Citizens’ insurance, i.e. health and nursing care insurance that everyone pays into, has been a topic here in the blog again and again, most recently in connection with a discussion at the WIdO symposium on May 4, 2023, and then with the book “The Economic Reason of Solidarity ” by Hartmut Reiners and finally with the reference to Hubert Aiwanger’s lack of memory when it comes to his party’s basic program.
The issue can be approached in terms of identity politics, as a call for a commitment in one direction or the other, usually following the old pattern of “freedom or socialism”, or you can look at individual economic arguments and discuss their viability.
I want to do the latter here again with a view to a press release from the Bavarian Business Association (vbw) from August 1, 2023. There it says:
“Especially in rural areas, the additional revenue that practicing doctors earn from privately insured people helps to improve the quality of care. If these were to disappear with the introduction of citizens’ insurance, there would be a significant deterioration in care.”
The reason given is:
“This additional turnover, which is typical for private health insurance, arises because private patients pay higher fees for many services than those charged by those with statutory health insurance. Doctors, therapists and hospitals can invest the additional financial resources in specialist staff or modern practice infrastructure. All patients benefit from this.”
It is, of course, true that those with private insurance generally leave more money with a private doctor than those with statutory health insurance. A completely different question, however, is whether there would be less money available to doctors overall with citizens’ insurance. If the contributions of privately insured people were to flow into citizens’ insurance, the contribution revenue would not be smaller, it would just be distributed differently. And if they also paid income-related contributions, the contribution revenue would be even larger.
Just in passing, because hospitals are also addressed in the passage: For hospitals, DRG financing is the same for privately and legally insured people, so nothing would change with citizens’ insurance. Those with statutory health insurance can also buy single rooms and treatment by a senior doctor through private supplementary insurance, although the latter is not always recommended.
The passage in the vbw press release also suggests that the PKV also secures the supply infrastructure for those with statutory health insurance in rural areas. However, given that almost 90% of the population are legally insured, this is a somewhat idiosyncratic view; conversely, it tends to be a shoe-in. The large number of people with statutory health insurance and the mandate of the statutory health insurance associations ensure that those with private insurance in rural areas also have a doctor close to their home. Quite apart from the fact that the health insurance company is not responsible for hospital investments anyway; that is the responsibility of the states. However, countries are increasingly less likely to meet this obligation, so hospitals’ investments are cross-financed from treatment proceeds. This is one point of contention among many in the current hospital reform.
The statements in the vbw press release are based on the PKV Regional Atlas of Bavaria, as this passage in the press release indicates:
“In the rural district of Wunsiedel, the doctors in private practice receive additional income from privately insured people with an average real value of 81,755 euros per year, while in the practices in the greater Nuremberg area it is “only” 52,841 euros.”
Such “real value” indicators are presented in the PKV Regional Atlas of Bavaria. They should show how much additional sales are generated in the practices taking cost structures into account. The data from the PKV regional atlas is indeed impressive. According to this, doctors in rural areas would benefit significantly more from private health insurance revenue than doctors in cities:
It is unclear where the values for Wunsiedel and the “Greater Nuremberg Area” come from in the vbw press release. The PKV regional atlas shows 67,656 euros for the Wunsiedel district, not 81,755 euros, and the data for the Nuremberg region cannot be found in the PKV atlas either. The PKV regional atlas is from 2019. If the vbw received more recent data from the PKV, the large differences from the 2019 data would be an indication of the instability of the data.
Whatever the data describes, it seems strange when, for example, the independent city of Landshut has the lowest “real value” at 22,275 euros, while the Landshut district has the highest at 182,904 euros, i.e. 8 times that of the city. How can that be? Such significant small-scale differences also exist in other regions. There are no different cost structures in the city and district of Landshut; the nominal values also shown in the PKV regional atlas differ by the same magnitude (Landshut district 170,026 euros versus the city of Landshut 19,603 euros). Large cost structure differences between directly neighboring regions would not be plausible anyway.
In the PKV regional atlas, the data is used to justify theses that are highly relevant to health policy (p. 47):
“The prejudice that individual privately insured people in rural areas use the medical infrastructure financed by the statutory health insurance across the board as “free riders” must be viewed as unsubstantiated in view of the amount of the real value of the age-adjusted additional sales in rural areas.
In addition, the PKV Regional Atlas of Bavaria refutes another popular and political misconception. The fact that the proportion of privately insured people is particularly relevant for the location decision of medical service providers and that there is therefore an unequal distribution of doctors between cities and rural areas. In this context, the regional results for Bavaria point in a completely different direction.”
The data for the city and district of Landshut is an exemplary test of this. If the additional turnover from private health insurance patients in the district alone is to be of such magnitude, how high must the total turnover be? Do only radiologists work in the Landshut district, or do doctors at their income level? And is there really still a need for financial support for settlements in rural areas?
As I said, the data is impressive. But health policy needs reliable and convincing data. Is it you?