Health economics

from Wikipedia, the free encyclopedia

Health economics ( English medical economics, health economics , French économie de la santé, économie médicale ) is an interdisciplinary science that deals with the production, distribution and consumption of scarce health goods in health care and thus elements of health sciences and the national and business administration combined.

In principle, the supply and demand of health services and health insurance services are analyzed, whereby the consideration of existing information asymmetries is of particular importance. In addition, different health systems need to be highlighted. The tension between medical effectiveness ("health ...") and economic efficiency ("... economy") is expanded by the quality of health care and the fair use of health goods. The optimal use of limited health budgets is paramount. The most common practical application of health economic methods is decision analysis in which health services should preferably be invested.

Importance and Development

Magical square of health economics

The resources of the health care system are characterized by perpetual scarcity. The economic efficiency principle states that the services to be reimbursed by the statutory health insurances (GKVen) and to be provided by the medical service providers “must be sufficient, appropriate and economical; they must not exceed what is necessary. Services that are not necessary or uneconomical can not be claimed by the insured, the service providers are not allowed to provide and the health insurances not approve ".

Against this background, the task arises to create a balance between the medical possibilities, their financial feasibility, as well as quality and fairness. With scientific methods, health economics supports decision-making in the health sector. One speaks of the magic square of health economics (illustration).

The development and importance are made clear by the laws enacted in Germany. The development began in 1977 with the first health reform , the Health Insurance Cost Reduction Act . Among other things, additional payments for medicines, bandages and remedies as well as the reduction of subsidies for dental prosthesis services were regulated. Since then, further health reforms have taken place continuously. In 2007, with Section 35b of the Social Code Book V, the profitability audit for new drugs and drugs of "special importance" was introduced.

Goal setting

Basic principle of health economic evaluation

One of the many tasks of health economics is the development of models and tools for measuring and evaluating changes in methods and processes in health care through medical or health policy interventions and new health technologies. The term technology is very broad and includes, among other things, drugs, remedies and aids , laboratory technology or diagnostics, as well as forms of care and insurance. In the comparative health economic analysis, economically more favorable, qualitatively equivalent or better alternatives can be shown. This can also include stacking , as it can result in lower dosages and therefore usually also lower costs.

Health economics pursues the idea of ​​fulfilling economic principles: a relationship is established between the additional benefit of an intervention and the scarcity of resources used.

Furthermore, it is the intention of health economics to analyze interactions between the health system and the national economy .

Core elements of the health economic evaluation

In health economic analysis, standards for the implementation and publication of health economic studies have been given high priority. They define the necessary content and procedures for the health economic analysis.

Perspectives

When considering the costs and benefits of a specific health service or measure, it is important to consider different perspectives. Depending on the perspective chosen, a health economic analysis will lead to completely different results. What is advantageous for the patient does not have to be desirable for the health insurance, which is part of the payment obligation, or for the employer.

A distinction is usually made between the following basic perspectives:

  • Patient: for example financial burden or co-payments.
  • Service provider (doctor, hospital): e.g. remuneration for services or cost structure.
  • Health insurance: for example reimbursement of costs.
  • Society: for example distributive justice , allocation or maintenance of health and work ability.
  • Employer: for example, lost work or early retirement .
  • GKV insured community: New introduction by the Institute for Quality and Efficiency in Health Care

Benefit assessment

In addition to the direct costs and benefits , the indirect, positive and negative external effects of a health service play a significant role in the assessment . Since benefit does not only consist of monetary quantities, medical or epidemiological outcome units must also be taken into account. Examples of this are gained symptom-free days, the number of tumors avoided, changes in blood pressure or additional years of life gained with life-saving measures.

Cost assessment

Costs in health economics include the consumption of monetary resources for one or more medical measures carried out. However, costs are not only related to funds; Rather, costs in health economics can also be negative effects (e.g. side effects) that result from a measure. They are therefore directly related to the benefit. The importance of the cost depends on the point of view. For a patient, the monetary costs of treatment covered by the health insurance are of no interest, while they are the most important for the health insurance. The side effects of treatment are the major cost to the patient.

For a more precise definition, health economics distinguishes between different types of costs.

The most important are:

Direct costs

Direct costs are the monetary resources needed to treat a patient. They include costs for medication, laboratory, personnel, administration and other materials needed for treatment. Costs that arise from treatment are also direct costs. (e.g. costs of treating side effects). Direct costs are difficult to determine in retrospective studies , as it is often not possible to precisely record the costs. In a prospective study , the costs can be determined as precisely as required.

Indirect costs

Indirect costs are monetary costs that are incurred by the patient in their personal environment, e.g. B. caused by loss of earnings due to illness. On the other hand, there is the indirect benefit associated with improving the patient's health and the resulting improved performance (e.g. patient is able to work again). The human capital approach is often used to estimate costs and benefits , which is based on the patient's income to calculate the loss of productivity due to treatment or illness. People without earnings who have no indirect benefit from increasing their productivity are disadvantaged here.

Intangible costs

Costs and benefits that cannot be directly measured in monetary terms are referred to as intangible. A distinction is made between physical, psychological and social factors. These include, for example, fear, pain, stress, joy, happiness, changes in compliance or quality of life. There are several approaches to measuring intangible effects. The QALY approach (Quality Adjusted Lifeyears) is very common here. The allocation of costs arises from the willingness to spend money in order to achieve positive results like happiness or to avoid negative results like pain or fear.

Methods of health economic evaluation

A methodologically well-founded evaluation is based on models and data. These data are either systematically recorded or collected in samples or estimated from other data. The data is structured by a process model and made available for analysis. The granularity of the modeling is determined appropriately for the objective of the evaluation.

Cost analysis

Cost analyzes are an elementary part of value projects, which always focus on optimizing the value of the product focus under consideration (e.g. product, assembly, corporate division, business process). The value-determining components of benefit and effort are mapped and analyzed in accordance with the project objective, the project environment and the available resources.

Cost minimization analyzes

The cost-minimization analysis is the simplest variant of an economic study. If clinical data prove at least the equivalence of two therapy alternatives, often only the cost side is considered because of the lower effort. The aim is to find the cheaper alternative. The cost minimization analysis, which is sometimes also referred to as a cost-cost analysis, is a special case of the cost-effectiveness analysis discussed below.

Cost-benefit analyzes

In the cost-benefit analysis (also KNA), all future discounted income and costs of a project based on the present are calculated and, provided there are alternatives, compared with their value. It is an analytical process in which the urgently needed costs are weighed against the expected income. Both the costs and the benefits are measured in monetary units so that the profitability of a treatment can be determined directly. If the (monetized) benefits exceed the costs, the treatment makes sense.
Problem: When several projects are taking place at the same time, it is difficult to properly attribute the costs and benefits to the projects.

Cost-effectiveness analyzes

Efficiency frontier of the IQWiG institute

The cost-effectiveness analysis (abbreviated KEA) compares the costs of medicinal therapies with their effects. In contrast to the cost-benefit analysis, the therapeutic result is not presented in monetary terms, but as a clinical or physical parameter. These can be surrogate parameters (laboratory value, blood pressure) or patient-relevant measures of effectiveness (outcome) such as days of sickness avoided or years of life gained. The prerequisite is that the interventions examined have identical clinical endpoints and that the consolidation to a single target parameter still does justice to the often complex effects and side effects of drug therapy. In addition, there is the assumption or possibly the problem that the endpoints, such as the years of life gained, are qualitatively equivalent.

The result of a cost-effectiveness analysis could be presented in absolute terms as the amount of money spent on a clinical or physical unit. Since treatment alternatives are usually examined, however, the incremental display makes more sense and is therefore standard: The additional costs of a new therapy compared to the established one are set in relation to the additionally gained effectiveness. In the English-language literature, the abbreviation ICER for "incremental cost-effectiveness ratio" has become established.

One of the most common outcome parameters of a KEA is the cost per life-year gained (CLYG).

Cost-benefit analysis

The cost-utility analysis is an economic study in which the costs are expressed in monetary terms, but the consequences as benefits or utility values. The utility value is a quantity that reflects the preferences of the target group concerned and their state of health. One of the most common applications is the assessment of the quality of life of patients in health economic analyzes. Values ​​between 0 (death) and 1 (perfect health) are defined. Multiplying this so-called utility value by life expectancy results in the quality-adjusted years of life. The measurement of quality of life from the patient's perspective has developed into a research area of ​​its own. It is very complex. There is also still no consensus on an ideal procedure. Nevertheless, the consideration of the patient's perspective leads to the fact that not only the pure extension of life is seen as the primary therapeutic goal and, under certain circumstances, ties up all available means, but also subjectively relevant improvements in quality of life - such as the improvement of eyesight - are given an appropriate priority. As a measure of effectiveness, the unit of quality-adjusted life year QALY for “quality-adjusted life year” has established itself, which is compared with the costs incurred. With such an indication-independent standardization of the treatment result, comparisons between different measures in the health care system are possible.

Profitability analyzes for pharmaceuticals in Germany

Since 2007 IQWiG has been a legally anchored institute, which deals with the examination of the benefit in relation to the costs of newly approved drugs. Australia played a pioneering role and established such an institution back in 1987. In addition to Canada and Switzerland, many European countries followed in 1994.

Until now, as soon as the approval for new drugs was granted after checking the quality, efficacy and safety, the pharmaceutical industry could set the prices freely and the health insurance companies had to reimburse the costs for a medical prescription.

Criticism and limits

The analysis and control of health economics is viewed critically by many health care professionals. Politicians often decide against the rationalization and rationing recommendations of health economists, as these cannot be implemented for political reasons (e.g. hospital closings). Since health economics is very heavy on medicine and pharmaceuticals, the social environment of each individual patient is largely disregarded. A very strong concentration on price and market mechanisms, as well as their self-interest, make many experts doubt the methods of health economists. The independence of health economic analyzes is often questioned because most studies are carried out and financed on behalf of interest groups (such as the pharmaceutical industry, medical professionals or health insurance companies). Better explanations and viable solutions that can be implemented through easily understandable health economics are required. Methods such as “ standard gamble ” and “ time trade-off ” are only suitable to a limited extent, as they are very time-consuming, expensive and therefore difficult to incorporate into everyday life.

Health economics is strongly influenced by methodological limits. This includes the quality of life, as well as the monetization of benefits. Another limit not to be ignored is the appreciation of life. Ethical conflict situations occur frequently and are also the subject of medical ethics .

Education

Several German universities now offer interdisciplinary courses in health economics. It is usually embedded in the areas of business administration and economics, social sciences and, increasingly, business informatics.

The aim is on the one hand to convey an understanding of health economic interrelationships in an overall concept, on the other hand to weigh the efficiency of health care products against their costs. In addition to the major in health economics, modules for management in the health sector, quality assurance, decision theory and health economic evaluation, but also cost and performance accounting, organization and human resources or marketing are taught. Medicine and working with patients, on the other hand, do not play an essential role.

ethics

In addition to the business and financial goals, there are also ethical questions about justice and equality in modern healthcare. Health economists face the difficult task of uniting economic and ethical balance in their analyzes.

See also

Individual evidence

  1. ↑ SGB ​​V Statutory Health Insurance, Section 12 (1)
  2. ↑ Hanoverian consensus
  3. ↑ iqwig website
  4. ^ P. Doubt, F. Breyer, M. Kifmann. Health economics. Berlin, Heidelberg, New York. 6th edition. 2013. p. 24.
  5. ↑ Biesecker / Kesting, Mikroökonomie , Oldenbourg, 2003.

literature

  • Kornelia van der Beek, Gregor van der Beek: 'Health Economics - Introduction.' Oldenbourg Verlag, Munich 2011, ISBN 978-3-486-58686-2 .
  • Friedrich Breyer, Peter Zweifel, Mathias Kifmann: Health Economics. 5th, revised. Edition, Springer, Berlin / Heidelberg 2005.
  • Michael F. Drummond et al: Methods for the Economic Evaluation of Health Care Programs . 3rd, revised. Edition. Oxford University Press, Oxford 2005, ISBN 3-540-22816-0 .
  • Leonhard Hajen , Holger Paetow, Harald Schuhmacher: Health Economics. Structures - methods - practical examples. 4th, revised. u. exp. Edition. Kohlhammer, Stuttgart 2007, ISBN 978-3-17-019938-5 .
  • Karl W. Lauterbach , Matthias Schrappe (Eds.): Health economics, quality management and evidence-based medicine. a systematic introduction. 2., revised. Edition. Schattauer, Stuttgart / New York 2003,
  • Karl W. Lauterbach, Stephanie Stock, Helmut Brunner (eds.): Health economics. Textbook for medical professionals and other health professionals. Hans Huber, 2006, ISBN 3-456-84333-X .
  • Peter Oberender, Thomas Ecker: Basic elements of health economics. PCO-Verlag, Bayreuth 2001, ISBN 3-931319-78-4 .
  • David Matusiewicz, Jürgen Wasem: Health Economics in Germany - A Look Back Forward. In: Mühlbauer among others: Future prospects of the health economy. LIT-Verlag, 2012, pp. 420-439.
  • G. Noelle, E. Jaskulla, PT Sawicki: Aspects of the health economic assessment in the health system. In: Federal Health Gazette - Health Research - Health Protection. 49, 2006, pp. 28-33.
  • Thomas Rice: Keyword: health economics. A critical discussion . KomPart-Verlag, Bonn 2004.
  • Reinhard Rychlik: Health Economics. Health and practice. Ferdinand Enke Verlag, Stuttgart 1999.
  • Herbert Rebscher: Health Economics and Health Policy. Economica Verlag, Heidelberg 2006.
  • Dennis Häckl: New Technologies in Healthcare. Gabler Verlag | Springer Fachmedien Wiesbaden, Leipzig 2010, ISBN 978-3-8349-2410-0 .
  • O. Schöffski, JM Graf vd Schulenburg Health economic evaluations. 3. Edition. Springer, 2007.

Web links