to Reform the Risk Structure Compensation Scheme (RSA-Reform-Act)

To improve risk structure compensation based on scientific evidence, the German Bundestag (Federal Assembly, i.e. the lower house of the German Parliament) enacted a reform of the compensation mechanism. The Act to Reform the Risk Structure Compensation Scheme in SHI from 2001 aimed at

• preventing that concentration of insurees with cost-intensive conditions leads to financial disadvantages for some sickness funds,
• enhancing competition between sickness funds to improve quality of care, particularly for insurees with chronic conditions,   
• preventing risk selection to the detriment of patients with chronic conditions. (It should be noted, though, that German sickness funds are obliged to contract with all insurees independent of their health status.) 

To achieve these aims, the RSA Reform Act stipulated two steps: 

• As from 2002, the introduction of two short-term measures; a "risk pool" to compensate sickness funds for insurees with high medical expenses - such as AIDS patients - and additional payments for chronically ill insurees enrolled in disease management programs.
• As from 2007, the inclusion of morbidity-based categories in the risk structure compensation scheme as a long-term measure to improve quality of care and competition between sickness funds. 

Looking beyond national borders

International experiences, particularly from the U.S. and from the Netherlands, guided the discussion on morbidity-oriented risk structure compensation. In the U.S., several morbidity-oriented classification models have been developed. In the Netherlands, first steps towards implementing morbidity-oriented risk compensation had been taken: Pharmaceutical cost groups introduced in 2002 and diagnosis cost groups introduced in 2004 served as an example for developing morbidity-based categories in the German context.

Initiators of idea/main actors

• Regierung

• Leistungserbringer

• Kostenträger

• Wissenschaft

Approach of idea

The approach of the idea is described as:
new: Guided by experiences from the U.S. and from the Netherlands, the introduction of morbidity-oriented criteria constitutes a new approach in the German risk structure compensation scheme.
amended: The existing risk structure compensation scheme, which was based on socio-demographic adjusters and invalidity among insurees, has been expanded to include morbidity-based categories.

Stakeholder positions

The Federal Ministry of Health strongly supports the morbi-RSA and has made it a priority for the financial reform of the social health insurance system. The Ministry appointed a Scientific Advisory Board in 2007 to develop morbidity-based categories for risk structure compensation.

The Federal Social Insurance Authority is an independent authority in charge of implementing the risk structure compensation scheme. The Federal Social Insurance Authority is empowered to take the final decision regarding the compensation rates.

A Scientific Advisory Board was entrusted with investigating appropriate diagnoses, weighting factors and classification models. Their report formed the basis for the decision of the Federal Social Insurance Authority. While the Board stressed the importance of a morbi-RSA, the members stressed the importance of strictly applying the criteria stated by law. All Board members resigned in March 2008 to express their discontent with, among others, the inclusion of diseases such as diabetes and hypertension in the morbi-RSAas such diseases were "preventable" and/ or not "closely definable" and/ or not "highly cost-intensive" and, thus, did not conform to legal requirements (for definition of the terms, please see section "adoption and implementation").

Statutory Health Insurers are divided into supporters and opponents:

• Sickness funds with many elderly insurees and people with chronic diseases favor the morbi-RSA. They perceive the reformed allocation procedure as more equitable and expect distributions to better cover the morbidity risks of their insurees.
• Sickness funds with many "good risks" or insurees with diseases not included in the morbi-RSA expect smaller allocations than before. Apart from financial problems, many sickness funds criticize that the structure of the morbi-RSA has made it impossible to plan budgets reliably.

The Federal Association of Statutory Health Insurance Physicians claims that the morbi-RSA creates incentives for manipulation and corruption. The Association warns of alliances between payers and providers where providers are encouraged to "upcode" their patients so as to fit into the newly created morbidity categories.

Actors and positions

Regierung
Federal Ministry of Health	sehr unterstützend		stark dagegen
Federal Social Insurance Authority	sehr unterstützend		stark dagegen
Leistungserbringer
Federal Association of Statutory Health Insurance Physicians	sehr unterstützend		stark dagegen
Kostenträger
Sickness funds with many elderly insurees/people with chronic conditions	sehr unterstützend		stark dagegen
Sickness funds with many ?good risks?	sehr unterstützend		stark dagegen
Wissenschaft
Scientific Advisory Board	sehr unterstützend		stark dagegen

Influences in policy making and legislation

The RSA-Reform-Act

In 2002, the Bundestag adopted the RSA-Reform-Act which stipulated two steps: the introduction of a "risk pool" and financial incentives for disease management programs as from 2002, and the inclusion of morbidity-based categoriesin RSA as from 2007 (see section "origins of health policy").

The Reform Deadlock

While the RSA-Reform-Act had scheduled 2007 for implementing the morbi-RSA, data collection problems and political obstacles resulted in a reform deadlock:

• A scientific report had been commissioned by the Bundestag to assess available morbidity-based classification models (Reschke et al, 2005). The report, though, was delayed for several months, because sickness funds faced problems of collecting the morbidity-oriented data needed for adapting international classification models to the German context.
• When the report was launched in 2005, the political constellation in the Federal Council (the upper house of the German Parliament) did not allow legislative progress regarding morbi-RSA.

Morbi-RSA Gains Momentum Again

In their coalition agreement of 2005, Christian Democrats and Social Democrats agreed on refining and further improving the risk structure compensation scheme. This rather vague wording was specified during negotiations for the envisaged health care reform. The resulting political compromise yielded

• introducing directly morbidity-based risk structure compensation as from 2009
• selecting a classification model and adapting it to the German context
• selecting 50-80 diseases as a "filter" to limit the spectrum of morbidity and to increase planning capacity of sickness funds
• abolishing the "risk pool" to simplify risk structure compensation

The Legal Basis

The Act to Strengthen Competition in Statutory Health Insurance, passed in February 2007, and the subsequentamendments to the "risk structure compensation regulation" (Risikostrukturausgleichsverordnung, RSAV) created the main legal basis for introducing the morbi-RSA. The regulation governs

• data collection: The Federal Social Insurance Authority and the sickness funds negotiate the technical details with each other (see section "adoption and implementation").
• data security: Sickness funds need to pseudonymise morbidity-related information before sending them to the Federal Social Insurance Authority. 
• criteria for the classification model: The model should utilize diagnoses (without limiting these to the in- or outpatient sector) and pharmaceutical prescriptions. Besides, the model has to be prospective and minimize incentives for risk selection.
• criteria for the 50-80 diseases: The diseases must be "chronic cost-intensive" or "severe". Moreover, they have to be "closely definable" and have an essential impact on both provision of care and on expenditure of sickness funds
• implementation: The Federal Ministry of Health appoints a Scientific Advisory Board with experts from a medical, health economics, pharmaceutical, statistical and epidemiological background. Based on their recommendations, the Federal Social Insurance Authority decides on the 50-80 diseases and a classification model. The sickness funds have to be consulted.

Legislative outcome

success

Actors and influence

Regierung
Federal Ministry of Health	sehr groß		kein
Federal Social Insurance Authority	sehr groß		kein
Leistungserbringer
Federal Association of Statutory Health Insurance Physicians	sehr groß		kein
Kostenträger
Sickness funds with many elderly insurees/people with chronic conditions	sehr groß		kein
Sickness funds with many ?good risks?	sehr groß		kein
Wissenschaft
Scientific Advisory Board	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

To implement the amended "risk structure compensation regulation", the following steps were taken:

• procedure of data collection: The sickness funds pseudonymise and report pharmaceutical prescriptions, outpatient and inpatient diagnoses and expenses to the Federal Social Insurance Authority. For 2007, the sickness funds sent data of a representative sample, as from 2008, data of all insurees.
• appointment of the Scientific Advisory Board: In May 2007, the Federal Ministry of Health appointed a Scientific Advisory Board with six experts from a medical, health economics, pharmaceutical, statistical and epidemiological background to investigate classification models and to select 50-80 diseases for the morbi-RSA.
• report of the Scientific Advisory Board: In December 2007, the Board recommended to select the US-developed classification model DCG/HCC (diagnosis cost groups/hierarchical condition categories) which enables arranging diseases in hierarchical categories. To select 50-80 diseases, the Board operationalized the terms "chronic", "severe", "closely definable" and "costly". "Chronic" was defined as persistence of certain diagnoses over at least two quarters among at least 50% of patients, costs being 50% above average costs. "Severe" was defined as requiring inpatient care for more than 10% of those affected. The term "closely definable" was based on the diagnoses of the HCC-classification model."Costly" was based on a ranking of logarithmitized per capita costs of all DCGs, with the most expensive ones being selected (roughly the top 30%). In addition, it was analysed whether the actual per capita costs were at least 50% higher than the SHI-wide average costs per person.
• consultation process for the selection of diseases: In January 2008, the Federal Social Insurance Authority consulted the sickness funds. Among others, some sickness funds criticized splitting diseases in several groups and stressed the inseparability of disease entities. Hospitalisation as a criterium for "severe" diseases was disputed, as this would not only lead to neglect of conditions which entail high pharmaceutical expenditure, but also contradicts efforts to promote ambulatory care.
• comments of other stakeholders:  20 stakeholders, such as patients´ organisations and associations of providers, commented on the report of the Scientific Advisory Board. Some stakeholders criticized the list of diseases as incomplete. For example, in a joint report with two sickness funds, the Federal Association of Statutory Health Insurance Physicians stipulated to include Alzheimer´s disease in the morbi-RSA. Other stakeholders demanded deleting certain conditions from the list. It was debated, for example, whether bleeding during early pregnancy should be removed from the list of diseases.
• decision of the Federal Social Insurance Authority:  In March 2008, the Federal Social Insurance Authority determined the diseases to be considered. The Authority rebutted criticism of the hierarchical categorisation of diseases, on the grounds that many diseases, such as cancer, occur in various clinical conditions with differing costs. Hospitalisation as a criterium for "severe" diseases remained unchanged, as patients with high pharmaceutical costs are to be covered under the definition of "chronic cost-intensive" conditions. The Federal Social Insurance Authority followed the suggestions to include Alzheimer´s disease in the morbi-RSA. According to the Authority, pregnancy per se constitutes a potentially cost-intensive risk both "chronic" (as the diagnosis persists over two quarters) and "severe" (due to the high hospitalisation rate) which, thus, needs to be included in the morbi-RSA. The calculations for the other diseases were re-run, this time giving a higher weight to the prevalence of a disease, i.e. favouring prevalent but not so costly diseases over rare but individually costly diseases.
• resignation of the Scientific Advisory Board: In March 2008, the Board resigned because of controversies with the Federal Social Insurance Authority. The Board expressed their discontent with, among others, the inclusion of diseases such as diabetes (instead of only diabetes with certain complications) and hypertension (which it did not neither regard as a "closely definable" disease nor as costly) in the morbi-RSA.

Monitoring and evaluation

"A learning system"

According to the Federal Social Insurance Authority, the morbi-RSA is a "learning system" which requires regular updating. So far, the morbi-RSA is limited to 80 diseases to prevent unforeseeable distortions in competition and to increase planning capacity of sickness funds. Though, the Federal Social Insurance Authority supports continuous improvement of the morbi-RSA by, for example, including age-morbidity interactions, to respond to the demographic and epidemiological transition. In that respect, the 80 diseases as well as the payments will be recalculated annually. A systematic evaluation of the morbid-RSA is, however, not yet planned or envisaged.

Expected outcome

The introduction of morbidity-based categories in risk structure compensation has been highly debated. Expected trends and debated issues are outlined below.

Expected Trends

A Year of Transition

As almost half of the 168 billion Euro pooled in the health fund will be redistributed according to morbidity-based categories, the morbi-RSA entails a major reorganization of financial flows. 2009 is supposed to be a year of transition where many sickness funds will struggle to survive. Experts expect several developments:

• In the initial stage, cost-containment is expected to be the main strategy of sickness funds. 
• By mid 2009, many sickness funds will probably be forced to levy extra contributions from their insurees, if the premiums allocated from the health fund do not cover all expenses.
• Financial problems will lead to market concentration, especially small sickness funds are likely to disappear. The Federal Social Insurance Authority expects 30 - 40 mergers of the 200 sickness funds for 2009.
• In the long run, given the uniform contribution rate, non-financial aspects such as a dense network of branch offices probably gain in importance for competition. Moreover, sickness funds are likely to promote better steering of selected patient groups through the healthcare system.

Stimulus for Innovative Care Management

The morbi-RSA challenges the traditional strategy of sicknes funds: attracting primarily healthy and wealthy insurees. For the first time, sickness funds can profit from sick insurees. This paradigmatic shift could considerably improve quality of care for patients with chronic conditions included in the morbi-RSA. Some sickness funds consider expanding

• case management programs,
• special contracts for chronic care,
• building cross-sector partnerships with physicians and hospitals,
• specializing in insurance for patients with diabetes or cancer.

The rationale for this reorganization is twofold. Not only shall special offers attract patients with certain chronic diseases and, thus, entail additional premiums from the health fund. But an improved chronic care infrastructure is also increasingly seen as necessary for using the additional premiums efficiently.

More equity? - Yes, but only for some

The morbi-RSA was aimed at increasing equity at the level of sickness funds and at the level of insurees. At the level of sickness funds, morbidity-related distribution of funds is supposed to equalize starting points for competition between sickness funds. However, critics claim that

• the 80 diseases included in the morbi-RSA do not reflect the whole spectrum of morbidity. Many cost-intensive but relatively rare diseases were not included.
• the morbi-RSA is complex and intransparent - it creates a new "black box" and leaves many sickness funds without any planning capacity.

At the level of insurees, the degree of equity is debated as well:

• Sickness funds profit only from patients with the "right" diseases - diseases which are included in the morbi-RSA. The quality of care for other patients will not necessarily diminish, as their legal entitlements remain unchanged and the payment of providers does not depend on the morbidity-oriented premiums which sickness funds receive. In practice, though, patients with the "right" diseases may be better off, when sickness funds compete for them by offering special care programs.

• At the same time, sickness funds may have less financial interest in promoting enrolment in disease management programs. Although increasing evidence shows the success of disease management programs, the flat rate paid under the morbi-RSA is notably lower than the previous payments. Given such financial disincentives, the morbi-RSA could reduce the role of disease management programs (Wasem, 2007). It should be noted, though, that additional premiums for "chronic cost-intensive" conditions complement the reduced flatrate for participants of disease management programs.

… still Competition for Young and Healthy Insurees

Despite incentives to insure patients with certain diseases, many sickness funds still favour, in principle, young and healthy people for two main reasons:

• Attracting people with diseases is risky: The true morbidity risks are mostly unknown and incalculable, as there is no completely "transparent patient" yet.

• From a long-term perspective, specific care programs for e.g. chronic conditions may lower treatment costs. From a short-term perspective, though, their development costs time and efforts. Smaller sickness funds often lack resources to set up such programs, larger sickness funds with a risk mix of insurees may not want to specialise for strategic reasons.

 

Debated Issues

Transparent Insurees?

As from 2009, sickness funds collect not only socio-demographic data, but also morbidity-related data on diagnoses and pharmaceutical prescriptions. Data security is debated. Sickness funds pseudonymise the data before sending them to the Federal Social Insurance Authority. However, sickness funds themselves are able to relate the data to their insurees. To receive additional allocations from the health fund, sickness funds need to match standing data and diagnosis-related data. Although matching is strictly limited to this purpose, there is a grey area. It is discussed, for example, whether sickness funds are allowed to match data to examine coding of diagnoses by physicians.

Incentives for Manipulation?

Many stakeholders criticize the possibility of manipulating diagnoses to receive additional premiums from the health fund. Minister of Health Ulla Schmidt denounces alliances between physicians and sickness funds, where physicians are paid for reviewing their diagnoses, as corruption. The debate focuses on the distinction between "up-coding" and "right-coding": All sickness funds officially disapprove of "up-coding" patients by assigning them a medically unjustified, but more lucrative diagnosis. Instead, the term "right-coding" is used for describing efforts to improve recording of existing, yet unreported morbidity.

Sending Costs Sky-High?

Critics warn that the morbi-RSA will increase costs for two main reasons. First, basing morbidity-oriented additional payments to sickness funds on diagnoses, partly "validated" through pharmaceutical prescriptions, is seen as a disincentive for cost-containment. Critics claim that, despite rising costs for pharmaceuticals and hospital treatment, insurers have an interest in promoting pharmaceutical prescriptions and inpatient diagnoses to receive additional allocations from the health fund. Second, critics caution that the morbi-RSA will increase reporting of cost-intensive diseases, as a result of either "right-coding" or "up-coding" (which, however, is easier in the ambulatory sector, where the first agreements between physicians and sickness funds have been signed to carefully document all diagnoses). The Federal Social Insurance Authority, though, stresses that the financial endowment of the health fund is fixed. Thus, proliferation of reported morbidity would merely reduce the monetary value of additional payments, to the detriment of sickness funds themselves.

Disincentives for prevention?

Critics claim that the morbi-RSA does not encourage investment in health, as strategies to prevent illness are not rewarded: there is the danger that sickness funds rather profit when they enlist many sick insurees. The Federal Social Insurance Authority presents two counterarguments to stress that sickness funds are still interested in prevention: First, if their clients are healthy, sickness funds will not receive additional allocations from the health fund. But they also avoid costs of disease. Second, according to the prospective procedure, diagnoses of the previous year determine how much money sickness funds receive in the subsequent year. Thus, sickness funds profit when their insurees´ health status improves over the years.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

Impact on quality of health care services: While the morbi-RSA may improve care for patients with chronic diseases (e.g. by expansion of case management programs), the overall impact on the quality of health care services cannot be assessed yet. In the long term, improved quality of care for patients with chronic might "spill over" to other patient groups or it will be to their detriment (if the focus remains on those with additional allocations).

Level of equity: The introduction of morbidity-oriented categories in risk structure compensation is aimed at more equitable distribution of funds, corresponding to morbidity-related expenditure of sickness funds. Particularly patients with chronic diseases which are included in the morbi-RSA may profit from innovative models of care. Regarding patients with the "wrong" diseases, though, the situation remains unchanged or worsens.

Impact on cost-efficiency:  The morbi-RSA may easily influence behaviour of sickness funds and providers (through their contracts with the sickness funds). While this may be beneficial, i.e. that appropriate treatments will be given to a larger percentage of affected patients, "gaming" (i.e. treating patients who do not actually have a given disease as if they had it to label them accordingly). This would have a negative effect on both the quality and the cost-efficiency of the system. Only manipulating diagnoses ("up-coding") would also have a negative effect on cost-efficiency (while being neutral to quality). Overall, the hope is thoughthat sickness funds will be increasingly pressured to optimize allocation of resources by managing patients efficiently in the long term.

References

Sources of Information

Bundesversicherungsamt. Festlegung der im morbiditätsorientierten Risikostrukturausgleich zu berücksichtigenden Krankheiten durch das Bundesversicherungsamt, 2008 (Available online at www.der-gesundheitsfonds.de/fileadmin/redaktion/Dokumente/Risikostrukturausgleich/
20_Dokumentation_der_Festlegung.pdf)

Bundesversicherungsamt. So funktioniert der neue Risikostrukturausgleich im Gesundheitsfonds, 2008 (Available online at www.bundesversicherungsamt.de/cln_100/nn_1046668/DE/Risikostrukturausgleich/
Wie__funktioniert__Morbi__RSA,templateId=raw,property=publicationFile.pdf/
Wie_funktioniert_Morbi_RSA.pdf)

"Der Morbi-RSA bringt für Kassen den gläsernen Versicherten". Ärzte Zeitung,  January 29, 2009. (Also available online at www.hautsache.de/News/Der-Morbi-RSA-bringt-fuer-Kassen-den-glaesernen-Versicherten.php)

"Fonds zwingt Kassen zum Umdenken". Financial Times Deutschland, February 13, 2009. (Also available online at www.ftd.de/unternehmen/gesundheitswirtschaft/:Gesundheitswirtschaft-Fonds-zwingt-Kassen-zum-Umdenken/473618.html?p=4)

Göpffarth, Dirk. Der Risikostrukturausgleich auf dem Weg zur direkten Morbiditätsorientierung. GGW (7) 3: 23-30, 2007

Jacobs, Klaus, Peter Reschke, Dieter Cassel and Jürgen Wasem. Zur Wirkung des Risikostrukturausgleichs in der gesetzlichen Krankenversicherung Eine Untersuchung im Auftrag des Bundesministeriums für Gesundheit. Baden-Baden: Nomos, 2001. (Also available online at www.iges.de/publikationen/gutachten/rsa_gutachten/e5166/infoboxContent
5178/RSA-Gutachten2001_ger.pdf)

Jacobs Klaus und Sabine Schulze  Der morbiditätsorientierte Risikostrukturausgleich: notwendige Funktionsbedingung für sinnvollen Wettbeweb in der GKV. GGW  (7) 3: 7-14, 2007

Lauterbach Karl and Eberhard Wille. Modell eines fairen Wettbewerbs durch den Risikostrukturausgleich. Mannheim: Köln, 2001. (Also available online at www.medizin.uni-koeln.de/kai/igmg/endgutachten_rsa.pdf)

Reschke Peter et al. Klassifikationsmodelle für Versicherte im Risikostrukturausgleich. Bonn: Bundesministerium für Gesundheit und Soziale Sicherung, Referat Information Publikation, Redaktion, 2005

Schneider, Udo, Volker Ulrich and Eberhard Wille. Risk Adjustment Systems in Health Insurance Markets in the US, Germany, Netherlands and Switzerland. CESifo DICE REPORT Journal for institutional comparisons (6) 3: 37-49, 2008

Wasem, Jürgen. Die Weiterentwicklung des Risikostrukturausgleichs ab dem Jahr 2009. GGW (7) 3: 15-22, 2007

Figures 1 and 2: own translation of Bundesversicherungsamt. So funktioniert der neue Risikostrukturausgleich im Gesundheitsfonds, 2008: 5-6

Author/s and/or contributors to this survey

Schang, Laura

Reviewer: Reinhard Busse, TU Berlin

This report was written during an internship at Bertelsmann Foundation. Laura Schang is studying the Bachelor of European Public Health in Maastricht.

Empfohlene Zitierweise für diesen Online-Artikel:

Schang, Laura. "Morbidity-based risk structure compensation". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/ger/a13/1