49
care providers and the pharmaceutical industry respectively. But a closer look at the
history of health care reform acts reveals that the government is not as helpless as this
theory hypothesises. In the past, government was able to accomplish – from the view
of the suppliers – uncomfortable SHI-modi? cations, e.g. the introduction of the drug
budget in 1993 or the inclusion of patent-protected drugs into the reference-price system in 2004.35 Consequently, one can adhere to the fact that, contrary to the presumptions of the theory of “negotiation democracy”, government is able to implement
strong control instruments even against the ambitions of associations and special interest groups.
But it must also be recognised that health policy repeatedly had a split personality
in the past: in contrast to the of? cial stated goals of cost-containment and contribution
rate stability, the same government which introduced reference pricing excluded patented drugs and thus offered health care suppliers the possibility of circumventing
price controls. Equally astonishing is that the same government which established the
drug budget, counteracted it itself abstaining from claiming regresses in cases where
the budget was exceeded, not to mention that this most restrictive control instrument
was ? nally abolished. Another example is the non-consideration of a positive list, although this control instrument had been discussed several times. Thus it can be stated
that succeeding governments were either unable or unwilling to vigorously pursue the
announced goal of cost-containment in the last decades.
3.4. The Perspective of Public Choice
The main failure of the theory of “negotiation democracy” is it basically assumes that
politicians are really interested in decreasing drug expenditure. An investigation into
the self-interests of politicians reveals a different picture:
Politicians aspire towards vote maximization. They do not act unsel? shly to satisfy
the preferences of people, but they try to attain or stay in power (Downs 1957). Since
health politics is always one of the most followed policy ? elds, especially during election campaigns, it is understandable that it plays an important role in election chances.
People react highly sensitively to reductions in health care provision or increasing
fees. Therefore politicians at least of? cially call for a comprehensive standard bene? t
catalogue and contribution rates stability. However, since the concurrent ageing of the
population demographics and technological progress cause health care cost escalation,36
another sector which pays is needed. Instead of burdening the electorate, it should be
attractive for politicians to cut costs at the expense of the suppliers. But the medical
fraternity is especially disposed to having a close relationship to patients and act as
35 A detailed overview of the history of health care reform acts and negotiation democracy is given
in Blankart and Wolf (2005).
36 For the interrelation of the ageing demographics, technological progress and increasing health
care costs see e.g. Knappe (1995), PROGNOS (1998), Breyer and Ulrich (2000), Hof (2001),
Postler (2003).
50
opinion multipliers. Accordingly, burdening physicians could hardly be used as a
votes-maximizing strategy. On the contrary, political decisions against the powerful
pharmaceutical business companies are very popular. Their bad reputation is based on
the perception of electors, who say that many drugs are considered to be useless or
even harmful, but are successful in the market because of a huge amount of advertising. High net operating margins, on average in the OECD of 7 %, are ascribed to excessive retail prices (Breyer et al. 2003, p. 422). Moreover, this highly internationalised
economic sector is deemed a precursor of globalisation, which is associated with social irresponsibility (the international concentration of the industry, displacement of
production locations and the problem of providing cheap medicine in developing
countries) by large parts of the population. Even the methods of production and research are caught in the critic’s cross? re due to experiments on animals and environmental pollution. Recently, these reservations have been invigorated by ethical
arguments concerning stem-cell research.
Thus it can be supposed that savings at the expense of the pharmaceutical industry
are more accepted by the public than bene? t cuts or increasing contribution rates. But
the pharmaceutical industry is a growth industry which generated a turnover of € 29.4
billion in 2006 with 113,000 often highly-quali? ed employees in Germany (VFA
2007). The pharmaceutical sector is a key industry for economical prosperity. Furthermore it is highly organised with diverse associations and strong political connections.37
Consequently, politicians have to combine two diametrically opposed ambitions:
vote-maximizing and economic prosperity. In the following we try to ? nd out how
politicians dealt with this dilemma of interests in the past.
3.5. Model Speci? cation and Methodology
The purpose of this chapter is to ? nd an explanation for the development of the SHI’s
drug expenditure by using an econometric approach and by paying special consideration to political interests.38 To validate our results, we apply two different model speci? cations: an OLS regression in ? rst differences and an ECM. For the following, the
variables are presented ? rst because they are identical in both approaches. Subsequently the models’ speci? cations are shown.
3.5.1. The Endogenous Variable
We try to explain the SHI’s pharmaceutical expenditure (drug costs which are reimbursed by sickness funds plus insurants’ out-of-pocket payments). To achieve per capita values, we divide total expenditure by the number of insurants. The necessary
37 For further information see Blankart and Wolf (2005).
38 The econometric approach traces back to Breyer and Ulrich (2000).
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References
Zusammenfassung
Der Arzneimittelsektor der Gesetzlichen Krankenversicherung stand wiederholt im Fokus zahlreicher Gesundheitsreformen. Dennoch ist es bislang nicht gelungen, den Trend steigender Ausgaben nachhaltig zu bremsen. Die vorliegende Untersuchung leistet einen Beitrag dazu, die Ursachen dieser Entwicklung zu erklären und Lösungsansätze aufzuzeigen. Mittels Hauptkomponenten- und Cluster-Analyse wurden Gruppen von Arzneimitteln mit vergleichbaren Konsumeigenschaften gebildet. Jede Gruppe wurde auf den Einfluss der Altersabhängigkeit und des technologischen Fortschritts hin analysiert. Aufbauend auf diesen Ergebnissen wurde eine Prognose der zukünftigen Ausgabenentwicklung bis zum Jahr 2050 erstellt. Obwohl die Hauptkostenfaktoren exogen sind, steht der Gesetzgeber dem vorhergesagten ansteigenden Kostenpfad nicht hilflos gegenüber. Im Gegenteil: Anhand ökonometrischer Tests wird gezeigt, dass die Gesundheitspolitik in der Vergangenheit durch wahl- und klientelorientierte Interessendurchsetzung geprägt war. Mehr Effizienz in der Arzneimittelversorgung könnte durch die Einführung individueller Gesundheitssparkonten erzielt werden. Dies bestätigen die Resultate eines vertikal differenzierten Wettbewerbsmodells.