Annika Herr

Aim: This study aims to examine differences in disease burden between informal caregivers and non-caregivers using claims data, with a particular focus on mental disorders and on characteristics related to high morbidity. Subject and methods: The study applied a retrospective observational design using claims data from two major German statutory health insurance funds. We identified 139,002 informal caregivers based on caregiving-related insurance records and compared them to 272,716 insured individuals without official caregiving responsibilities. The analysis assessed morbidity based on documented diagnoses coded according to the International Classification of Diseases. Disease categories included mental and behavioral disorders, musculoskeletal disorders, cardiovascular diseases, and other major diagnostic groups. We calculated odds ratios with 95% confidence intervals using logistic regression models and additionally examined the influence of sociodemographic and care-specific variables on relevant conditions. Results: Informal caregivers showed significantly higher odds of overall morbidity than non-caregivers. The analyses revealed the largest differences for mental and behavioral disorders, including depressive episodes and stress and adjustment disorders. Stress-related and mood disorders were more common among female caregivers and among caregivers whose care recipients had higher care levels. Conclusion: Informal caregivers experience a higher disease burden than non-caregivers, particularly regarding mental health conditions. These findings highlight the need for targeted prevention and support strategies to reduce health risks among caregivers and to address their role as a vulnerable population in public health planning.

Amidst demographic shifts, advanced economies are facing critical nursing shortages. This study analyzes how long-term care in German nursing homes relate to these shortages using administrative data for the period 2007 to 2017. Our analysis reveals that higher nursing shortages correlate with decreased nurse-to-resident ratios, changes in the qualification mix of nurse personnel, and reduced occupancy rates. These findings suggest that nurse shortages might be a threat to the quality of care and the financial sustainability of nursing homes at the margin of being profitable.

Objective: Depression is a major challenge for many people and societies, also accelerated by the COVID-19 pandemic. Around 300 million people worldwide are affected by a depressive disorder. Health insurances encourage patients to use applications (“apps”) to tackle, for example, mild and moderate depression. The advantages of these depression apps are well understood, but their dissemination and adoption rates among intended users leave room for improvement. To enhance their uptake, we provide a holistic view regarding critical design aspects of depression apps and develop design principles (DPs) for depression apps. Methods: We use a qualitative approach with 58 semistructured interviews between March 2021 and August 2022 with different stakeholders (healthcare providers, patients with mild and moderate depression, app developers and operators, and health insurance companies) to derive our DPs to provide a holistic view of the crucial design factors of depression apps. We then evaluated our DPs derived from four individuals from the health sector in terms of appropriateness and completeness. Results: Following this approach, we examine seven meta-requirements (MRs) like “quality” and “simplicity” to deduce 16 corresponding DPs for depression apps. Our prescriptive design knowledge enables us to carve out interrelations and contributes to the literature on depression app design knowledge. Generally, our MRs and DPs derived were evaluated positively. Conclusions: Our research ignites a structured discussion among stakeholders in the healthcare sector, for example, scientists and practitioners, about the importance of specific design aspects of depression apps and the overall development process from planning to dissemination.

Approximately 32 percent of individuals aged over 64 years old, with care needs, are residing in nursing homes in Germany. However, this percentage exhibits significant regional disparities, ranging from under 15 percent in certain counties to over 50 percent in others. The purpose of this study is to elucidate the underlying factors explaining this regional variation in nursing home utilization. We employed comprehensive administrative data encompassing the entire elderly care-dependent population and all nursing homes. Our analytical approach involves the use of linear regression models at the county level, accounting for an extensive array of control variables and fixed effects. Additionally, we analyzed regional dependencies by applying spatial lag models. In summary, our model successfully predicts up to 73 percent of the observed regional variation in nursing home utilization. Key factors include care needs, the presence of informal care support and the supply of professional care. Spatial dependencies can be detected but exhibit a minor influence on these variations controlling for care needs. Noteworthy, enabling factors, such as a region’s wealth or rurality, have a very limited impact in a country with a generous social insurance system that covers care for those with limited financial resources.

Many healthcare systems prohibit primary care physicians from dispensing the drugs they prescribe due to concerns that this encourages excessive, ineffective or unnecessarily costly prescribing. Using data from the English National Health Service for 2011–2018, we estimate the impact of physician dispensing rights on prescribing behavior at the extensive margin (comparing practices that dispense and those that do not) and the intensive margin (comparing practices with different proportions of patients to whom they dispense). We control for practices selecting into dispensing based on observable (OLS, entropy balancing) and unobservable practice characteristics (2SLS). We find that physician dispensing increases drug costs per patient by 3.1%, due to more, and more expensive, drugs being prescribed. Reimbursement is partly based on a fixed fee per package dispensed and we find that dispensing practices prescribe smaller packages. As the proportion of the practice population for whom they can dispense increases, dispensing practices behave more like non‐dispensing practices.

This paper evaluates the causal effects of changes in reference prices (RP) on prices, copayments, and overall expenditures for off-patent pharmaceuticals. With reference pricing, firms set prices freely and the health plan covers the expenses only up to a certain threshold. We use quarterly data of the German market for anti-epileptics at the package level and at the active substance level and exploit that the RP has been adjusted in some of the active substances but not in others in a difference-in-differences framework. At the product level, we find that a lower RP reduces prices for both brand-name drugs and generics, but leads to higher copayments, especially for brand-name drugs. At the aggregate level, we find that a lower RP leads to savings for the public health insurer since revenues decrease substantially for brand-name firms and, to a lesser extent, also for generic firms. Overall expenditures (payments by the health insurer and the patients) for brand-name drugs decrease in proportion to the decrease in the RP, while the adjustment does not significantly influence overall expenditures for generics.

Many countries limit public and private reimbursement for nursing care costs for social or financial reasons. Still, quality varies across nursing homes. We explore the causal link between case‐mix adjusted nurse staffing ratios as an indicator of care quality and different price components in Swiss nursing homes. The Swiss reimbursement system limits and subsidizes the care price at the cantonal level, which implicitly limits staffing ratios, while the residents cover the nursing home‐specific lodging price privately. To estimate causal effects, we exploit (i) the exogeneity of the Swiss care price regulation, (ii) nursing‐home fixed effects estimations and (iii) instrumental variables for the lodging price. Our estimates show a positive impact of prices on certified staffing ratios. We find that a 10% increase in care prices increases certified staffing ratios by 3–4%. A comparable 10% increase in lodging prices raises certified staffing ratios by 1.5–10% (depending on the model). Our findings highlight that price limits for nursing care impose a limit on staffing ratios. Furthermore, our results indicate that providers circumvent price limits by increasing lodging prices that are privately covered. Thus, this cost shifting implicitly shifts the financial burden to the residents.