A few weeks ago, the “PKV Regional Atlas of Bavaria” was the topic of discussion here. Figures were presented there to show that private health insurance ensures high incomes, especially for doctors in rural areas. However, the calculation is strange, the data is not plausible and may be based on an incorrect regional relationship between contribution revenue and the number of doctors.
Today in the Süddeutsche Zeitung Nina von Hardenberg took up the PKV regional atlas under the heading “Country is worthwhile for doctors”. The basis is obviously, as in the summer press release from the Bavarian Business Association, which was the reason for my first blog post, an update of the PKV regional atlas 2019.
Ms. von Hardenberg writes that the atlas “is available exclusively to the SZ.” However, the Munich Merkur is also reporting today, perhaps it also has an “exclusive” copy of the PKV brochure. There are also such atlases with corresponding press support for other federal states.
Ms. von Hardenberg further writes:
“The study breaks down sales from private patients by city, district and region for the first time. It turns out that the country doctors have no reason to complain.”
The fact that the study presented to her “for the first time” breaks down sales by cities and districts is not entirely true; there was already the Regional Atlas of Bavaria 2019. And the country doctors have no reason to complain, they can say themselves.
She continues to follow the PKV Association’s argument and questions the common findings about the effects of many PKV insured people and medical branches:
“In the discussion about the shortage of doctors, it is often claimed that the higher proportion of private patients and the associated better earning potential attracted doctors to the cities.”
It would have been good if Ms. von Hardenberg had taken note of the discussion and responded to it. The report of the Scientific Commission for a Modern Remuneration System, for example, confirms the well-known urban-rural distribution of PKV revenues:
And as far as the connection between privately insured people and branches is concerned, one can see from a somewhat older but fundamentally still valid study by Sundmacher & Ozegowski that this connection is not only claimed, but can be proven (p. 35):
“Overall, our analysis supports the thesis that the proportion of those insured by private health insurance in the total population determines to a relevant extent the location choice of doctors willing to establish themselves. A high density of PKV insured people is associated in particular with a higher density of specialists. In this analysis, the correlation between the proportion of privately insured people and the density of doctors can be viewed independently of third factors such as the presence of university hospitals, the attractiveness of an area and the estimated medical need.”
What’s more: The regional distribution of the proportion of PKV insured people reveals a particularly pronounced regional density of PKV insured people in the affluent belt in southern Bavaria. This should definitely be taken into account when analyzing urban-rural differences.
In the PKV regional atlas, urban-rural differences are analyzed in an original way. The SZ follows the PKV association uncritically here too:
“Above all, in Bavaria there are no more private patients living in the city than in the countryside. The aim of the study is to clear up this oft-cited misunderstanding. In the discussion about the shortage of doctors, it is often claimed that the higher proportion of private patients and the associated better earning potential attracted doctors to the cities.
But has she researched whether this is really a misunderstanding? One does not know. The 2019 regional atlas, which is accessible online, has already put forward the same argument. If you look at Table 3 with a list of the private health insurance market share for the Bavarian districts and cities, you may rub your eyes in a bit of surprise. There, the districts are assigned settlement structural region types from the Federal Institute for Building, Urban and Spatial Planning (BBSR). 1 for urban regions, 2 for regions with urbanization approaches, 3 for rural regions.
However, this is the classification of the 18 spatial planning regions in Bavaria, in which the BBSR applies certain criteria that characterize a larger region. If you simply transfer this to all districts and cities in the respective regions, as the PKV regional atlas did, the district of Erding, for example, gets a 1 in the greater Munich area, while the city of Bamberg, with its almost 80,000 inhabitants, gets a 3. i.e. “rural area” because there is no major city in the spatial planning region. Regensburg, with its 150,000 inhabitants, inherits the 2 of the surrounding planning region. Augsburg with around 300,000 inhabitants only gets a 2.
According to this scheme, of the 25 independent cities in Bavaria, 16 (!) are assigned to regional type 3, rural area, and only 5 are assigned to regional type 1, urban region. There are only two spatial planning regions of regional type 1 in Bavaria – the greater Munich area and the greater Nuremberg area. One could have used BBSR data to make finer settlement structural classifications; Erding, for example, would then have been classified as a rural region.
Perhaps this is already taken into account in the current version of the regional atlas, if not, the differentiation according to regional types at the district level is meaningless, as are the associated statements about urban-rural differences.
However, the market share of private health insurance is often slightly higher around the cities than in the cities themselves: many higher earners live in single-family homes in the countryside. But that doesn’t characterize rural regions as a whole.
At the end of the article the cat is let out of the bag:
“For the PKV, the study is also an argument against the repeated calls for the merger of statutory and private health insurance.”
So that’s what it’s about. But how viable is the argument? Assuming that the data in the PKV regional atlas correctly reflects the income situation in Bavaria: does this mean that all other, stronger arguments for eliminating this parallel structure in full insurance, which is almost unique in the world, are no longer applicable? And shouldn’t the study then result in a demand to abolish all financial support programs for branches in rural areas? After all, says Ms. von Hardenberg, “country doctors have no reason to complain”? However, neither the PKV Association nor Ms. von Hardenberg are making this demand – rightly so.
Instead, Ms. von Hardenberg quotes at the end from the coalition agreement between the CSU and the FW:
“We support statutory and private health insurance. We reject uniform insurance.”
It would have been good journalism to at least point out that there is something completely different in the FW’s basic program and to ask the FW how this contradiction is assessed.
Instead, Nina von Hardenberg accepts the PKV Association’s argument completely uncritically. It does not compare the data from the PKV Association with other findings, it does not question the data or the associated political strategy. This was not a masterpiece of medical journalism.