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Kostenbeteiligung für Patienten - Reformansatz ohne Evidenz! Theoretische Betrachtungen und empirische Befunde aus Industrieländern

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  • Holst, Jens

Abstract

Die internationale Gesundheitssystemforschung zeigt in praktisch allen Industrieländern einen einheitlichen Trend auf: die zunehmende Verlagerung der Kosten von der solidarischen Finanzierung auf die privaten Haushalte. Gesetzgeber wie Berater begründen dies üblicherweise mit der Stärkung von Kostenbewusstsein und vor allem der Eigenverantwortung. Wirtschaftswissenschaftler betrachten Selbstbeteiligungen in der Gesundheitsversorgung als notwendig, um dem Missbrauch der Solidargemeinschaft entgegenzuwirken. Von Gebühren und Zuzahlungen erwarten sie eine vernünftigere Inanspruchnahme der Gesundheitsleistungen und eine finanzielle Stabilisierung der Systeme. Die Sicht vieler Politiker und Wirtschaftsexperten auf den Gesundheitsmarkt ist durch das Theorem des versichertenseitigen Moral Hazard geprägt. Dieses Modell macht Kran-kenversicherte zu rationalen Nutzenmaximierern, die zum eigenen Vorteil über den Bedarf hinaus Leistungen in Anspruch nähmen und dadurch gesamtgesellschaftliche Wohlfahrtsverluste verursachten. Moral Hazard in der Krankenversicherung gehört zum Standard-Repertoire ökonomischer Lehrbücher. Die vorliegende Arbeit wertet die umfangreiche Literatur über Ansätze und Versuche der Kostenbeteiligung von Patienten aus, die in den letzten vier Jahrzehnten erschienen ist. Dabei stellt sich heraus, dass belastbare Belege für das Moral-Hazard-Verhalten von Versicherten bzw. Patienten bisher fehlen und die üblicherweise angeführte Empirie für den Nachweis ungeeignet ist. Gesundheitswissenschaftliche, versorgungsbezogene und klinische Studien legen vielmehr nahe, dass die Versicherten das System nicht ausnutzen wollen oder können. Die Einführung von Kostenbeteiligungen für Patienten scheint eher die bedarfsgerechte Versorgung zu gefährden, weil sie Kranke von der Inanspruchnahme abhalten. Die Vorstellung von der rationalen Nutzung des Gesundheitswesens entpuppt sich als realitätsfremd. Nach gründlicher Auswertung des Forschungsstandes kommt der Autor zum Schluss, dass Moral Hazard in der Krankenversicherung ein Popanz der akademischen Wirtschaftstheorie geblieben ist. Für die Einführung von Kostenbeteiligungen für Patienten fehlt es an hinrei-chender realitätsbasierter Evidenz. In Anbetracht der schädlichen versorgungspolitischen Effekte erscheinen die Rücknahme aller Patientenzuzahlungen und der Verzicht auf Selbstbeteiligungen geboten. -- International health service research highlights a uniform tendency in practically all industrialised countries: the increasing shift of costs from solidarity-based financing to private households. Legislators and advisors usually justify this policy through the need to encourage cost-consciousness and mainly self-responsibility”. Economists consider cost-sharing in health care to be necessary for preventing abuse of the caring society. They expect user charges and co-payments to motivate a more rational” utilisation of health care and, thus, the financial stabilisation of health systems. Many politicians and economists base their assumptions on the health market” on the theorem of demand-side moral hazard. This model transforms enrollees into rational utility maximisers” who are consuming services beyond their needs thereby causing welfare losses to the society as a whole. Moral hazard in health insurance belongs to the standard repertoires of economic textbooks. The present study analyses the extensive literature on approaches and experiments to introduce patient cost-sharing published during the last 40 years. Results show that persuasive evidence for demand- side moral hazard is still lacking. Furthermore, the usually quoted empiricism turns out to be inappropriate for proving evidence. Health science, service research and clinical studies rather suggest that health insurance beneficiaries are not aiming at or willing to abuse the health system. In fact, introducing patient cost-sharing seems to endanger adequate health care since they deter the ill from claiming benefits. The idea of rational” use emerges as out of touch with reality. After a systematic in-depth review of current research on the topic, the author concludes that moral hazard in health insurance is a bogey of academic economic theory. Adequate reality-based evidence for implementing patient user fees and co-payments is lacking. In view of the detrimental effects on health service utilisation, it is advised to cancel existing co-payments and to abandon costsharing policies.

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Bibliographic Info

Paper provided by Social Science Research Center Berlin (WZB) in its series Discussion Papers, Research Group Public Health with number SP I 2008-305.

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Date of creation: 2008
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Handle: RePEc:zbw:wzbhea:spi2008305

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  1. Donald Willison & Mary Wiktorowicz & Paul Grootendorst & Bernie O'Brien & Mitchell Levine & Raisa Deber & Jeremiah Hurley, 2001. "International Experience With Pharmaceutical Policy: Common Challenges and Lessons for Canada," Centre for Health Economics and Policy Analysis Working Paper Series 2001-08, Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada.
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  5. Tin Su & Subhash Pokhrel & Adjima Gbangou & Steffen Flessa, 2006. "Determinants of household health expenditure on western institutional health care," The European Journal of Health Economics, Springer, vol. 7(3), pages 195-203, September.
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