25 penditure for older people grew faster than for younger people. Relating to multimorbidity, Naegele (1999) con? rmed that there exists a typical age-related morbidity.8 This brief overview of empirical surveys demonstrates the ongoing debate about the in? uence of the ageing population on the development of health care expenditure. At the moment, only two observations seem to be established: ? rstly, a great proportion of all lifetime health care expenditure accrues in the last months before death. This speaks in favour of the compression thesis, but this insight on its own does not answer the question of how prolonged expectancy of life will in? uence total health care disbursements. Even hypothetical cost savings from delay in morbidity need not be large enough to compensate for cost increases due to potential multimorbidity in the highest age-groups (Miller 2000). Secondly, per capita health care expenditure for older people has grown faster than for younger people in the past. Wasem (1995) called this observation “steeping“ of health care expenditure pro? les. Unless concurrent expenditure for younger people decreases, this observation speaks in favour of the medicalisation thesis. 2.4. Medicalisation and Compression Theses in the Pharmaceutical Sector As long as comprehensive individual medical records are not available, the best conceivable method to ? nd indication for the dynamic relationship between age and disbursements is to analyse the development of the age-related expenditure pro? les. For the pharmaceutical market, Buchner (2002) found that the SHI drug expenditure pro- ? le remained almost constant between 1988 and 1998. This would imply that neither the medicalisation nor compression effect exists. But medications are highly heterogeneous goods which are used against a great number of different disturbances of health. It can be supposed that some drugs are mainly prescribed for diseases which normally occur in the last months of life and others are used largely independently from distance to death and there is an incrementally greater consumption at higher ages. If the trends of the various drugs cancel each other out, looking at total expenditure conceals those different developments. Even if the total expenditure pro? le seem to be unaffected by the ageing population, it could be possible that the pharmaceutical sector partly develops accordingly to both the medicalisation and the compression theses.9 Since results of expenditure forecasts differ depending on whether a 8 Strengthening of the medicalisation thesis could also follow from the so-called “Sisyphus-Syndrome”. According to that theory, medical achievements support the ageing population and could lead to changes of political majorities. If older people win a majority, more political pressure towards comprehensive health care provision could accrue. Zweifel (1989) did not found empirical evidence for this theory. Zweifel et al. (2005) suggest that a “Sisyphus-Syndrome” may have been operative in the OECD countries until the end of the past century. 9 This supposition coincides with the “bi-modal” concept (Kane 1988, SVR 2004) which constitutes a middle-way between both disputed theses. It is based on the assumption that, on average, the population’s health status continuously improves, but concurrently the number of disabled 26 uniform development of the whole drug market or diverse developments in market segments are assumed, it is essential to scrutinise whether the drug market must be subdivided. For this we apply principal components and cluster analysis in the following. 2.4.1. Data All pharmaceutical consumption and expenditure data used stem from the SHI Drug Index, which distinguishes not only between gender and 19 age groups but also between the 88 indication areas of the “Red List”: the pharmaceutical catalogue of certi- ? ed drugs in Germany.10 Each indication area represents a group of drugs with the same main application ? eld, i.e. they are used against similar disturbances of health. Because some of the groups are unoccupied and, due to changes in the classi? cation of the indication areas for the observed period between 1988 and 2004, persistent data for only 50 groups are available – covering around 95 % of whole consumption and 90 % of total drug expenditure, respectively. Hence the analysis has been divided for men and for women by considering data differentiated into 50 indication areas and 19 age groups from 1988 to 2004. For this reason, it is based on 16,150 observations in each case. All data have been standardised by use of mean values and standard deviations. Since expenditure is highly affected by various parameters which could conceal the in? uence of ageing, the analysis does not refer to drug expenditure but directly to consumption, using De? ned Daily Dosages (DDDs). A DDD represents “the assumed average maintenance dose per day for a drug used for its main indication in adults” (WHO 2006). Taking DDD as a technical scale unit instead of drug expenditure offers the substantial advantage that a de? ned quantity of an active substance is directly measured. It enables the observation of drug consumption broadly unattached from alterations in package sizing, prices or dose rates. 2.4.2. Principal Components Analysis The idea is that it should be possible to compose groups of pharmaceuticals whose members are characterised by similar demand attributes. Since there exists a great variety of different causes for the occurrence of diseases, a theoretical method is needed to explicitly extract the in? uence of ageing. Therefore, we use principal components analysis (PCA) – a mathematical technique used to reduce the number of variables and diseased persons as well as the number of long term care patients increases. As a result, the expenditure pro? les would develop somewhere between the predictions of medicalisation and compression theses. 10 The “Red List” is published annually on behalf of the “German Pharmaceutical Industry Association” (BPI), the “German Association of Research-Based Pharmaceutical Companies” (VFA), the “German Generics Association” and the “Federal Association of Pharmaceutical Manufacturers” (BAH).