The new risk adjustment formula in Germany: implementation and first experiences.

Area of Science:

• Health Economics
• Public Health Policy
• Healthcare Regulation

Background:

• Germany's sickness fund competition relies on risk adjustment to ensure fairness among funds with diverse patient populations.
• The previous demographic model was replaced in 2009 by a morbidity-based system.
• This system incorporates 80 severe or chronic diseases within a hierarchical structure.

Purpose of the Study:

• To evaluate the performance of Germany's 2009 morbidity-based risk adjustment system.
• To compare the new system's effectiveness against the prior demographic model.
• To identify areas for improvement in the risk adjustment formula.

Main Methods:

• Evaluation based on 2009 data, the first year of the new system's implementation.
• Analysis of individual and group-level performance metrics.
• Joint analysis of coding and prescription patterns to assess behavioral changes.

Main Results:

• Significant improvements in individual and group-level performance compared to the old model.
• Enhanced predictive accuracy at the sickness fund level.
• No discernible changes in coding or prescription behavior attributable to the new system.

Conclusions:

• The 2009 morbidity-based risk adjustment system demonstrates improved performance and predictive accuracy.
• Identified issues include underpayment for older populations and multi-morbidity, and overpayment for those without conditions.
• Further refinements are needed to address age-related and multi-morbidity payment disparities.