How to spend the health care budget? Priority setting in the German health care system

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1 Jacobs University Bremen How to spend the health care budget? Priority setting in the German health care system Margrit Schreier Adele Diederich Jeannette Winkelhage Petra Lietz Priorisierung in der Medizin FOR 655 Nr. 28 / 2011 Campus Ring Bremen Germany FOR 655 Working Paper serves to disseminate the research results of work in progress prior to publication to encourage academic debate. Copyright remains with the authors.

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3 Die Reihe Priorisierung in der Medizin umfasst Arbeits- und Forschungsberichte der DFG Forschergruppe FOR655 Priorisierung in der Medizin: eine theoretische und empirische Analyse unter besonderer Berücksichtigung der Gesetzlichen Krankenversicherung (GKV. Die Berichte und weitere Informationen zu der Forschergruppe können abgerufen werden unter: oder The series Priorisierung in der Medizin consists of working papers and research reports of the DFG (Deutsche Forschungsgemeinschaft i.e. German Research Foundation Research Group FOR655 Priorisierung in der Medizin: eine theoretische und empirische Analyse unter besonderer Berücksichtigung der Gesetzlichen Krankenversicherung (GKV. (Prioritizing in Medicine: A Theoretical and Empirical Analysis in Consideration of the Public Health Insurance System Reports and further information can be found at or Impressum: Campus Ring Bremen Germany ISSN

4 Margrit Schreier et al. How to spend the health care budget? Priority setting in the German health care system Margrit Schreier, Adele Diederich, Jeannette Winkelhage, Petra Lietz Jacobs University Bremen Background: Health expenditure in Germany ranks among the highest in the world. Still, not all health and treatment measures that are desirable can be funded. Therefore, priority setting already occurs on an everyday basis, but an explicit discussion involving different interest groups, including the general public, has so far been lacking. Methods: Semi-standardised interviews were conducted with 45 purposefully selected members of six different stakeholder groups (healthy persons, patients, physicians, nursing personnel, politicians, and administrators) about priority decisions and criteria. Interviews were fully transcribed, and qualitative content analysis was carried out. Results: Results are presented concerning the spending of the health care budget. Participants across all stakeholder groups are highly divided concerning the introduction of a rule limiting the costs of cancer treatment. Members of professional stakeholder groups are more opposed than the general public to the reallocation of funds from patient treatment to the improvement of clinical practice and to the financing of nonevidence based measures by public insurance. Nursing personnel and persons aged 62 and above would be especially willing to pay more in order to maintain the standard of health care in Germany. Conclusions: Opinions are indeed widely divergent, underlining the importance of involving members from all groups in the process of implementing prioritization measures. Descriptive comparisons highlight potentially contentious areas, especially between the general public and professional stakeholder groups, and areas emerge where the stake of specific interest groups seems especially high. Key words: health care costs, health care rationing, decision making, stakeholders Margrit Schreier Jacobs University Bremen School of Humanities and Social Sciences Campus Ring Bremen Phone: ; fax: -3303; 2

5 Margrit Schreier et al. 1. Introduction Health expenditure in Germany ranks among the highest in the world. In 2006 the total spending accounted for 10.6% of the Gross Domestic Product (GDP) which was only topped by the United States (15.3%), Switzerland (11.3%) and France (11.1%) (OECD, 2008). Spending pressure stems from epidemiologic and demographic change as well as from new medical and technological developments in diagnosis and therapy. The financial situation of the German public health care system requires limiting health care benefits as providing patients with every medical intervention they might want is impossible. Determining priorities within patients groups, indication, or practice and implementing preferential treatments has long been an ongoing discussion in many countries (Ham, 1997; Ham & Robert, 2003; Sabik & Lie, 2008) and legitimacy, efficiency, justice or fairness are pressing issues in health ethics, health law, social medicine and health politics (Cappelen & Norheim, 2006; Fleck, 2002; Menon et al., 2007; Rawls, 1999). Although in Germany a public debate on priority setting in health care has been called for repeatedly (ZEKO, 2000; ZEKO, 2007), it is mainly the physicians perspectives and values as well as the interests of their sponsors that have been voiced; the perspectives of patients and the public are deemed irrelevant, even though research has repeatedly shown that the public explicitly wishes to be involved in these decisions (Westphal et al., 2001; Lees et al., 2002; Litva et al., 2005). Also, allocation of scarce resources in a publicly financed health care system should be explicit and transparent for general acceptance, legitimacy and fairness matters (Martin et al., 2002; Rosen, 2006). Rationing and prioritizing medical benefits is already a reality: Qualitative interviews in Germany reveal that due to financial constraints physicians feel able to provide only basic health care (Strech et al., 2008). When selecting treatment options, they do so according to financial criteria (Strech et al., 2008) and the criteria of evidence based medicine (Kern et al., 1999). A survey study in the UK, however, shows that only 4% of the general public considers evidence-based medicine a pertinent criterion in health care (Lees et al., 2002), revealing a possibly contentious area. In Germany, several attempts have been undertaken to reform the public health care system to close the gap between needs and resources, with moderate success. Unlike in other countries, where various stakeholder groups, including the public, have been included in ongoing discussions about prioritization within the health care system (such as England, Denmark, New Zealand, or Sweden), in Germany the public has rarely, if ever, been involved, the necessity for allocating resources not been broadly discussed. The current study is aimed at filling this void. In a first step, we aim to identify core opinions and criteria in priority setting concerning diseases, therapies, lifestyle, demographic factors, economic, and ethical issues by conducting semi-standardized interviews. In order to cover a broad range of opinions, different stakeholder groups are included (for details, see below). In a second step, opinions, issues, and criteria thus identified have been incorporated into a 3

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7 How to spend the health care budget? questionnaire that, in turn, will be administered to a representative sample of 2000 persons in order to obtain the view of the German public on these matters. Below, we report selected results from the stakeholder interviews, which focus on interview questions concerning specific regulations within the German health care system. This allows for assessing positions vis-à-vis core areas of the public health care system and to simultaneously, by comparing views across the different stakeholder groups, identify tentatively potentially contentious areas. 2. Methods To assess a wide range of positions concerning prioritizing in health care, semistandardised interviews were conducted with participants (N = 45) who were purposefully selected in two steps (OECD, 2008). In a first step, relevant stakeholder groups were identified: healthy persons (n = 9), patients (n = 12), physicians (n = 7), politicians (n = 5), nursing personnel (n = 6), and health insurance administrators (n = 6). In a second step, stratified purposive sampling was applied, with selection criteria and strata differing across stakeholder groups so as to, in each case, yield a heterogeneous sample. Gender and type of health insurance (public vs. private) were incorporated as implicit strata across all stakeholder groups: The average age of participants was 47 years, 26 participants were male, 19 were female; 31 were members of a public health fund, and 13 were privately insured (with one value missing). The interview guide consisted of six topic areas: (1) Status quo personal experience of priority setting now and in the past; (2) Future development general questions; (3) Future development prioritizing of patient groups; (4) Future development prioritizing of health care, goals in health care, and treatments; (5) Perspectives on priority setting; (6) Concluding questions. In this contribution, we will focus on data relating to section (5). Here, participants were presented with questions concerning general guidelines and decisions in spending the health care budget. Specifically, questions focused on: (1) acceptance of the guideline adopted in the UK according to which the costs of cancer therapy must not exceed Euro per life year gained by administering the therapy; (2) acceptance of using funds from the therapy-related health care budget towards the implementation of guidelines for clinical practice; (3) acceptance of public funding of therapeutic measures that do not fulfil the criteria of evidence-based medicine; (4) decision as to whether participants would prefer the monthly contribution to the public health insurance system to remain the same, with fewer treatments included in the system, or the monthly contribution to increase, with services provided by the system remaining unchanged. For each question, the reasons underlying participants decisions and positions were also obtained. Interviews were conducted from January through May 2008 in 20 German cities. The average duration of the interviews was 75 minutes. All interviews were tape recorded and fully transcribed. The interviews were analyzed using qualitative content analysis (Rosen & Karlberg, 2002).The interview questions served as a general framework, with subcategories and some additional categories generated inductively from the data. The final category frame comprised 89 categories and a total of 435 subcategories. Units of coding were idea units. Due to unequal marginal distributions, percentage of agreement was used instead of kappa to assess intercoder agreement between two independent coders. 3

8 Margrit Schreier et al. Following trial coding, intercoder agreement was 96.6% across all categories and 83.7% across all subcategories for the final version of the coding scheme. For the material we are focusing on here interviewees opinions about perspectives on priority setting - the coding schedule typically consisted of the following categories: opinion (in favour, opposed, undecided); degree of deliberation (change of opinion before reaching a final decision: yes / no); reasons in favour; reasons against; additional considerations or conditions. Only those reasons and additional considerations will be reported below that were mentioned by a minimum of approximately 10% of the participants (i.e. by a minimum of four persons). 3. Results Considering the small number of participants, only descriptive results - separately for each interview question - will be provided The costs of cancer treatment Opinions among participants are divided as to whether a guideline should be adopted that limits the financing of cancer therapy to a maximum of Euros per life year: while the majority of participants (48.9%) are opposed to adopting such a guideline, 35.6% would be in favour with 15.6% undecided. The decision, however, is clearly a difficult one to make for the participants: especially those who finally decide in favour of the regulation do so only after carefully considering the pros and cons, and almost without exception they change their opinion at least once in the course of this deliberation process (87.5%; compared to 18.2% opinion change among those opposing the regulation). Also, their considerations are dominated by reasons against adopting this regulation: leaving aside the Miscellaneous category, only two types of reasons are provided in favour of the guideline, whereas 12 different reasons are given against adopting the guideline. This high proportion of reasons against adopting the guideline indicates that the participants even if they finally decide in favour of implementing the rule clearly have strong reservations about doing so. Also, those who favour adopting the guideline do not do so unconditionally, but mention a number of criteria that have to be met before implementing such a regulation. The two reasons in favour of the regulation are: because the public health care system is under financial pressure (66.7%), and because such a limitation would provide a clear regulation, equally applicable to everyone (33.3%). Among the criteria stipulated by those who ultimately favour adopting the rule, two criteria are clearly considered to be most important: that exceptions are possible (40%), and that the funds that are saved by implementing such a regulation are invested elsewhere in the health care system (45%). The most important reasons why participants ultimately decide against adopting the rule are: that this kind of decision should not depend on financial considerations alone (70.7%); because, if the rule were adopted, those who are financially better off would simply cover the costs exceeding Euros themselves, thus resulting in an inequality of health care depending on income (34.1%); because the participants are convinced that other funds are available inside or outside the public health care system that can be used towards covering the treatment costs (26.8%); because each case is unique and should be judged on its own merit (24.4%); because the situation in Germany is considered to be different from the situation in England, not warranting 4

9 How to spend the health care budget? such drastic measures (17.1%); and because participants assume that the public would be strongly opposed to implementing such a limitation (12.2%). Among the stakeholder groups, it is surprisingly those who are themselves suffering from an illness who are most in favour of adopting such a guideline (58.3%). When comparing subgroups in the sample according to sociodemographic characteristics, women (57.9%), persons aged 31 to 62 (60%), persons who have completed tertiary education (53.3%), and participants who are members of the German public health insurance system (51.6%) are most strongly against limiting the cost of cancer therapy. Persons who have not completed vocational training are the ones who are most in favour of implementing such a limitation (85.7%). Patient treatment versus allocation of funds to the improvement of clinical practice Again, opinions are divided, with 42.2% of the participants arguing in favour of such a reallocation of funds, and 48.9% being opposed (and 8.9% undecided). This decision seems not as difficult as the previous one: 33.3% of the participants go through a deliberation process, changing their opinion at least once, but there is no clear association between the degree of deliberation and the outcome of the decision process. Again, more reasons are provided against the decision to reallocate some of the funds away from patient care and treatment, but with five different reasons against reallocation and two reasons in favour, the imbalance is not as pronounced as for the previous question concerning the costs of cancer treatment. Participants favour the reallocation of funds into the implementation of guidelines for clinical practice because they assume that this will advance the implementation of new therapies and other medical innovations in patient care (78.6%). A second reason is that the funds that are reallocated toward the implementation of guidelines for clinical practice are considered to be detracted from the patient care budget only in the short run. Ultimately, these participants argue, the money will also help to improve patient care and treatment (60.7%). 24.4% of those who are in favour of such a reallocation, however, also argue that they agree only under the condition that the funds to be reallocated remain within reasonable limits. The reasons against such a reallocation participants mention are mainly financial: 65.6% argue that sufficient funds are available for financing the implementation of guidelines for clinical practice elsewhere within or outside the health care budget. 40.6% believe that the implementation of guidelines is already taking place to a sufficient extent; and 28.1% argue that the funds available for patient care are insufficient to start with. Participants also doubt the usefulness of guidelines for clinical practice (18.8%) and wonder about the further increase of administrative measures this would involve (15.6%). When comparing participants across stakeholder groups, members of the general public tend to advocate a reallocation of funds (healthy persons: 66.7%; patients: 58.3% in favour), whereas the members of most professional stakeholder groups are more likely to be opposed to this measure (physicians: 85.7%; politicians: 80%; nursing personnel: 66.7%). Sociodemographic characteristics are for the most part not related to participants positions on this issue, except for education: participants who have not completed vocational training are almost unanimously in favour of reallocating funds (85.7%), whereas there is a slight tendency among participants who have completed tertiary education to be opposed to this measure (60%). 5

10 Margrit Schreier et al. Evidence-based medicine Faced with the question whether or not the public health care system should cover only evidence-based measures, a slight majority of participants are in favour of public health insurance covering measures that do not pass the test of evidence-based medicine (51.1%). 42.8% of the participants change their opinion at least once before coming to a decision about the issue, but there is no relationship between the direction of the decision and the degree of deliberation. Whereas only three reasons are provided for financing evidence-based measures exclusively, eight reasons are given why public financing should also include non evidence-based measures. The main reasons in favour of covering non evidence-based measures are: that such measures may also have a positive effect on the patient s state of health (88.5%); that the experience and knowledge of the medical practitioner can be considered sufficient evidence (61.5%); because studies that would constitute sufficient evidence have not yet been conducted for every imaginable measure or treatment option (61.5%). Additional reasons include the cost of providing appropriate evidence (23.1%), doubts concerning the soundness of such studies (23.1%), that non evidence-based treatment options may be less costly (19.2%), and several others that are mentioned only by one or two participants. The main reasons why participants argue that non evidence-based measures should not be included in public health care are, first, that evidence of the positive effect of these measures is, by definition, lacking (85.2%); that limiting public funds to evidencebased measures only would be reasonable considering the high costs of health care and the limited budget (40.7%), and that, again by definition, little is known about any potentially dangerous side effects of non evidence-based measures (14.8%). The comparison between stakeholder groups shows that the majority of patients are in favour of financing non evidence-based measures through public health insurance (75%); so are politicians (60%) and members of the public health insurance administration (66.7%). A slight majority of medical personnel (physicians: 57.1%; nursing personnel: 50%) are opposed to having public insurance cover non evidencebased measures. When taking into consideration sociodemographic criteria, the following subgroups tend to be in favour of including non evidence-based measures in the public health insurance: men (57.7%), those aged 30 and above (31-62 years: 56%; 63 and above: 62.5%), and those who have completed vocational training, but not tertiary education (85.7%). Willingness to pay more for health care Asked whether they would be willing to pay more in order to retain the present standard of health care in Germany, 46.7% of participants are willing to pay more, 22.2% would prefer to keep contributions stable at the cost of reducing the number of measures covered by the health care system, and 28.8% do not express a clear opinion. 33.3% reconsider their position at least once during the deliberation process. Among those who are willing to pay more, a surprising 61.9% would be willing to increase their contribution by 20-25%. Among the reasons why they would be willing to pay more, participants mention that they consider the present public health care system to be below standard (63.6%), that more money is needed in order to maintain adequate health care (27.3%), and to ensure adequate health care for everyone, regardless of age, income, etc. (22.7%). The most frequently mentioned reason why participants would not be willing to pay more is, not surprisingly, that they consider a higher contribution to be too expensive (57.1%). Other reasons include: that additional funds for financing public health care are available from other sources (34.3%), that a reduction of public 6

11 How to spend the health care budget? health care would still be sufficient (37.1%), that the present means are sufficient to ensure adequate health care (20%), and that the present health care service is already sufficient (11.4%). Comparing across stakeholder groups, members of the nursing staff are especially willing to pay more to ensure adequate health care (83.3%). When taking sociodemographic characteristics into consideration, those in the age group above 62 years are especially willing to pay more (87.5%). The remaining sociodemographic characteristics are not related to willingness to pay more. 4. Conclusions The results from qualitative interviews with a small, purposefully selected sample allow only for a limited comparison with prior, largely survey-based research. Nevertheless it is noticeable that the members of the general public who were interviewed in this study seem far more willing to consider ways of limiting health care costs than participants from earlier studies (Rosen, 2006; Rosen & Karlberg, 2002) be it by limiting the costs of cancer treatment, by reallocating funds to the improvement of clinical practice, or by carefully considering the advantages and disadvantages of financing only therapeutic measures that meet the criteria of evidence-based medicine (Lees et al., 2002). When it comes to limiting the costs of cancer treatment, members of the general public are even more willing to consider doing so than health care practitioners (Strech et al., 2008). Also, participants from this study express a greater willingness to increase their payment for public health insurance in order to maintain a high quality of health care than do participants from earlier studies (Fattore, 1999; King & Maynard, 1999; Patton, 2002). It remains to be seen whether these results also hold for the survey study planned with a representative sample of the German population. However, the analysis also shows that opinions regarding priority setting in the German health care system are highly divided which underlines the importance of having different stakeholders participate in the pertinent deliberation and decision processes, including the general public. A closer look reveals two different response patterns. Concerning questions 1 to 3 (cancer treatment, reallocation of funds, evidence-based medicine), the participants voice heterogeneous positions vis-à-vis the issues raised. With respect to question 4 (willingness to pay more), a substantial percentage of the participants are undecided. Whereas questions 1 to 3 are concerned with specific prioritization measures, question 4 relates to the German health care system as a whole. These response patterns, which are in line with prior results obtained in focus groups (Litva et al., 2002), suggest that participants find it more difficult to give an opinion about measures concerning the health care system as such, even where their own financial contribution is at issue, than about specific measures. This is not to say, however, that decisions about specific measures are taken lightly: the number of times participants change their opinions concerning the adoption of a guideline limiting the financing of cancer therapy to a maximum of Euro per life year and concerning the coverage of non evidence-based measures by public health insurance demonstrates that these are highly contested issues. The contested nature of these decisions is further emphasized by the many reasons given in support of the more cost-intensive measures, i.e. not adopting the Euro rule and continuing to finance non evidence-based measures. 7

12 Margrit Schreier et al. While this study provides only descriptive data based on a small number of purposefully selected participants, group comparisons nevertheless suggest potential areas of contention that should be explored further. The public (including both healthy persons and patients), for instance, favors the reallocation of funds to implementing guidelines for clinical practice, whereas most professional stakeholder groups (physicians, politicians, administrators) are opposed to such a reallocation. Concerning the funding of non evidence-based medicine, members of the medical profession (physicians and nursing personnel) are more often of the opinion that such measures should not be covered by public health insurance. Here, potential conflicts between the public at large and specific professional stakeholder groups become visible. The results further show that certain groups have more of a stake regarding specific prioritization decisions than others. Patients in particular are opposed to adopting the regulation that limits the costs of cancer treatments to Euro per life year, and patients are also among those who advocate that non evidence-based measures continue to be covered by public health insurance. Persons aged 63 and above would be willing to pay higher contributions in order to maintain the present standard of public health care in Germany. So, incidentally, would members of the nursing personnel, suggesting strong concerns about the potential deterioration of the health care system if this finding can indeed be confirmed in future studies. Another noticeable difference between groups is that those participants who did not complete vocational training seem to have the least reservations about hard prioritization decisions: they are willing to adopt the regulation limiting the costs of cancer treatment and they are in favor of reallocating funds to implementing guidelines for clinical practice. It is a matter of speculation whether this readiness to adopt priority setting measures is perhaps the result of considering such measures in isolation, without taking into account potential consequences for those concerned, including their own persons if they ever found themselves in this situation. Again, further research is needed, including a more in-depth examination of the argument structure. References Boyatzis, RE. (1998): Transforming qualitative information. Thousand Oaks, London, New Delhi: Sage Cappelen, AW./Norheim, OF. (2006): Responsibility, fairness, and rationing in healthcare 76: Fattore, G. (1999): Clarifying the scope of Italian NHS coverage. Is it feasible? Is it desirable? Health Policy 50(1-2): Fleck, LM. (2002): Rationing: don't give up. The Hastings Center Report 32(2):35-6. Ham, C. (1997): Priority setting in health care: learning from international experience. Health Policy 42(1): Ham, C./Robert G. (2003): Reasonable Rationing: International Experience of Priority Setting in Health Care. Open University Press. Kern, A./Beske, F./Lescow, H. (1999): Leistungseinschränkung oder Rationierung im Gesundheitswesen? Deutsches Ärzteblatt 96(Heft 3):A113-A117. King, D./Maynard A. (1999): Public opinion and rationing in the United Kingdom. Health Policy 50(1-2): Lees, A./Scott, N./Scott, SN./MacDonald, S./Campbell, C. (2002): Deciding how NHS money is spent: a survey of general public and medical views. Health Expect 5(1):

13 How to spend the health care budget? Litva, A./Coast, J./Donovan, J./Eyles, J./Shepherd, M./Tacchi, J. et al. (2002): 'The public is too subjective': public involvement at different levels of health-care decision making. Social Science & Medicine 54(12): Martin, DK./Giacomini, M./Singer, PA. (2002): Fairness, accountability for reasonableness, and the views of priority setting decision-makers. Health Policy 61(3): Menon, D./Stafinski, T./Martin D. (2007): Priority-setting for healthcare: who, how, and is it fair? Health Policy 84(2-3): OECD, (2008): OECD Health Data Statistics and Indicators for 30 Countries, accessed 16 November Patton, MQ. (2002): Qualitative Research and Evaluation Methods. 3 ed. Thousand Oaks: Sage Publications; Rosén, P./Karlberg, I. (2002: Opinions of Swedish citizens, health-care politicians, administrators and doctors on rationing and health-care financing. Health Expect 5(2): Rosén, P. (2006): Public dialogue on healthcare prioritisation. Health Policy 79(1): Rawls; J. (1999): A Theory of Justice. Cambridge: Belknap Press of Harvard University. Sabik, LM/Lie, RK. (2008): Priority setting in health care: Lessons from the experiences of eight countries. International Journal for Equity in Health 7(4):1-13. Strec,h, D./Börchers, K./Freyer, D./Neumann, A./Wasem, J./Marckmann, G. (2008): Ärztliches Handeln bei Mittelknappheit. Ethik in der Medizin 20(2): Werntoft, E./Hallberg, IR./Edberg, AK. (2007): Prioritization and resource allocation in health care. The views of older people receiving continuous public care and service. Health Expectations 10(2): Westphal, R./Röstermundt, A-K./Raspe, H. (2001): Die Bedeutung ausgewählter präventiver, therapeutischer und rehabilitativer Leistungen im Spiegel eines Bevölkerungssurveys. Das Gesundheitswesen 63(5): ZEKO. (2007) Stellungnahme der Zentralen Kommission zur Wahrung ethischer Grundsätze in der Medizin und ihren Grenzgebieten (Zentrale Ethikkommission) bei der Bundesärztekammer zur Priorisierung medizinischer Leistungen im System der Gesetzlichen Krankenversicherung (GKV) - Zusammenfassung Deutsches Ärzteblatt 104(40): ZEKO. (2000) Zentrale Kommission zur Wahrung ethischer Grundsätze in der Medizin und ihren Grenzgebieten (Zentrale Ethikkommission): Prioritäten in der medizinischen Versorgung im System der Gesetzlichen Krankenversicherung (GKV): Müssen und können wir uns entscheiden? Deutsches Ärzteblatt 97(15):

14 Margrit Schreier et al. Working Paper Series FOR Hartmut Kliemt: Priority setting in the age of genomics, December 2007 (1) 2. Marlies Ahlert: If not only numbers count allocation of equal chances, December 2007 (2) 3. Stefan Felder: The variance of length of stay and the optimal DRG outlier payments, December 2007 (3) 4. Jeannette Winkelhage, Adele Diederich, Simone Heil, Petra Lietz, Felix Schmitz-Justen, Margrit Schreier: Qualitative Stakeholder-Interviews: Entwicklung eines Interviewleitfadens zur Erfassung von Prioritäten in der medizinischen Versorgung, December 2007 (4) 5. Antje Köckeritz: A cooperative bargaining model for two groups of patients, January 2008 (1) 6. Marlies Ahlert and Hartmut Kliemt: Necessary and sufficient conditions to make the numbers count, January 2008 (2) 7. Stefan Felder and Andreas Werblow: Do the age profiles of health care expenditure really steepen over time? New evidence from Swiss Cantons, February 2008 (3) 8. Marlies Ahlert, Wolfgang Granigg, Gertrud Greif-Higer, Hartmut Kliemt, Gerd Otto: Prioritätsänderungen in der Allokation postmortaler Spender- Lebern Grundsätzliche und aktuelle Fragen, February 2008 (4) 9. Marlies Ahlert, Stefan Felder, Bodo Vogt: How economists and physicians trade off efficiency and equity in medically and neutrally framed allocation problems, February 2008 (5) 10. Adele Diederich, Hartmut Kliemt, Public health care priorities at the polls a note, March 2008 (6) 11. Stefan Felder: To wait or to pay for medical treatment? Restraining ex-post moral hazard in health insurance, April 2008 (7) 12. Margrit Schreier, Felix Schmitz-Justen, Adele Diederich, Petra Lietz, Jeannette Winkelhage und Simone Heil: Sampling in qualitativen Untersuchungen, Juli 2008 (8) 13. Petra Lietz: Questionnaire design in attitude and opinion research: Current state of an art, September 2008 (9) 10

15 How to spend the health care budget? 14. Margrit Schreier, Adele Diederich: Kriterien der Priorisierung: Praxis anderer Länder und erste Ergebnisse einer qualitativen Befragung in Deutschland, Oktober 2008 (10) 15. Jeannette Winkelhage, Susanne Winkel, Margrit Schreier, Simone Heil, Petra Lietz, Adele Diederich: Qualitative Inhaltsanalyse: Entwicklung eines Kategoriensystems zur Analyse von Stakeholderinterviews zu Prioritäten in der medizinischen Versorgung, Oktober 2008 (11) 16. Anhang zu FOR 655 Working Paper Nr. 15 / 2008, Oktober 2008 (11) 17. Marlies Ahlert and Hartmut Kliemt: Towards Understanding the Ethical Implications of Priority Changes: The Example of Kidney Allocation, 18. Adele Diederich, Petra Lietz, Marina Otten, Maike Schnoor, Margrit Schreier, Jessica Schröter, Jeannette Winkelhage, Norman Wirsik: Fragebogen zur Erhebung von Präferenzen in der Bevölkerung bezüglich der Verteilung von Gesundheitsleistungen in der GKV, August 2009 (2) 19. Jeannette Winkelhage, Margrit Schreier, Adele Diederich: Explorationsstudien zur Priorisierung medizinischer Leistungen: Kriterien und Präferenzen von Ärzten und Pflegepersonal, August 2009 (3) 20. Jeannette Winkelhage, Adele Diederich, Margrit Schreier: Explorationsstudien zur Priorisierung medizinischer Leistungen: Kriterien und Präferenzen von gesunden und erkrankten Personen, August 2009 (4) 21. Adele Diederich, Maike Schnoor, Jeannette Winkelhage, Margrit Schreier: Präferenzen in der Bevölkerung hinsichtlich der Allokation medizinischer Leistungen - Entwicklung eines Fragebogens für eine repräsentative Bevölkerungsbefragung, September 2009 (5) 22. Norman Wirsik, Adele Diederich, Margrit Schreier: Conjoint-Analyse: Prätest zu Evaluation von patientenbezogenen Merkmalen und dem Einfluss von Proxies auf die Bildung von Rangfolge. November 2009 (6) 23. Marina Otten, Margrit Schreier, Adele Diederich: Explorationsstudien zur Priorisierung medizinischer Leistungen: Kriterien und Präferenzen von Vertreter/Innen der Krankenkassen. Dezember 2009 (7) 24. Margrit Schreier, Adele Diederich, Maike Schnoor: Explorationsstudien zur Priorisierung medizinischer Leistungen: Kriterien und Präferenzen von Politiker/innen. Juni 2010 (1) 25. Marlies Ahlert, Katja Funke, Lars Schwettmann: Thresholds, Productivity, and Context: An Experimental Study on Determinants of Distributive Behaviour. Juni 2010 (2) 11

16 Margrit Schreier et al. 26. Simone Heil, Margrit Schreier, Jeannette Winkelhage, Adele Diederich: Explorationsstudien zur Priorisierung medizinischer Leistungen: Kriterien und Präferenzen verschiedener Stakeholdergruppen. Juli 2010 (3). 27. Adele Diederich, Margrit Schreier: Einstellung zur Priorisierung in der medizinischen Versorgung: Ergebnisse einer repräsentativen Bevölkerungsbefragung. August 2010 (4) 12

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