Reforming Germany's risk structure equalization schemetaking stock at the halfway point

Aim In 2002, the German Bundestag enacted a major reform of the risk structure equalization scheme (RSA) between sickness funds. This reform consisted of two short-term measures, the "risk pool" as stop-loss reinsurance for sickness funds and the introduction of financial incentives for disease management programs. In the medium term, the sociodemographic risk adjusters are to be complemented by morbidity-based categories. The short-term measures are evaluated in this paper and the arguments for the medium-term measure reviewed. Subject and methods Selective mobility is detected as a problem of open enrolment and incomplete risk adjustment. Using routine data from Germany's RSA scheme, the development of case mixes and expenditures of sickness funds with different growth rates were compared. Risk pool and disease management programmes were evaluated using the results of the 2003 annual procedure of the RSA scheme. Predictive ratios were calculated for certain types of sickness funds. Results The short-term measures were shown to have had little effect. Despite a tendency to automatic control, selective mobility remains a massive problem in Germany's managed competition system. Conclusion The introduction of a directly morbiditybased system remains an important measure to ensure competition between sickness funds. The suggestions of an expert group commissioned by the Ministry of Health are a good basis for the further development, but incentive concerns regarding the use of pharmacy data have to be addressed.