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  • BIOETHICS FORUM ESSAY

Germany Institutes Incentives for Cancer Patients

A controversial element of Germany’s most recent health care reforms entered into force at the beginning of this year. Copayments for the chronically ill will double, to 2% from 1% of gross annual income, for patients who have not taken part in counselling sessions for certain age and sex-related screening and prevention programs before becoming sick.

The new requirement, in form of the binding “Chroniker-Richtlinie,” applies to all women born after April 1, 1987, and all men born after April 1, 1962. At first, it will extend only to breast-, colon- and cervical cancer patients. To avoid the increase, they must have attended a counselling session about the advantages and disadvantages of (respectively) mammography, fecal occult blood tests or colonoscopy, and pap-smears. Other diseases and screens will be added in the future, subject to approval by the relevant authority (theGemeinsame Bundesausschuss, or G-BA).

In practical terms, all those insured through the statutory sickness funds will be issued a “prevention-passport” that documents their participation in counselling sessions. While people with severe mental diseases are exempt from the regulation, all others must attend counselling no later than two years after the recommended age for the respective disease to be eligible for the lower copayments. Counselling is to be offered by medical professionals who are also qualified to carry out the respective screens. It will be based on information brochures already available via the G-BA. A formal evaluation of the new policy will be carried out, using cervical cancer as an example.

When the initial health care reforms were passed by the German Parliament on February 2, 2007, a heated debate raged over the issue of personal responsibility, and in particular about whether the revised law might force the chronically ill to undergo screening. Because of the controversy, it was agreed that the precise content of the new requirement would not be specified until early 2008.

In its final report, the G-BA cautioned against making copayments conditional on actual participation in the respective diagnostic tests. Instead, the now adopted policy was proposed, with the alternative of just distributing information leaflets. The G-BA notes several areas of concern that speak against mandatory or more directive screening approaches. These include the fact that, for these screens, a very large number of people need to be screened to prevent a single adverse outcome (an unfavorable “NNS ratio”); absence of evidence that screening programs will lead to net savings; the importance of shared decision making and informed consent in view of the risk-benefit balance of the screens; and the “right not to know,” which is viewed as widely accepted by ethicists, health professionals, and lawyers and as backed up by the German Constitution.

The German Minster for Health, Ulla Schmidt, welcomed the new regulation in her announcement: “Early diagnosis enables better treatment. This is why the statutory sickness funds offer a range of screening and disease-prevention measures. I would like more people to make use of them, and the most recent reforms have created new incentives. It is important that all take more responsibility: for their own health, and also towards the community of people who jointly fund health care and ultimately pay for the treatment of chronic diseases.”

As to whether the new policy creates incentives for those taking part, as Schmidt emphasizes, or disincentives for those who do not, it is worth noting Dan Wikler’s 1978 paper “Persuasion and Coercion for Health” (Millbank Memorial Fund Quarterly/Health and Society, Vol 56, No 3, 1978). He presents the following thought experiment to illustrate that although incentives might appear morally less controversial than disincentives, this may often just be a matter of framing a particular policy:

Suppose, for example, that the Government wants to induce the obese to lose weight, and that a mandatory national insurance plan is about to go into effect. The Government threatens the obese with higher premiums unless they lose their excess weight. Before the plan is instituted, however, someone objects that the extra charges planned for eager eaters make the plan coercive. No adequate justification is found. Instead of calling off the program, however, some subtle changes are made. The insurance scheme is announced with higher premiums than had been originally planned. No extra charges are imposed on anyone; instead, discounts are offered to all those who avoid overweight. Instead of coercion, the plan now uses positive incentives; and this does not require the kind of justification needed for the former plan.

It appears that the new reform provides an interesting real-life example of a not so dissimilar case.

Harald Schmidt is Research Associate at LSE Health, and Assistant Director of the Nuffield Council on Bioethics, London. The views expressed here are his own and may not be attributed to the Council.

Published on: January 11, 2008
Published in: Health Care Reform & Policy

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