Department of Health Services Management, Munich School of Management, Ludwig Maximilians University Munich, Schackstrasse 4, 80539, Munich, Germany.
BMC e.V., Friedrichstrasse 36, 10117, Berlin, Germany.
Eur J Health Econ. 2016 May;17(4):443-51. doi: 10.1007/s10198-015-0691-z. Epub 2015 Apr 30.
In recent years, the co-existence in Germany of two parallel comprehensive insurance systems-statutory health insurance (SHI) and private health insurance (PHI)-has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.
The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.
Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.
From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.
近年来，德国同时存在两种并行的综合保险体系——法定健康保险（SHI）和私人健康保险（PHI），这被认为是造成医生在地域分布上持续不平等的一个可能原因。本研究在控制 SHI 患者平均收入地区差异的情况下，调查了私人保险患者比例对 SHI 认证医生密度的影响。
使用 SHI 系统和德国人口普查的完整行政数据估计一个地区居民的私人医疗保险比例。使用多项插补技术估计缺失值。所有模型均控制了从治疗 SHI 参保患者中获得的门诊医生估计平均收入以及 2010 年德国地区层面确定的一系列协变量。
我们的结果表明，居民中私人医疗保险比例每变化一个百分点，专科医生和全科医生的密度就分别增加 2.1%和 1.3%。农村地区较高的 SHI 收入并不能弥补这种影响。
从财务角度来看，医生在私人保险比例较高的地区开设新诊所是合理的。从 SHI 系统患者的角度来看，PHI 的激励效应可能导致医疗服务在富裕和城市地区集中。到目前为止，基于需求的规划机制还无法解决这种不平衡。
