Martin Karlsson, CINCH, University of Duisburg-Essen
Tobias J. Klein, Tilburg University
Nicolas Ziebarth, Cornell University
IFS, London
March 28, 2015
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• Statutory health insurance (SHI):
•
•
• mandatory for employees with gross wage earnings below a defined threshold (54,900 EUR in 2015); premium is about 14-16% of the gross wage up to the contribution ceiling (49,500 EUR in 2015) about 130 “sickness funds”, offer more or less the same basic package, easy to switch between them, competition based on premia and extra coverage generous minimum package, minimal cost sharing
• Private health insurance (PHI)
•
•
•
•
• high-income employees (good risks?) can opt out (hard to opt back in); 10% of the German population (9 million) do so
43 private insurance companies premia are risk-related (as of the time they sign up) implicit savings contract, as premia are higher than expected expenditures at young ages range of different health plans, some of which with substantial cost sharing
2 / 28

• Mostly private settings: providers not employed by government
• Reimbursement rates are set by the government (PHI) and a council consisting of representatives of physicians, sickness funds, and the government at the regional level (SHI)
• Outpatient care: PHI reimbursement more generous than SHI reimbursement, leads to more favorable treatment, lower waiting times, over-treatment
• Inpatient care: reimbursement does not depend on insurance status
• Evidence in favor of negative effects of PHI on doctor visits and no effect on inpatient care
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2000
1500
1000
500
0
4000
3500
3000
2500
13
12
11
10
9
8
7
6
5
4
3
German Federal Health Monitoring, 2015 Spending per person Percent of GDP
Note: this is the available data from the Gesundheitsberichterstattung des Bundes (GBE).
Differences to the data Eric used in his small paper.
(i)
(ii)
This contains all expenditures whereas the US data only contain “personal health care expenditures” which excludes government administration, public health activities and investments. Personal health care expenditures in this form are not available for
Germany.
The spending per person shows nominal values in our graph whereas French uses 2005 dollars. The latter is also not available from the GBE. We could just express everything in
2005 euros, using the average inflation rate (I guess that is what French did or used). The question is how useful this would be. It basically then shows health care inflation about the average inflation.
An alternative would be to use OECD Health Data which would also be available for most of the other countries. This would mostly make sense if every team used these data – then they could be directly compared. Maybe you should discuss this at the workshop.
OCED Health Data for Germany includes annual data since 1960 BUT not for total expenditures, only for “individual + collective health care, HC.1-HC.9. This comes closer to “personal health expenditures (HC.1-HC.5) but is not exactly the same and includes more categories. Details can be found here: http://stats.oecd.org/fileview2.aspx?IDFile=bd8e3b78-1c2c-4559-af30-d552e81b71b1 , page 2.
The advantage of the OECD Health Data is that it is available not only in 2005 prices but also in
USD Power Purchasing Parities.

4500!
4000!
3500!
3000!
2500!
2000!
1500!
1000!
500!
0!
!
!
Here!is!the!according!graph!(that!Tobi!suggested):!three!different!definitions!of!per!capita!health!
care!expenditures!since!1970!with!consistent!OCED!health!data.!If!I!see!it!correctly,!all!other!
countries!could!use!the!same!OCED!Health!Data!base!and!produce!similar!graphs!that!we!could!
directly!compare.!It!would!be!great!if!we!could!agree!on!that!at!the!worship!in!March!in!London.!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
OCED!Health!Data!2015!
Spending!per!person,!2005!USD!PPP!
Spending!per!person,!Nadonal!Currency!
Spending!per!person,!2005!CPI!Nadonal!Currency!
!
Fig$2.: !Per!Capita!Health!Care!Spending!( Individual)and)Collective,)HC.13HC.9
)!for!Germany!Using!Three!
Different!Definitions!(1970;2012)!

Tab 2. Total Health Expenditures—By Payors and Expenditure Categories
Payors
1992
Federal, state, or local authorities 11,1
Statutory Health Insurance
Statutory Long-Term Insurance
Statutory Pension Insurance
Statutory Accident Insurance
62,2
2,2
1,8
Private Health Insurance
Employers
Out of pocket
Expenditures
Investments
Prevention
Physician Services
Basic services
7,4
4,4
10,9
4.2
3.8
28.3
10.7
3.9
4.0
27.5
10.1
1995
10,7
60,2
2,8
2,4
1,8
7,6
4,2
10,4
2000
6,4
58,2
7,8
1,7
1,7
8,3
4,1
11,8
3.9
3.5
26.8
9.2
3.8
3.7
26.7
8.4
Extra services
Laboratory services
Radiation services
Long-term care and other care
Therapeutic care
Maternicy-related care
12.6
2.7
2.3
15.8
4.5
0.2
12.4
2.7
2.3
18.2
4.8
0.3
12.6
2.5
2.5
19.2
5.0
0.3
Accomodation and Food
Goods
Prescription drugs
Medical devices
Dental care (material and lab) others
Transportation
8.6
28.4
16.0
5.3
3.4
3.6
1.3
8.5
26.1
14.1
5.2
2.9
3.8
1.5
7.7
26.6
14.8
5.5
2.5
3.8
1.6
Administration 4.9 5.3 5.3 5.4
Source: German Federal Health Monitoring 2015, www.gbe-bund.de
7.3
27.4
16.4
5.0
2.1
3.9
1.6
13.1
2.5
2.7
18.5
5.2
0.3
2005
5,6
56,5
7,4
1,5
1,7
9,2
4,3
13,8
Note: As you can see we do not have exactly the same categories as French. On the payor side, this is the case by construction. On the expenditure side, there are simply differences in how the data are collected and categorized.
3.5
3.8
27.4
8.2
2010
4,9
57,5
7,5
1,4
1,6
9,3
4,3
13,5
14.0
2.5
2.8
18.1
5.4
0.3
7.0
27.5
16.1
4.9
2.3
4.2
1.7
5.2
3.3
3.6
27.8
8.2
2012
4,8
57,4
7,7
1,4
1,6
9,3
4,3
13,5
14.3
2.5
2.8
18.5
5.7
0.3
7.1
26.8
15.2
5.0
2.2
4.3
1.8
5.1

Tab 3. Private Health Insurance---Total Spending by Categories
Total expenditures
Investments
Preventive Services
Physician Services
Long-term care
Accomodation and Food (inpatient)
Goods
Transportation
Administration
1992
1.827
1995
2.318
2000
2.888
Source: German Federal Health Monitoring 2015, www.gbe-bund.de
2005
3.554
2010 2012
11.679 14.275 17.604 22.023 26.773 27.963
220
59
128
78
117
100
233
132
150
162
77
176
4.982
1.188
6.199
1.593
7.426
2.292
9.375 11.656 12.287
2.849 3.537 3.776
1.075
2.254
73
1.205
2.653
102
1.216
3.434
131
1.112
4.587
181
1.264 1.299
5.999 6.288
244 288
3.761 3.772

• Medical claims data from a large private insurance company in
Germany
• Additional information on
•
• insured that are related to calculating the premia, such as BMI and age information on insurance contract (deductible, premium)
10 / 28

0-24
Mean S.D.
Mean
All
25-64 65+
S.D.
Mean S.D.
Q1 60 71
Q2 392 107
4
722
Q3 839 158 2,052
Q4 1,564 283 4,300
16
348
456
931
656
2,276
4,209
7,611
503
453
699
1,373
Q5 5,097 8,453 15,734 17,640 23,879 21,953
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Levels
Par SE Par
Log
SE
L1 0.566
0.001
0.584
0.001
L2 0.493
0.002
0.530
0.001
L3 0.477
0.002
0.498
0.002
L5 0.492
0.004
0.455
0.003
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Q1
Entire 2005 − 11 Period
Q2 Q3 Q4 Q5 Q1
Only t
0
− 2011
Q2 Q3 Q4 Q5
One-Year Transition Probabilities
Q1 65.20
12.10
8.62
6.63
4.38
64.06
13.88
8.06
6.46
4.35
Q2 17.42
42.15
22.75
11.83
5.45
19.38
41.57
23.19
10.89
5.13
Q3 9.74
26.37
31.68
22.42
10.93
9.66
26.35
32.33
22.48
10.44
Q4 6.38
12.73
24.60
34.11
23.44
5.72
12.40
24.09
35.21
23.79
Q5 3.80
5.99
11.45
24.79
55.28
3.45
5.48
10.85
24.68
56.31
Two-Year Transition Probabilities
Q1 59.31
12.62
9.37
7.43
5.70
60.55
12.06
8.72
6.73
5.10
Q2 20.18
38.68
21.72
12.26
6.25
23.49
38.30
21.37
11.77
6.24
Q3 12.35
26.73
29.08
21.62
11.82
12.02
27.19
29.37
21.22
12.11
Q4 8.51
14.42
24.69
31.80
23.14
8.05
13.87
24.96
32.62
22.91
Q5 5.32
7.25
13.44
26.11
51.11
4.77
7.31
13.10
26.58
51.26
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Q1
Entire 2005 − 11 Period
Q2 Q3 Q4 Q5 Q1
Only t
0
− 2011
Q2 Q3 Q4 Q5
Three-Year Transition Probabilities
Q1 55.32
13.24
10.10
8.06
6.18
56.29
11.28
9.81
8.07
5.86
Q2 21.15
35.88
21.77
12.58
6.55
24.60
35.71
21.54
12.12
6.22
Q3 14.44
26.52
27.74
21.14
11.91
14.40
27.60
27.60
21.06
11.77
Q4 9.91
15.82
24.71
30.26
22.98
8.56
16.01
25.29
30.30
23.15
Q5 6.39
7.86
14.54
27.09
49.27
5.73
7.52
14.04
27.71
49.82
Five-Year Transition Probabilities
Q1 49.31
14.47
11.44
8.73
6.45
49.53
14.45
11.21
8.43
6.50
Q2 23.28
31.56
21.61
12.84
6.65
23.91
31.65
21.56
12.56
6.45
Q3 16.26
26.32
26.45
20.18
11.97
16.59
26.54
26.05
20.47
11.94
Q4 11.69
16.88
25.08
28.92
22.83
11.03
17.05
25.16
29.06
22.99
Q5 7.62
9.80
16.65
29.12
46.35
7.42
9.89
16.72
29.14
46.33
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2005
2011
Sum 2010-11
Sum 2009-11
Sum 2007-11
Gini
Coefficient SE
Share going to top 1%
0.620
0.002
0.158
0.630
0.002
0.160
0.593
0.002
0.133
0.569
0.002
0.116
0.544
0.002
0.099
top 10%
0.529
0.529
0.475
0.444
0.409
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Mean
SD
N
All Males Females
Deceased Survivors Deceased Survivors Deceased Survivors
Current Year (2011)
29,472
44,734
279
4,844
9,716
60,292
32,444
49,700
195
4,176
8,543
35,528
Year before Death (2010)
22,572
29,329
84
5,803
11,116
24,764
Mean
SD
N
Mean
SD
N
27,984
41,641
266
4,681
8,442
57,222
29,786
43,632
186
4,067
8,236
33,775
Two Years before Death (2009)
23,795
36,509
80
5,564
8,653
23,447
14,555
23,412
245
4,347
7,507
54,420
13,818
25,778
167
3,717
6,929
32,118
16,132
17,337
78
5,253
8,185
22,302
27 / 28

All
Euro Per Cent
Year of Death
Year before Death
29,472
27,984
Two Years Before Death 14,555
Three Last Years
Lifetime Costs
72,011
563,282
Males
Euro
5.2
32,444
5.0
29,786
2.6
13,818
12.8
76,048
100.0
486,948
Per Cent
6.7
6.1
2.8
15.6
100.0
Females
Euro
22,572
23,795
16,132
62,499
639,616
Per Cent
3.5
3.7
2.5
9.8
100.0
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