Advertisement

The European Journal of Health Economics

, Volume 17, Issue 4, pp 443–451 | Cite as

Regional distribution of physicians: the role of comprehensive private health insurance in Germany

  • Leonie SundmacherEmail author
  • Susanne Ozegowski
Original Paper

Abstract

Objective

In recent years, the co-existence in Germany of two parallel comprehensive insurance systems—statutory health insurance (SHI) and private health insurance (PHI)—has been posited as a possible cause of a persistent unequal regional distribution of physicians. The present study investigates the effect of the proportion of privately insured patients on the density of SHI-licensed physicians, while controlling for regional variations in the average income from SHI patients.

Methods

The proportion of residents in a district with private health insurance is estimated using complete administrative data from the SHI system and the German population census. Missing values are estimated using multiple imputation techniques. All models control for the estimated average income ambulatory physicians generate from treating SHI insured patients and a well-defined set of covariates on the level of districts in Germany in 2010.

Results

Our results show that every percentage change in the proportion of residents with private health insurance is associated with increases of 2.1 and 1.3 % in the density of specialists and GPs respectively. Higher SHI income in rural areas does not compensate for this effect.

Conclusion

From a financial perspective, it is rational for a physician to locate a new practice in a district with a high proportion of privately insured patients. From the perspective of patients in the SHI system, the incentive effects of PHI presumably contribute to a concentration of health care services in wealthy and urban areas. To date, the needs-based planning mechanism has been unable to address this imbalance.

Keywords

Germany Private health insurance Statutory health insurance Physician density Regional variation Needs-based planning Physician income 

JEL Classification

I11 I14 I13 I18 H51 

References

  1. 1.
    OECD: regional access to health. In: OECD Regions at a Glance 2013. OECD Publishing, 124f. http://dx.doi.org/10.1787/reg_glance-2013-39-en (2013). Accessed 05 Nov 2014
  2. 2.
    Ozegowski, S., Sundmacher, L.: Is the needs-based planning mechanism effectively needs-based? An analysis of the regional distribution of outpatient care providers. Gesundheitswesen 74(10), 618–626 (2012)CrossRefPubMedGoogle Scholar
  3. 3.
    Dussault, G., Franceschini, M.C.: Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum. Resour. Health 4, 12 (2006)CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dieleman, M., Kane, S., Zwanikken, P., Gerretsen, B.: Realist review and synthesis of retention studies for health workers in rural and remote areas. Technical Report No 1, World Health Organization, Geneva (2011)Google Scholar
  5. 5.
    Daniels, Z.M., VanLeit, B.J., Skipper, B.J., Sanders, M.L., Rhyne, R.L.: Factors in recruiting and retaining health professionals for rural practice. J. Rural Health 23(1), 62–71 (2007)CrossRefPubMedGoogle Scholar
  6. 6.
    Hegney, D., McCarthy, A., Rogers-Clark, C., Gorman, D.: Retaining rural and remote area nurses: the Queensland, Australia experience. J. Nurs. Adm. 32(3), 128–135 (2002)CrossRefPubMedGoogle Scholar
  7. 7.
    Hancock, C., Steinbach, A., Nesbitt, T.S., Adler, S.R., Auerswald, C.L.: Why doctors choose small towns: a developmental model of rural physician recruitment and retention. Soc. Sci. Med. 69, 1368–1376 (2009)CrossRefPubMedGoogle Scholar
  8. 8.
    Pathman, D.E., Konrad, T.R., Agnew, C.R.: Studying the retention of rural physicians. J. Rural Health. 10(3), 183–192 (1999)CrossRefGoogle Scholar
  9. 9.
    Han, G.S., Humphreys, J.S.: Integration and retention of international medical graduates in rural communities. J. Sociol. 42(2), 189–207 (2006)CrossRefGoogle Scholar
  10. 10.
    Watson, C.: The relationship between physician practice location and medical school area: an empirical model. Soc. Sci. Med. 14, 61–69 (1980)Google Scholar
  11. 11.
    Mayo, E., Matthews, M.: Spousal perspectives on factors influencing recruitment and retention of rural family physicians. Can. J. Rural Med. 11(4), 271–276 (2006)PubMedGoogle Scholar
  12. 12.
    Kazanjian, A., Paglicca, N.: Key factors in physicians choice of practice location: findings from a survey of practitioners and their spouses. Health Place 2, 27–34 (1996)CrossRefGoogle Scholar
  13. 13.
    Szafran, O., Crutcher, R.A., Chayrors, R.G.: Location of family medicine graduates practice—what factors influence Albertans choice? Can. Fam. Physicians 42, 2279–2285 (2001)Google Scholar
  14. 14.
    Pathman, D.E., Konrad, T.R., Dann, R., Koch, G.: Retention of primary care physicians in rural health professional shortage areas. Am. J. Public Health 94(10), 1723–1729 (2004)CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Rabinowitz, H.K., Diamond, J.J., Hojat, M., Hazelwood, C.E.: Demographic, educational and economic factors related to recruitment and retentions of physicians in rural Pennsylvania. J. Rural Health 15(2), 212–216 (1999)CrossRefPubMedGoogle Scholar
  16. 16.
    Fruen, M.A., Hadley, J., Korper, S.P.: Effects of financial incentives on physicians specialty on location decision. Health Policy Educ. 1, 143–159 (1980)CrossRefPubMedGoogle Scholar
  17. 17.
    Scott, A., Witt, J., Humphreys, J., Joyce, C., Kalb, G., Jeon, S.H., McGrail, M.: Getting doctors into the bush: general Practitioners preferences for rural location. Soc. Sci. Med. 96, 33–44 (2013)CrossRefPubMedGoogle Scholar
  18. 18.
    Barninghausen, T., Bloom, D.: Financial incentives for return of services in underserved areas: a systematic review. BMC Health Serv. Res. 9, 86 (2009)CrossRefGoogle Scholar
  19. 19.
    Kolstad, J.R.: How to make rural jobs more attractive to health workers. Findings from a discrete choice experiment in Tanzania. Health Econ. 20, 196–211 (2011)CrossRefPubMedGoogle Scholar
  20. 20.
    Ubach, C., Scott, A., French, F., Awramenko, M., Needham, G.: What do hospital consultants value about their jobs? A discrete choice experiment. Br. Med. J. 326, 1432 (2003)CrossRefGoogle Scholar
  21. 21.
    Günther, O.H., Kürstein, B., Riedel-Heller, S.G., König, H.H.: The role of monetary and nonmonetary incentives on the choice of practice establishment: a stated preference study of young physicians in Germany. Health Serv. Res. 45, 212–229 (2010)CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Gächter, M., Schwazer, P., Theurl, E., Winner, H.: Physician density in a two-tiered health care system. Health Policy 106, 257–268 (2012)CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Meliala, A., Hort, K., Trisnantoro, L.: Adressing the unequal geographic distribution of specialist doctors in Indonesia: the role of the private sector and effectiveness of current regulations. Soc. Sci. Med. 82, 30–34 (2013)CrossRefPubMedGoogle Scholar
  24. 24.
    Klose, J., Rehbein, I.: Ärzteatlas 2011. Daten zur Versorgungsdichte von Vertragsärzten. AOK Bundesverband, Berlin (2011)Google Scholar
  25. 25.
    Walendzik, A., Manouguian, M., Greß, S., Wasem, J.: Vergütungsunterschiede im ambulanten ärztlichen Bereich zwischen PK und GKV und Modelle der Vergütungsangleichung. Sozialer Fortschritt. 58, 63–69 (2009)CrossRefGoogle Scholar
  26. 26.
    Destatis: Kostenstruktur bei Arzt- und Zahnarztpraxen sowie Praxen von psychologischen Psychotherapeuten 2011. Series 2 No. 1.6.1. Federal Statistics Office, Wiesbaden (2013)Google Scholar
  27. 27.
    Regionaldatenbank Deutschland: Beschäftigte des Bundes, der Länder, Gemeinden und Gemeindeverbände. Statistische Ämter des Bundes und der Länder. http://www.regionalstatistik.de (2014). Accessed 26 Oct 2014
  28. 28.
    Regionaldatenbank Deutschland: Verfügbares Einkommen der privaten Haushalte einschließlich privater Organisationen ohne Erwerbszweck. Statistische Ämter des Bundes und der Länder. http://www.regionalstatistik.de (2014). Accessed 26 Oct 2014
  29. 29.
    Little, R.J.A., Rubin, D.B.: Statistical analysis with missing data, 2nd edn. Wiley, New York (2002)Google Scholar
  30. 30.
    Allison, P.D.: Missing data. Sage, Thousand Oaks (2001)Google Scholar
  31. 31.
    StataCorp 2013 Stata: Release 13. Statistical Software. College Station, TX: StataCorp LP (2013)Google Scholar
  32. 32.
    Rubin, D.B.: Multiple imputation for nonresponse in surveys. Wiley, New York (1987)CrossRefGoogle Scholar
  33. 33.
    Yett, D.C., Sloan, F.A.: Migration patterns of recent medical graduates. Inquiry 11, 125–142 (1974)PubMedGoogle Scholar
  34. 34.
    Kluge, J.: Der Traum von gleichwertigen Lebensverhältnissen. ifo Dresden berichtet 19(05), 05–17 (2012)Google Scholar
  35. 35.
    Wasem, J., Buchner, F., Lux, G., Weegen, L., Walendzik, A.: Ambulante ärztliche Vergütung in einem einheitlichen Versicherungssystem. Kompensation ärztlicher Einkommensverluste? Nomos Verlag (2013)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Department of Health Services Management, Munich School of ManagementLudwig Maximilians University MunichMunichGermany
  2. 2.BMC e.V.BerlinGermany

Personalised recommendations