Risk structure compensation

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The risk adjustment (RSA) is a financial compensation mechanism in social insurance system with freedom of choice among health insurers. In order to reduce the problem of risk selection , either health insurers with a "good" risk structure pay their insured persons compensation payments to insurers with a "bad" risk structure or those with the "good" risk structure receive lower allocations from a central point than those with a "bad" Risk structure. Risk structure compensation has been introduced in German statutory health insurance (GKV) since 1994.

Insurance theory and health system related background

In several countries with statutory health insurance systems, insured persons have been given freedom of choice between health insurance funds since the beginning of the 1990s, or options that have hitherto only been limited have been expanded. This freedom of choice on the part of the insured is typically accompanied by a state-prescribed obligation to contract on the part of the health insurance company. In addition to Germany, examples include the Netherlands , Belgium , Switzerland , Israel , the Czech Republic and Slovakia . In these countries there is competition between the health insurers for the insured. At the same time, the legislature in these countries has heavily regulated the options for health insurances to structure contributions: They either have to levy income-related contributions (as was the case until the end of 2008 and again from 2015 in Germany) or a health premium (as in Switzerland), or there are mixed systems of income-dependent contributions Contributions and health premiums application (such as in the Netherlands or Belgium and between 2009 and 2014 also in Germany, where the health premiums component is called “additional contribution independent of income”). In this situation, the financial situation of the health insurance funds would depend heavily on their insurance structure. This means that the health insurances would have a keen interest in having certain insured persons in their portfolios, but not others - in other words, they would try to carry out risk selection, or at least take advantage of the insured’s tendencies towards self-selection.

In order to neutralize these incentives, risk structure compensations have been introduced in all countries with freedom of choice between statutory health insurance and limitation of the premium calculation by the legislator; In some cases, private health insurance markets have also introduced such mechanisms, for example in various segments of the employer-managed health insurance market in the USA or in the managed care component of the US retiree health insurance Medicare ; Also within the framework of the Affordable Care Act , the core of the healthcare reform by US President Barack Obama , a risk structure compensation is being carried out to offset the burdens of competing health insurers. The international literature on health economics and actuarial theory also recommends this instrument if solidarity goals are to be achieved in competitive health insurance systems .

The exact design of the risk structure compensation depends on the respective financing system of the health insurance. In the international discussion, a distinction is made in particular between so-called “internal” and “external” compensation systems, depending on how the contribution payment is organized in the statutory health insurance. If the insured pay their contributions to the health insurances (as in Switzerland), an "internal" risk structure compensation takes place between these insurances: insurers with "good risks" pay to insurers with "bad risks". If, on the other hand, the contributors pay the contributions to a (in relation to the insurances "external") "health fund" (such as in the Netherlands or Belgium), this pays risk-adjusted flat rates to the health insurances for their insured persons. With the introduction of a health fund from 2009 as part of the 2007 health reform (Act to Strengthen Competition in Statutory Health Insurance - GKV-WSG), risk structure compensation in Germany has been transformed from an “internal” model to an “external” model.

In insurance theory and health economics, an alternative to a model of competitive health insurance with non-risk-related contributions and risk structure compensation is discussed that health insurers could levy risk-related contributions. Insured persons who cannot pay the resulting health insurance contributions due to their income or their state of health would receive a subsidy from tax revenues. In Germany, for example, the Association of Research-Based Pharmaceutical Manufacturers has proposed the transition to such a model . None of the political parties in Germany has so far adopted this model; rather, it is an expression of the “solidarity principle” that the contribution payments made by the individual insured are not linked to their health risk.

Risk structure compensation in the German statutory health insurance

The risk structure compensation (RSA) of the statutory health insurance is a financial compensation introduced in 1994 between all statutory health insurance companies with the exception of the agricultural health insurance companies . It had a forerunner in the financial compensation introduced in 1977 by the Health Insurance Cost Reduction Act to compensate for the different burdens of the health insurance companies in the health insurance of pensioners. Its introduction was agreed in 1992 in Lahnstein as part of a major health reform between the CDU and the SPD and was an accompanying measure for the free choice of health insurance providers that came into force in 1996 and the resulting increased competition between health insurance companies for good risks. The legal basis for the RSA form the substantially §§ 265-273 SGB V . The specific conditions of its implementation are regulated by the "Ordinance on the Procedure for Risk Structure Compensation in Statutory Health Insurance (Risk Structure Compensation Ordinance - RSAV)" of January 3, 1994 ( Federal Law Gazette I p. 55 ). A major reform of the RSA was made in 2002. With the introduction of the health fund at the beginning of 2009, the RSA was fundamentally redesigned. Another major reform was passed by the Bundestag in February 2020.

Compensation system from 1994 to 2001

The RSA is intended to compensate for the disadvantages that result from the different structure of insured persons in the individual health insurance companies and types of insurance company. When the RSA was introduced, it was assumed that the differences in the structure of the insured would take on two dimensions:

1) On the income side: Since the members paid their income-related contributions to the health insurance companies, differences in the average income per insured person resulted in corresponding advantages or disadvantages: Health insurance companies with below-average incomes of their members had to calculate higher contribution rates for the same expenses than health insurance companies with above-average incomes of their members . Correspondingly, the so-called “financial power equalization” in the RSA provided that health insurance companies with above-average incomes of their insured persons made payments to funds with below-average incomes per insured person, with which the effects of these income differences were compensated by around 92%.
2) On the expenditure side: In view of the state of knowledge at the time, it was assumed in particular that the advantages and disadvantages of health insurances resulted from the age and gender distribution of the insured, since younger insured persons cause significantly lower health expenditure on average than older ones. Correspondingly, as part of the so-called “contribution requirement compensation” of the RSA, payments were made from health insurance companies with above-average young insured persons to funds with above-average old insured persons. In addition, it was taken into account whether the insured persons were receiving disability pensions, as these persons caused particularly high health expenditure, i.e. an above-average proportion of these persons in the insured clientele of a health insurance company was disadvantageous.

RSA reform from 2001, RSA from 2002 to 2008

In 2000 and 2001, following a resolution by the German Bundestag in connection with the 2000 health reform, IGES / Cassel / J. Wasem prepared an expert report for the Federal Ministry of Health with an inventory and suggestions for the further development of the RSA. At the same time, K. Lauterbach / E. Wille prepared an expert opinion for the central associations of the health insurance companies. From the proposals in both reports, the expert groups developed a joint consensus paper, from which the ministry developed a draft law for an RSA reform; the law came into force on January 1, 2002.

The main contents of the law were:

1) The factors that can be compensated in the RSA have been expanded to include “enrollment in an accredited structured treatment program”. For this purpose, the coordinating committee in health insurance (a body made up of representatives from doctors, hospitals and health insurance companies - it was installed with the health reform in 2000 and abolished again with the health reform of 2003, in favor of the joint federal committee that has existed since then) was commissioned to identify suitable diseases to determine who are suitable for such a structured treatment program ( disease management program ). Such programs have been introduced for type 1 and 2 diabetes mellitus, breast cancer, coronary heart disease, asthma and chronic obstructive pulmonary disease (COPD). Enrollment in the programs is voluntary for the insured; The health insurance companies conclude contracts with the associations of statutory health insurance physicians or other organizations of service providers for the provision of services in the disease management programs.
2) For very spending-intensive insured persons (with annual costs above - at that time - 40,000  DM , a risk pool was installed which financed 60% of the expenses exceeding 40,000 DM (threshold value) jointly by all health insurance companies Value at € 20,450, 2004 and 2005 at € 20,750.74, 2006 and 2007 at € 21,051.48 and most recently in 2008 at € 21,352.21.
3) It was decided that from 2007 the burden of disease (morbidity) should also be taken into account as a compensation factor in the risk structure compensation. A statutory ordinance of the federal government was supposed to issue further details, but this was no longer passed in time, so that until the end of 2008 the morbidity was not taken into account in the RSA as a compensation factor.

Compensation system from 2009

With the law to strengthen competition in statutory health insurance (GKV-WSG) from 2007, the legislature fundamentally redesigned the financing system of statutory health insurance by introducing the health fund . The health fund immediately requires a redesign of the RSA, since the contributors now pay the contributions to the health fund through the health insurance companies. The need for a revenue-side compensation (the previous financial power compensation) is no longer necessary, since the health insurance companies with above-average incomes of their insured can no longer derive any direct benefit from it. Since the beginning of 2009, the risk structure compensation has only related to the expenditure side by differentiating the allocations that the health insurances receive from the health fund according to the risk structure of the insured. Accordingly, the headline of the central legal reference, § 266 SGB ​​V, reads : "Allocations from the health fund (risk structure compensation)".

At the same time, the legislature decided to make the transition to morbidity orientation in risk structure compensation with the introduction of the health fund. For this, a differentiation of the assignments after enrollment / non-enrollment in disease management programs has been abolished. However, the health insurance companies receive a standardized reimbursement of the program costs incurred for registered insured persons; this flat-rate reimbursement of program costs amounts to € 15 per month per insured person in 2009. The allocations to the health insurance companies from the health fund for benefits in kind are therefore now based on the age, gender, reduced earning capacity and morbidity of the insured. There is a separate model for sick pay that does not include morbidity; Since 2015, half of the allocations have been determined according to the actual sick pay expenditure of a health insurance company (cf. § 269 SGB V).

When orienting on morbidity, the Federal Social Security Office , which is responsible for implementation , basically followed the report “Classification models for insured persons in risk structure compensation” submitted by IGES / Karl Lauterbach / Jürgen Wasem in summer 2004 . As suggested in the report, the morbidity is determined on the basis of diagnoses (discharge, secondary and secondary diagnoses from the hospital, diagnoses during treatment by resident doctors) as well as prescribed drugs. In accordance with a political compromise in the grand coalition, the morbidity orientation does not apply to all diseases, but to 80 chronic, expenditure-intensive diseases. The health insurance companies are obliged to regularly record the prescribed drugs and diagnoses in relation to the insured person, to pseudonymize them and to deliver them to the Federal Insurance Office by August 15 of the following year.

To support the Federal Insurance Office in developing the morbidity-oriented classification system, the law provides for a scientific advisory board to further develop the risk structure compensation. This advisory board was appointed at the beginning of 2007; he had elected the Bremen pharmacoepidemiologist Gerd Glaeske as chairman. In December 2007, the advisory board submitted its report on this matter. There was an intensive discussion in the specialist public about this report, since some major widespread diseases were not intended to be taken into account in the morbidity-oriented risk structure compensation ( Morbi-RSA ). After the Federal Insurance Office partially deviated from the proposals of the Scientific Advisory Board, the Advisory Board announced its resignation in March 2008. A new advisory board was appointed in March 2009; The Essen health economist Jürgen Wasem has been elected chairman.

The risk pool was abolished again with the entry into force of the morbidity-oriented RSA; it was last carried out for 2008.

Morbi-RSA effectiveness

In order to receive a money allocation from the Morbi-RSA, a number of criteria must be met:

  1. The patient must be diagnosed by a doctor with one of 80 diseases specified by the BVA and coded in the corresponding reports.
  2. The patient must either meet the so-called M2Q criterion (at least 2 quarters) (this means that the coding listed under 1. must be done twice in different quarters for outpatient treatment) or one of the diagnoses mentioned under 1. must be used as the main or secondary diagnosis a hospital stay.
  3. The patient must be treated with a drug or active ingredient specified by the BVA (only applies to some, not all diagnoses).
  4. The patient must have received at least 183 daily doses of the medication specified under 3. (certain chronic diseases) or at least 10 daily doses (certain acute diseases).

If these criteria are met, a flow of funds from the health fund is triggered under the Morbi-RSA. Critics of this risk structure compensation model fear that this model will lead to numerous manipulations. Some health insurance companies are currently developing software modules for practice software systems that are intended to promote so-called "upcoding" / "right coding". So could z. B. the diagnosis “heartburn” (not Morbi-RSA effective) can be replaced by the more severe diagnosis “inflammation of the esophagus” (Morbi-RSA effective). In the same way, the prescription of Morbi-RSA effective drugs could be promoted, which as a rule belong to the very strong and thus side effects and risky drugs. In addition, for the evaluation of the above-mentioned criteria for each individual patient, a high level of technical and personal effort has to be made, which, according to critics, leads to an increase in administrative costs.

The Scientific Advisory Board set up by the Federal Ministry of Health for the further development of the risk structure compensation presented an opinion on the effectiveness of the Morbi-RSA in September 2011. The result is that the Morbi-RSA has a significantly better targeting accuracy than the previous RSA. Corrections to further improve target accuracy are suggested at individual points.

Discussion of the distribution effect

In the new RSA from 2009 it is no longer possible to differentiate between “payers” and “recipients” of funds from the risk structure compensation, since all health insurance companies receive allocations from the health fund. Such a distinction was possible in the compensation system up to the end of 2008, in which compensation took place between the health insurance companies. The largest recipients of the RSA were then the general local health insurance funds. In 2005 they received around € 12.7 billion in payments from the risk structure adjustment; the miners received 1.6 billion euros. The largest contributors were the company coffers with approx. 8.9 billion euros and the salaried employee and worker replacement funds with approx. 4.1 billion euros. The paying health insurance companies often complained about overcompensation. In fact, individual AOKs and the miners who received RSA money had a lower contribution rate than paying health insurers. In its ruling on the RSA in 2005 , the Federal Constitutional Court classified this as not unconstitutional.

The criticism is countered that it is not the task of the RSA to guarantee identical contribution rates for all funds. If the RSA has the task of creating a level playing field for everyone within a competitive framework of the statutory health insurance companies, then the remaining difference in contribution rates after the RSA has been carried out should provide an image of the health insurance fund's performance, taking into account the differences in the structure of the insured.

See also

Individual evidence

  1. WPMM van de Ven et al: Risk Adjustment and Risk Selection on the Sickness Fund Insurance Market in Five European Countries. In: Health Policy. 65, 2003, pp. 75-98.
  2. a b W. PMM van de Ven et al .: Ellis R. Risk Adjustment in competitive health plan markets. In: AJ Culyer, JP Newhouse (Ed.): Handbook of Health Economics. Elsevier North Holland, Amsterdam 2000, pp. 755-845.
  3. Law of March 26, 2007; Federal Law Gazette I p. 378.
  4. ^ J. Wasem: The further development of the risk structure compensation from 2009. In: Health and Society Science. 7, 2007, pp. 15-22. For the introduction of the health fund cf. D. Göpffarth, St. Greß, K. Jacobs, J. Wasem (Eds.): Yearbook Risk Structure Adjustment 2007 - Health Fund . Asgard, St. Augustin 2007.
  5. ^ P. Doubt, M. Breuer: The case for risk-based premiums in public health insurance. In: Health Economics, Policy and Law. 1, 2006, pp. 171-88.
  6. Association of Researcher Drug Manufacturers V .: Making the healthcare system fit for the future. Concept for the reform of the health system in Germany. Berlin 2003.
  7. bill of the CDU and SPD Bundestag printed paper 12/3608
  8. a b K. Jacobs, P. Reschke, D. Cassel, J. Wasem: On the effect of the risk structure compensation in the statutory health insurance. An investigation on behalf of the Federal Ministry of Health. Nomos, Baden-Baden 2002, ISBN 3-7890-7761-5 .
  9. Karl W [ilhelm] Lauterbach, Eberhard Wille: Model of fair competition through the risk structure compensation. (PDF) Expert opinion on behalf of VdAK, AEV, AOK-BV and IKK-BV. January 28, 2001, archived from the original on January 13, 2006 ; Retrieved November 29, 2014 .
  10. ^ Law on the reform of the risk structure equalization of 10 December 2001; Federal Law Gazette I p. 3465.
  11. ^ Federal Ministry of Health - home page
  12. ^ Opinion on disease selection 2007.
  13. For the current members of the advisory board, see: Scientific advisory board for the further development of risk structure compensation.
  14. ^ Hendrik Schneider: Expert opinion on the Morbi-RSA. mm.wiwi.uni-due.de, September 26, 2011, accessed on October 14, 2011 .


  • F. Breyer, P. Zweifel, M. Kifmann: Health economics. Springer, Berlin 2007.
  • D. Göpffarth, St. Greß, K. Jacobs, J. Wasem (eds.): Yearbook Risk Structure Adjustment 2006 - 10 Years of Fund Choice . Asgard, St. Augustin, 2006.
  • D. Göpffarth, St. Greß, K. Jacobs, J. Wasem (Eds.): Yearbook Risk Structure Adjustment 2007 - Health Fund . Asgard, St. Augustin, 2007.
  • D. Göpffarth, St. Greß, K. Jacobs, J. Wasem (eds.): Yearbook Risk Structure Adjustment 2008 - Morbi-RSA. Asgard, St. Augustin, 2008.

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