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Gottlieb N, Ohm V, Knörnschild M. The Electronic Health Insurance Card for Asylum-Seekers in Berlin: Effects on the Local Health System. Int J Health Policy Manag 2022; 11:1325-1333. [PMID: 33949813 PMCID: PMC9808340 DOI: 10.34172/ijhpm.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/28/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In debates on asylum-seekers' access to healthcare it is frequently claimed that restrictions are necessary to prevent unduly high health service utilization and costs. Within Germany, healthcare provision for asylum-seekers varies across the different states. Berlin's authorities removed some barriers to healthcare for asylum-seekers by introducing an electronic health insurance card (HIC) in 2016. We used the HIC introduction in Berlin as an opportunity to investigate the effects of improved healthcare access for asylum-seekers on the local health system. METHODS The study applied a mixed-methods design. A cost analysis compared expenses for outpatient and inpatient health services for asylum-seekers before and after the HIC introduction, based on aggregate claims data and information on expenses for humanitarian healthcare provision that were retrieved from the Berlin authorities. Semi-structured interviews with 12 key informants explored organizational effects like administrative workloads and ethical dilemmas for staff. We performed a content analysis and used respondent validation to enhance the accuracy and trustworthiness of our results. RESULTS The HIC has reduced bureaucratic complexity and administrative workloads; it has enabled unprecedented financial transparency and control; and it has mitigated ethical tensions. All the while, average per person expenses for outpatient health services have declined since the HIC introduction. However, our cost analysis also indicates a rise in the utilization and costs of inpatient care. CONCLUSION The HIC introduction in Berlin suggests that the removal of barriers to healthcare for asylum-seekers can create win-win-situations by reducing administrative workloads, advancing financial transparency, and mitigating ethical tensions, whilst cutting the costs of outpatient healthcare provision. Removing barriers to healthcare thus appears to be a more prudent policy choice than maintaining mechanisms of restriction and control. However, high inpatient care utilization and costs warrant further research.
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Affiliation(s)
- Nora Gottlieb
- Department of Health Care Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Vanessa Ohm
- Berlin School of Public Health, Berlin, Germany
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Ziegler S, Wahedi K, Stiller M, Jahn R, Straßner C, Schwill S, Bozorgmehr K. Health and medical care for refugees: design and evaluation of a multidisciplinary clinical elective for medical students. GMS JOURNAL FOR MEDICAL EDUCATION 2021; 38:Doc39. [PMID: 33763524 PMCID: PMC7958918 DOI: 10.3205/zma001435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 09/30/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
Objective: Caring for refugee patients places special demands on health professionals. To date, medical students in Germany have rarely been systematically prepared for these challenges. This article reports on the development, conceptualisation, implementation, evaluation, and relevance of a multidisciplinary elective for medical students in the clinical study phase. Methodology: The course content was developed based on a needs-assessment among medical students and in cooperation with medical colleagues working in the field of refugee care. The course consisted of a seminar with medical, legal, administrative and socio-cultural learning content as well as a field placement in the medical outpatient clinic of the local reception centre for asylum seekers, which was accompanied by a systematic reflection process. The evaluation concept contained qualitative and quantitative elements. Results: 123 students completed the elective over six semesters (summer 2016 through to winter 2018). It was continuously evaluated and further developed. The students reported learning progress mainly in the following areas: Legal foundations of the asylum procedure and health care entitlements for asylum seekers; multi-perspectivity through multidisciplinarity as well as professional, ethical, interpersonal, and political insights gained through the practical experience. Summary: To prepare students for the complex challenges to be faced in medical care for refugees, a structured, multidisciplinary teaching programme, which combines theory, practice and reflection helps to foster insights into the many facets of this field of activity. The questions students brought to the seminar, the course contents and evaluation results are intended to inspire the design and implementation of similar courses at other universities.
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Affiliation(s)
- Sandra Ziegler
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Katharina Wahedi
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Mariella Stiller
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Rosa Jahn
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Cornelia Straßner
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Simon Schwill
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
| | - Kayvan Bozorgmehr
- Heidelberg University Hospital, Section Health Equity Studies & Migration, Department of General Medicine and Health Services Research, Heidelberg, Germany
- Bielefeld University, School of Public Health, Department of Population Medicine and Health Services Research, Bielefeld, Germany
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Wenner J, Bozorgmehr K, Duwendag S, Rolke K, Razum O. Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment. BMC Public Health 2020; 20:846. [PMID: 32493256 PMCID: PMC7269000 DOI: 10.1186/s12889-020-08981-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/24/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models. METHODS In Germany's largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex. RESULTS SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC. CONCLUSION The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.
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Affiliation(s)
- Judith Wenner
- Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, P.O. Box 10 01 31, 33501 Bielefeld, Germany
| | - Kayvan Bozorgmehr
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, P.O. Box 10 01 31, 33501 Bielefeld, Germany
| | - Stella Duwendag
- Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, P.O. Box 10 01 31, 33501 Bielefeld, Germany
| | - Kristin Rolke
- Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, P.O. Box 10 01 31, 33501 Bielefeld, Germany
| | - Oliver Razum
- Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, P.O. Box 10 01 31, 33501 Bielefeld, Germany
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Wenner J, Rolke K, Breckenkamp J, Sauzet O, Bozorgmehr K, Razum O. Inequalities in realised access to healthcare among recently arrived refugees depending on local access model: study protocol for a quasi-experimental study. BMJ Open 2019; 9:e027357. [PMID: 31152034 PMCID: PMC6550014 DOI: 10.1136/bmjopen-2018-027357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION In many countries, including Germany, newly arriving refugees face specific entitlement restrictions and access barriers to healthcare. While entitlement restrictions apply to all refugees who seek protection in Germany during the first months, the barriers to access depend on the model that the states and the municipalities implement locally. Currently, two different models exist: the healthcare voucher model (HcV) and the electronic health card model (eHC). The aim of the study is to analyse the consequences of these two different access models on newly arrived refugees' realised access to healthcare. METHODS AND ANALYSIS The random assignment of refugees to municipalities allows for a quasi-experimental design by comparing realised access to healthcare among refugees in six municipalities in North Rhine-Westphalia which have implemented HcV or eHC. We compare realised access to healthcare using ambulatory care sensitive conditions and health expenditure as outcome indicators, and use of emergency care, preventive care, psychotherapeutic or psychiatric care, and of therapeutic devices as process indicators. Results will be adjusted for aggregated information on age, sex, socioeconomic structure of the municipalities and density of general practitioners or specialists. ETHICS AND DISSEMINATION We cooperated with local welfare offices and the statutory health insurance for data collection. Thereby, we were able to avoid recruiting large numbers of refugee patients immediately after arrival while their access and entitlement to healthcare are restricted. We developed an extensive data protection concept and ensured that all data collected are fully anonymised. Results will be published in peer-reviewed journals and summarised in reports to the funding agency.
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Affiliation(s)
- Judith Wenner
- Department of Epidemiology and International Public Health, Bielefeld School of Public Health, Bielefeld, Germany
| | - Kristin Rolke
- Department of Epidemiology and International Public Health, Bielefeld School of Public Health, Bielefeld, Germany
| | - Jürgen Breckenkamp
- Department of Epidemiology and International Public Health, Bielefeld School of Public Health, Bielefeld, Germany
| | - Odile Sauzet
- Department of Epidemiology and International Public Health, Bielefeld School of Public Health, Bielefeld, Germany
| | - Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
- Department of Population Medicine and Health Services Research, Bielefeld School of Public Health, Bielefeld, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, Bielefeld School of Public Health, Bielefeld, Germany
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Affiliation(s)
- Jodi D Stookey
- Children's Hospital Oakland Research Institute, Oakland, CA, USA.
- , San Francisco, USA.
| | - Jürgen König
- Department of Nutritional Sciences, University of Vienna, Vienna, Austria
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Lichtl C, Lutz T, Szecsenyi J, Bozorgmehr K. Differences in the prevalence of hospitalizations and utilization of emergency outpatient services for ambulatory care sensitive conditions between asylum-seeking children and children of the general population: a cross-sectional medical records study (2015). BMC Health Serv Res 2017; 17:731. [PMID: 29141614 PMCID: PMC5688672 DOI: 10.1186/s12913-017-2672-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/03/2017] [Indexed: 11/10/2022] Open
Abstract
Background Hospitalizations for ambulatory care sensitive (ACS) conditions are established indicators for the availability and quality of ambulatory care. We aimed to assess the differences between asylum-seeking children and children of the general population in a German city with respect to (i) the prevalence of ACS hospitalizations, and (ii) the utilization of emergency outpatient services for ACS conditions. Methods Using anonymous account data, all children admitted to the University Hospital Heidelberg in 2015 were included in our study. A unique cost unit distinguished asylum seekers residing in a nearby reception center (exposed) from the children of the general population. We adapted international lists of ACS conditions and calculated the prevalence of ACS hospitalizations and the utilization of emergency outpatient services for ACS conditions, attributable fractions among the exposed (Afe) and the population attributable fraction among total admissions (PAF) for each outcome. Differences in the prevalence of each outcome between exposed and controls were analyzed in logistic regression models adjusted for sex, age group and quarterly admission. Results Of the 32,015 admissions in 2015, 19.9% (6287) were from inpatient and 80.1% (25,638) from outpatient care. In inpatient care, 9.8% (622) of all admissions were hospitalizations for ACS conditions. The Afe of ACS hospitalizations was 46.57%, the PAF was 1.12%. Emergency service use for ACS conditions could be identified in 8.3% (3088) of all admissions (Afe: 79.57%, PAF: 5.08%). The odds ratio (OR) of asylum-seeking children being hospitalized for ACS conditions in comparison to the control group was 1.81 [95% confidence interval, CI: 1.02; 3.2]. The OR of the asylumseeking population compared to the general population for the utilization of emergency service use for ACS conditions was 4.93 [95% CI: 4.11; 5.91]. Conclusions Asylum-seeking children had significantly higher odds of ACS hospitalization and of utilization of emergency outpatient services for ACS conditions. Using the concept of ACS conditions allowed measuring the strength of primary care provided to this local asylum-seeking population. This approach could help to compare the strength of primary care provision in different locations, and allow an objective.
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Affiliation(s)
- Célina Lichtl
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Thomas Lutz
- Center for Child and Adolescent Medicine, Department of General Pediatrics, Metabolism, Gastroenterology, Nephrology, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Kayvan Bozorgmehr
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
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