Why do German physicians reject managed care?

Insurance barriers and inequalities in health care access: evidence from dual practice

BACKGROUND

We investigate access disparities in pharmaceutical care among German patients with type 2 diabetes, focusing on differences between public and private health insurance schemes. The primary objectives include investigating whether patients with private health insurance experience enhanced access to antidiabetic care and analyzing whether the treatment received by public and private patients is influenced by the practice composition, particularly the proportion of private patients.

METHODS

We estimate fixed effect regression models, to isolate the effect of insurance schemes on treatment choices. We utilize data from a prescriber panel comprising 681 physicians collectively serving 68,362 patients undergoing antidiabetic treatments.

RESULTS

The analysis reveals a significant effect of the patient's insurance status on antidiabetic care access. Patients covered by private insurance show a 10-percentage-point higher likelihood of receiving less complex treatments compared to those with public insurance. Furthermore, the composition of physicians' practices plays a crucial role in determining the likelihood of patients receiving less complex treatments. Notably, the most pronounced disparities in access are observed in practices mirroring the regional average composition.

CONCLUSIONS

Our findings underscore strategic physician navigation across diverse health insurance schemes in ambulatory care settings, impacting patient access to innovative treatments.

Policy as a strategy to innovate in health care? A content analysis of innovation policies in Germany, 1994-2017

Determining what innovation means for healthcare is becoming increasingly complex. Health policy addresses this challenge by designing initiatives to improve healthcare quality and efficiency, one example being the German Innovation Fund of 2015. We investigate the innovation concept underlying 25 years of German health policy to analyse which and why some innovations are sustainable in a healthcare system. Expanding a previous approach to identify changes in the semantic understanding of 'innovation', we identify the semantic understandings of innovation, variation in health innovation policy contingencies. We use Henry Mintzberg's approach to classify patterns in health innovation policy to uncover predominant planning, adaptive, and entrepreneurial strategy modes. Systematic analysis resulted in 44 decision-relevant policy documents. Content was classified based on a qualitative content structuring method according to seven main categories and 57 subcategories. Results reveal that the innovation concept is undergoing a transformation from a science-based concept, dominated by planning and adaptive modes, towards an exploration of process innovations, dominated by adaptive and entrepreneurial strategy modes. This change in strategy is an essential contingency of high-volume instruments, such as the Innovation Fund, and their capability to support the emergence of process innovations that lead to structural changes in the healthcare system.

The relations between business model efficiency and novelty, and outcome while accounting for managed competition contract: a quantitative study among Dutch physiotherapy primary healthcare organisations

Background

Since 2006, business principles have been introduced to foster efficient healthcare by way of managed competition. Managed competition is expressed by a contract between a health insurer and a physiotherapy primary healthcare organisation (PTPHO). In such a managed environment, PTPHOs have to attain treatment service quality and financial PTPHO-centred outcomes Research shows that business model designs may enhance organisation-centred outcomes. A business model is a design (efficiency or novelty) of how a firm transacts with customers, partners, and vendors; how it connects with markets. However, research on managed competition contract and business model designs, in relation to PTPHO-centred outcomes is new to the healthcare literature. PTPHOs may not know how business model designs enhance outcomes. This study aims to delineate the relations between business model efficiency and novelty, and PTPHO-centred outcomes, while accounting for managed competition contract in Dutch healthcare.

Methods

A quantitative cross-sectional design was adopted. Using a questionnaire, the relations between managed competition, business model efficiency and novelty, and PTPHO-centred outcomes were investigated among PTPHO managers (n = 138). Theory-based expectations were set up and multiple linear regression analyses were applied.

Results

Managed competition and business model efficiency show no relation with PTPHO-centred outcomes. Moderation of the business model efficiency and PTPHO-centred outcomes relation by managed competition contract is not detected. Business model novelty shows a positive relation with PTPHO-centred outcomes. Moderation of the business model novelty and PTPHO-centred outcomes relation by managed competition contract is found.

Conclusions

There seem to be positive relations between business model novelty and PTPHO-centred outcomes on its own and moderated by managed competition contract. No relations seem to exist with business model efficiency. This implies that the combination of persistent use of health insurer-driven managed competition contracts and a naturally efficient PTPHOs may have left too few means for these organisations to contribute to healthcare reforms and attain PTPHO-centred outcomes. Organisation-driven innovation could stretch system-level regulations and provide room for new business models. Optimising contracts towards organisation-driven healthcare reform, including novelty requirements and corresponding reimbursements is suggested. PTPHO managers may want to shift their attitudes towards novel business models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08383-7.