Health-economic evaluation of the outpatient, inpatient, and public health sector in Germany: Insights from the first three COVID-19 waves

Aim: The aim of this study is to quantify the effectiveness and cost-effectiveness of the outpatient and inpatient sectors (specifically intensive care units, ICUs) and local health departments in managing the first three waves of the COVID-19 pandemic in Germany. Methods: The analysis is based on a modelling approach using secondary data. The effectiveness of each sector was measured by determining the reduction in the case fatality rate (CFR) of COVID-19 patients by May 7, 2021. A counterfactual scenario assuming the absence of each sector was used to quantify their effectiveness. Direct medical costs for each sector were calculated from a statutory health insurance perspective, utilizing reimbursement rates for both the inpatient and outpatient sectors. Incremental cost-effectiveness ratios (ICERs) were determined, representing the costs per death avoided. Results: The ICUs achieved the greatest reduction in the CFR of COVID-19 patients during the first three waves (1.9%). The outpatient sector followed with a reduction of 1.4%, and the local health departments contributed to a 0.3% decrease in the CFR. In terms of spending, ICUs had the highest expenditures among the sectors, resulting in an ICER of €59,055 per death avoided. On the other hand, local health departments were costlier but less effective than the outpatient sector. Results remained consistent across various input assumptions. Conclusion: During the first three waves of the COVID-19 pandemic in Germany, the inpatient sector (ICUs) made the largest contribution to preventing deaths while also incurring the highest costs.