The core of the German health-care system is the statutory health insurance (SHI). Coverage of the SHI has remained fairly constant at about 90% whereas the rest of the population is insured for the most part with private health insurance. The primary goal of health-care reforms since the 1990s has been to contain the expenditure of the SHI. The primary measures to do this have been the introduction of budgets and a shift of expenditure towards private households mainly in the form of benefit exclusions and increased co-payments. So far these measures did not have a negative effect on broad outcome measures such as life expectancy, which continued to rise, and self-assessed health of the population, which remained stable in the period 1992--2002. Besides cost containment another leitmotif of reform have been attempts to increase competition both between sickness funds and providers of care. These two strands of reforms also affected the incentive structures for both insurers and providers in various ways which this article describes. The immediate future of health-care reform will concern the mode of financing of the SHI which centres on the question if contributions proportional to income shall be maintained or if there shall be a radical shift towards flat-rate health premiums.

/pdf/analysing-the-impact-of-health-care-system-change-in-the-eu-sqen8z68sg.pdf

Analysing the impact of health-care system change in the EU member states--Germany.

The amount of out-of-pocket (OOP) payments within the German health care system has risen steadily within the last years. OOP payments aim to strengthen patients’ cost awareness and try to restrict the demand on medical necessary treatments. However, besides the intended decline of non-induced health care services there’s a risk that people also forgo necessary treatments because the utilization of health care services depends not only on need-factors but also on the ability to pay for it. Therefore, this paper aims to analyze the determinants of the total amount of OOP payments, the financial burden caused by OOP payments and the relinquishment of health care services due to OOP payments. The empirical analysis is based on cross-sectional data of the German subsample (n = 2851) of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a representative panel study among private households with persons above the age of 50 years and covers a wide range of topics, e.g. health behavior, health status and information about the socio-economic status. The analysis of the independent variables “total amount of OOP payments”, “financial burden due to OOP payments” and “forgone care” is carried out by the means of descriptive as well as multivariate regression methods. Individuals with low income as well as people suffering from chronic illnesses face a higher financial burden and forgo health care services more frequently at the same time. E.g. the financial burden of people who belong to the lowest income quintile is about eight times higher compared to individuals who belong to the highest quintile. The probability of forgone care for this group is about 5.6 percentage points higher [95% CI: 5.2 – 6.0]. Especially for the group of people with chronic illnesses and low-income earners it cannot be ruled out that they also forgo necessary medical treatments due to the relatively high financial burden they face. Hence, it is required to facilitate the access to necessary care for these groups.

/pdf/forgone-care-and-financial-burden-due-to-out-of-pocket-1ldbm79knw.pdf

Forgone care and financial burden due to out-of-pocket payments within the German health care system.

Background: Because community pharmacists are the most accessible healthcare professionals, they are often involved in managing minor ailments within the community setting.
Objective: This study evaluated the community pharmacists’ history taking practice, medicine dispensing and advice in response to acute diarrhea.
Methods: Authors conducted a simulated-patient study in 75 community pharmacies in Baghdad, Iraq from February to May 2015. The female simulated-patient complained of acute diarrhea that had lasted for one day and requested for medicine to treat her condition. After exiting each pharmacy, she then assessed the practices of the community pharmacists through the use of a specially designed checklist adopted with modifications from relevant guidelines. For history taking, a maximum total of eight was the highest obtainable score. Data collected was quantitatively analyzed and Mann-Whitney, Chi-square or Fishers exact tests were used at an alpha level of 0.05.
Results: All of the 75 pharmacies visited were managed by professionally qualified pharmacists. The most common questions asked during history taking were number of diarrheal episodes (n=62; 82.7%); duration of symptoms (n=59; 78.7%) and presence of other diseases and if any drug had been taken (n=58; 77.3%). Female pharmacists had a higher total mean score (6.45, SD=1.33) for history taking when compared to their male counterparts (4.34, SD=2.13); p <0.001. Medicine combination of diphenoxylate HCl 2.5mg + atropine sulphate 0.025mg (n=34; 27.9%) was most frequently dispensed while the least was oral rehydration salt (n=1; 0.8%). Around 20% (n=15) of pharmacists dispensed antimicrobial agents. Over half (n=46; 61.3%) of pharmacists indicated the frequency of use on the medicine packet. Conversely, less than half (n=33; 44.0%) gave any advice on food and fluid intake.
Conclusions: Majority of the community pharmacists asked at least four questions while taking patient history and was very likely to recommend antidiarrheal medicines as first line treatment options. The authors recommend the development of a minimum standard of practice as well as enhanced training for Iraqi community pharmacists.

/pdf/assessment-of-diarrhea-treatment-and-counseling-in-community-4f9t9jepem.pdf

Assessment of diarrhea treatment and counseling in community pharmacies in Baghdad, Iraq: A simulated patient study

Objective

To evaluate the current management of over-the-counter (OTC) insomnia complaints in Australian community pharmacies using standardized patient methodology.

Methods

Trained standardized patients visited a sample of 100 randomly selected South East Queensland community pharmacies in June 2011. The standardized patients enacted two OTC insomnia scenarios: a direct product request (DPR) (n = 50) and a symptom-based request (SBR) (n = 50). Results of the interactions were documented immediately after each visit and evaluated using the Pharmaceutical Society of Australia's WHAT STOP GO protocol as a standard comparison.

Key findings

Of all DPRs, 30% were handled entirely by the pharmacist, 70% of staff enquired about specific symptoms and 28% investigated the cause of insomnia. No staff investigated the frequency of product use. The DPR scenario resulted in a 92% supply of the requested doxylamine product (Restavit). In the SBR scenario, 18% of requests were handled entirely by the pharmacist, 58% of staff enquired about specific symptoms and 44% investigated the cause of insomnia. Staff recommended medicated products (38%), or herbal (78%) or non-drug techniques (18%). Investigation into smoking and alcohol intake was not undertaken in DPR or SBR interactions, while questioning on caffeine intake was undertaken in 2 and 14% of cases respectively. There were no significant differences found in the handling of sleep requests by pharmacists compared to pharmacy assistants.

Conclusion

The standardized patient methodology was a successful way to assess the community pharmacy counselling provided with OTC sleep requests and suboptimal staff responses were found when compared with recommended practice standards.

Management of over-the-counter insomnia complaints in Australian community pharmacies: A standardized patient study

Orally disintegrating drug carriers for paediatric pharmacotherapy.

The simulated patient methodology (SPM) is a form of participatory observation and can be used to assess the quality of counselling. The aim is to review those papers reporting the use of the SPM in German community pharmacies (CPs) from the beginning of 2005 to the end of 2018. The reporting items in the study were derived from the PRISMA Statement. We conducted a systematic search in the GVK-Plus, Embase, Web of Science, PubMed and Google Scholar databases. Additional sources included the personal literature collection of 1 of the reviewers and the reference lists from international systematic reviews and potentially relevant papers. The quality of the papers included was evaluated using the AXIS tool. A total of 5 papers were included. The SPM that was used varied greatly in the papers. The quality of counselling was assessed in the papers as being rather poor. The quality of the papers differed for specific assessment criteria. Only an extremely small number of papers could be included, in contrast to other countries. The papers for Germany demonstrate that there is a considerable need for improvement in the quality of counselling in CPs. Also, the deficits identified here for the application of the SPM should be avoided in future papers. It must also be recommended that the SPM be reported in future papers using uniform reporting standards, which are yet to be developed, to ensure better comparability.

Using the simulated patient methodology to assess the quality of counselling in german community pharmacies: a systematic review from 2005 to 2018

The law for the Modernisation of the Social Health Insurance System 2003 (“GKV-Modernisierungsgesetz – GMG” 2003) provides, among other measures, for a noticeable increase in co-payments and also for a reduction of possibilities for claiming exemptions from co-payments. Against this backdrop, the authors of the paper present, at the start, the varying news on co-insurance payments held by different political groups. Thereafter, the theoretical foundations of co-payments are described. Finally, on the basis of extensive empirically founded computations, the effects of the new co-payment rules (together with relevant new exemptions) are compared with the effects of the rules still in force.

https://www.econstor.eu/bitstream/10419/22776/1/253.pdf

Zuzahlungen nach dem GKV-Modernisierungsgesetz (GMG) unter Berücksichtigung von Härtefallregelungen

Background: In Germany, non-pharmacists (pharmacy technicians and pharmaceutical technical assistants) are permitted to advise on and sell medications in addition to pharmacists. The aim of this study was to determine if pharmacists and non-pharmacists referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory ('appropriate outcome') and what the quality of questioning and - if a medication was dispensed - the quality of information provided were in this context. The study also aimed to determine which factors predicted a necessary referral to a doctor. Methods: A cross-sectional, covert simulated patient study was conducted in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern. Each pharmacy was visited once by one of four trained investigators. They simulated a symptom-based request involving a grandmother with acute diarrhoea. A multivariate binary logistic regression analysis using potential variables from bivariate analysis was carried out to determine the predictors for a referral to a doctor. Results: All 199 planned visits were conducted. A necessary referral to a doctor was recommended in 59.8% (n=119) of all visits. The most commonly asked question was 'for whom is the medication?' (75.4%, n=150), while 'clarification by a doctor' was asked the least (17.6%, n=35). In 87.9% (n=175) of all visits a medication was dispensed. Multivariate analysis revealed that, unlike pharmacists, non-pharmacists have a 2.446 times higher likelihood of recommending a referral to a doctor (p = 0.044; 95% CI = 1.025-5.835). Conclusions: In almost half of the visits a necessary referral to a doctor was not recommended. Furthermore, the quality of questioning and the quality of information were below expectations. Moreover, involvement of non‑pharmacists was surprisingly identified as a relevant factor influencing the appropriate outcome.

/pdf/do-north-eastern-german-pharmacies-recommend-a-necessary-2fu5kvvk62.pdf

Do north-eastern German pharmacies recommend a necessary medical consultation for acute diarrhoea? Magnitude and determinants using a simulated patient approach.

Finanzierungsalternativen der Gesetzlichen Krankenversicherung

Background In Germany—as worldwide—headache is one of the most frequent causes of self-medication. The dispensing of over-the-counter (OTC) medications may only be carried out by community pharmacies (CPs). In doing so, CPs have to ensure “adequate” counseling, for both self-purchase and purchase for a third party, which also occurs in everyday pharmacy practice. The aim of this study was to evaluate the quality of counseling for headache OTC medications in German CPs and, as the first study worldwide, to analyze whether and to what extent there are differences in counseling between self-purchase and purchase for a third party. Methods A cross-sectional study was carried out using the covert simulated patient methodology (SPM) in all 42 CPs in the German big city Potsdam. With the help of 8 trained simulated patients (SPs), each CP was visited four times by a different SP. The SPs simulated in each CP two scenarios two times with the demand for an OTC medication against headache, which differed only in whether the demand was for themselves or for their boyfriend/girlfriend. Results All 168 planned pharmacy visits (84 visits per scenario) were successfully carried out. Overall, the median counseling score was 3.0 out of 9 points (interquartile range [IQR 2.0]). There were no significant differences between the two scenarios (Wilcoxon signed-rank test; p=0.495, r = 0.053). In a multivariate binary logistic regression analysis, the counseling level and the different scenarios were not significantly associated (adjusted odds ratio [AOR] = 1.635, 95% CI = 0.673–3.972, p=0.278). Conclusions Due to the partly considerable deficits in counseling of German CPs, policy-makers and the regional chambers of pharmacists are called upon to take appropriate measures to improve the quality of counseling. It is positive that no differences in counseling between self-purchase and purchase for a third party were found, but further verifying studies with a modified methodology are recommended.

The Quality of Counseling for Headache OTC Medications in German Community Pharmacies Using a Simulated Patient Approach: Are There Differences between Self-Purchase and Purchase for a Third Party?

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