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The economic cost of illness in the Federal Republic of Germany in the year 1980
Health Policy, Elsevier
6 (1966) 119-143
119
HPE00086
The economic cost of illness in the Federal Republic of Germany in the year 1980 Klaus-Dirk Department Accepted
Henke and Cornelia S. Behrens of Economics,
24 October
University
of Hannover,
F.R.G.
1985
Summary This paper provides an empirical investlgatlon of the economic cost of illness, disability and premature death in the Federal Republic of Germany in the year 1990. Direct and indirect cost of morbidlty and mortality are estimated and allocated to the disease categories of the ICD-lnternatlonal Classification of Diseases. Against the background of increasingly scarce resources in health care, the findings of cost of Illness studies obtain special significance for the setting of priorities for the allocation of these resources. In comparison to the status quo, a disease-orlented approach may provide a more differentiated and national basis for the ex-ante macroallocatlon of health care resources as well as for the identification of areas for increased efforts in prevention. cost of Illness; resource allocation;
Federal Republic of Germany
I. Introduction Until the present day, numerous cost of illness studies have been carried out mainly in the U.S.A., but also in some European countries, e.g. Sweden [1,2]. Apart from giving an indication of the burden of illness, disability, and death to society, it has been
Addressfor correspondence: Prof. Dr. K.D. Henke, Institut ver, Wunstorfer Strasse 14, D-3000 Hannover 91, F.R.G.
0168-8510/86/%03.50
0 1986 Elsevier Science Publishers
fiir Volkswirtschaftslehre,
B.V. (Biomedical
Division)
Universitlt
Hanno-
120
argued that the measurement of that burden takes on special significance for the setting of priorities for the allocation of scarce resources, and the evaluation of health research and health service programs [3]. Prior to the study [4] the main findings of which are presented below, there existed no comprehensive cost of illness study in West Germany, but rather a small number of analyses which attempted to estimate the cost of selected diseases [5-71. This situation was caused by the lack of appropriate data, in particular, in regard to data on health care expenditures and data on health resources utilization. While, in the meantime, more data have become available in West Germany, detailed statistics as for example are used in American cost of illness studies are still an exception in Germany. Thus, the findings of the present study have to be judged against this background, and to be viewed as a first attempt to develop information on the cost of illness in West Germany.
II. Methodological
background
of the present study
The present study relies on the various methodological concepts developed by Rice [ 1,8], which have a great influence on the state of the art of cost of illness studies until the present day [9-111. Direct costs of illness are estimated on the basis of expenditure data, although it is understood that expenditures may not reflect correctly the true opportunity costs of the resources which are used due to illness. Expenditures for the so-called “core” costs are identified, whereas various add-ons are not included. For the estimation of indirect costs of illness the traditional human capital approach is used. Whereas there are drawbacks of the concept vis-a-vis the alternative willingness-to-pay approach, the empirical development of the latter is yet still in its infancy in West Germany. Psychosocial costs are not estimated. Nevertheless, it may be argued that our estimates include at least some of the psychological and social consequences of illness, disability and death, viz. those which give rise to the consumption of some health care resources (e.g., psychiatric treatment) and/or entail productivity losses. The results presented below are prevalence-based estimates. The International Classification of Diseases (ICD, 1968) is used for the distribution of illness costs by disease categories.
Ill. Direct cost of illness in the Federal Republic of Germany in the year 1980 1. Background In 1976, the German Federal Statistical Office began to lay the theoretical foundation for comprehensive statistics combining the existing estimates ofpublic and private expenditures for health services [ 121. As of writing, annual expenditure data by type of
121
carrier and by object of expenditure or by type of health service are available for the period 1970 to 1982 [13,14]. In 1980, health care expenditures amount to DM 200520 million, including DM 11916 million for various preventive measures, maternity benefits, and nursing home care, DM 116 857 million for medical care treatment, DM 61 350 million for various health-related transfer payments, DM 2909 million for medical education and training, and medical research, DM 7488 million comprising, mainly, net costs of the various insurance carriers. Of these, transfer payments have to be deducted because, as indirect costs are estimated separately, they would imply double counting, leaving a sum of DM 139 170 million. Due to lack of appropriate data the allocation of expenditures by disease is limited in this analysis to a sum of DM 87 462 million (see Table 1 for details), i.e. approximately 63% of the outlay for health and medical care in 1980. The remaining 37% comprise a variety of personal and nonpersonal expenditures includingto name the quantitatively most important categories - public expenditures for nursing home care and for hospital construction, expenditures of the statutory health insurance for various drug sundries and medical appliances, the larger share of health care expenditures of private households, public expenditures for medical education and training, and medical research as well as the net cost of insurance. It can be assumed that due to the exclusion of these expenditure categories, the direct cost, especially of certain chronic diseases, will be underestimated. To enhance the statistical basis is an area for additional research so that (some of) these categories of expenditures can be included in future cost of illness studies in West Germany. 2. Estimating
procedure
For some expenditure categories the distribution by diagnosis is based on the type of (insurance) carrier, whereas other categories of expenditures are distributed by diagnosis on the basis of type of health service or the utilization of the specific type of service respectively. (a) Distribution of expenditures by diagnosis on the basis of type of (insurance) carrier The expenditures of the statutory accident insurance amounting to DM 1836 million are classified in the diagnostic group “injuries and adverse effects of chemical and other external conditions” (subsequently referred to as injuries). The outlays of the private health insurance reaching a sum of DM 5748 million are allocated according to statistics on the distribution of services by diagnosis published annually by the Association of Private Health Insurance Funds [15]. Use of these statistics is also made for the distribution by diagnosis of the expenditures of public employers amounting to DM 4469 million. (b) Distribution of expenditures by diagnosis on the basis of type of health service The expenditures of the statutory health insurance for services of physicians (DM 15 358 million) are allocated on the basis of the percentage distribution of
1
of expenditures
in the estimation
Derived
and calculated
69 386
Total
from Ref. 13.
93
514
3 306
70
1836
22
5 784
4 868
437
766
10
1939
343 2632
12573 1439 7351
906
1716
1734
901
20 876 15 358 5518 25 465
1342
544
Public and private employers
2189
Private households
364
2111
Amount
2189
87 462
12 573 1439 10 583
15679
85351 24 870 15 358 5861 30973 31 3 246
1407
334 3
Private health insurance
334
364
Statutory accident insurance
100.0
(1.6) 12.1
(14.4)
17.9
(0.0) 3.7
(6.7) 35.4
97.6 28.5 (17.6)
1.6
0.4
0.0
0.4
2.4
Percent
All expenditure carriers
and by type of health service, in million DM, 1980
6
3 236
Statutory pension insurance
carrier
6
Statutory health insurance
of direct cost of illness, by type of expenditure
14012
31 31
62
Public households
Type of carrier
included
(2) Medical care treatment ambulatory care physicians dentists hospital care tuberculosis aid inpatient rehabilitation treatment drugs, drug sundries and medical supplies from pharmacies from opticians dental prostheses
(1) Preventive measures and maternity benefits prevention of industrial accidents, first aid health insurance dental examination service measures for early detection of cancer maternity benefits
Type of service
Categories
Table
123
office visits to physicians, according to speciality, by (principal) diagnosis. These data stem from a representative sample of 13 185 office visits during the 4th quarter of 198 1 and the 1st quarter of 1982 [16]. The estimating procedure is based on the assumption that the cost of each office visit, by physician speciality, is the same. The allocation of expenditures of the statutory health insurance for hospital care amounting to DM 25465 million is based on the distribution of days of care by (principal) diagnosis. The data are obtained from a representative sample of cases/ days of hospital care by diagnosis as reported from the Federal Association of Local Sickness Funds [17]. In 1980, approximately 47% of the German population was insured in these funds. Here, the assumption is made that the cost of a day of hospital care for each type of disease is the same. Variations of daily costs are allowed for only in regard to insurance status, a day of hospital care being valued at DM 188.43 in the case of compulsory and voluntary members and their family dependents, and at DM 182.25 in the case of insured pensioners and their family dependents. The expenditures of the statutory health insurance for drugs and drug sundries from pharmacies are allocated by diagnosis on the basis of results from the Statutory Health Insurance Medical Index [ 181. The 1981 percentage distribution of sales in DM by diagnostic group is applied to the 1980 outlays for drugs and drug sundries amounting to DM 12573 million. The allocation of an amount of DM 3236 million for inpatient rehabilitation treatment granted by the statutory pension insurance is based on the distribution of cases of treatment by diagnosis as reported by the Association of Pension Insurance Carriers [19]. Here, it is assumed that the costs per case of treatment are the same for all diagnoses. The expenditures of various carriers for other types of services are classified as follows: - expenditures of public households and the statutory health insurance for maternity benefits (DM 1404 million) in the diagnostic group “deliveries and complications of pregnancy, child birth and puerperism” (subsequently referred to as maternity), - expenditures of the statutory health insurance for medical supplies from opticians (DM 1439 million) in the diagnostic group “diseases of the nervoussystemandsense organs”, - expenditures of the statutory health insurance for the early detection ofcertain forms of cancer (DM 334 million) in the diagnostic group “neoplasms”, - expenditures of the statutory health insurance, the statutory pension insurance and private households for dental services including dental prostheses (DM 15 134 million) in the diagnostic group “diseases of the digestive system”, - expenditures of the public households for tuberculosis aid (DM 31 million) in the diagnostic group “infective and parasitic diseases”. 3. Findings From Table 2 the summarized results for the allocation of expenditures by diagnosis and by type of carrier or by type of service can be obtained. Expenditures for diseases of the digestive system rank highest amounting to DM 22 552 million or 25.8% of the
expenditures
Diseases of the nervous system and sense organs Diseases of the circulatory system
240 563
729
146
24
263 179
55
Public employers
1439
334
31
2 161
1420
571
77
325 628
427
Physicians’ services
4314
1112
2029
148
2 140 987
456
Hospital care
service or by type of expenditure
Other health services*
and by type of health
311
189
Mental, psychoneurotic personality disorders
and
31
340 232
Neoplasms Allergic, endocrine, metabolic and nutritional diseases
Diseases of blood and blood-forming organs
72
Private health insurance
by diagnosis
Statutory accident insurance
- selected categories,
and parasitic
Infective diseases
Diagnosis
Health
Table 2
465
38
389
1
108 145
353
Inpatient rehabilitation treatment
carrier,
4221
387
1015
87
30 915
730
12453
4 941
4 339
368
3 540 3 086
2 124
Amount
14.2
5.7
5.0
0.4
4.0 3.5
2.4
Percent
Total expenditure
DM, 1980 Drugs, drug sundries from pharmacies
in million
for early detection
* Tuberculosis
aid, measures
1836
1836
All diagnoses
Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and illdefined conditions Injuries Miscellaneous 251 72 454 16 4 246 665
325 93 587 20 6 318 345
of cancer,
5 784 medical
4 868
1055 358
1365 463
277
358
supplies
15 358
797 2 268
283
46 4
2 129
616
695 1033
from opticians,
18342
1404
15 134
1878
dental
services,
25 465
2913
1355
223 205
1548
598 665
3 103 1871
1798
dental
3 236
15 168
74
3
1058
13
105 86
215
prostheses,
12573 maternity
3 767
1266
512
1095 304
1241
benefits.
87 462
6 574 3 203
2276
308 219
7 042
2578 1971
22 552 4115
5 767
100.0
7.5 3.7
2.6
0.4 0.2
8.1
2.9 2.3
25.8 4.7
6.6
126
total DM 87 462 million. The dominating position of this disease category islargelydue to the high proportion of expenditures for dental services. Being well recorded in the existing expenditure data, they constitute approximately 19% of the total expenditures included in this analysis, Diseases of the circulatory system are in second place with expenditures of DM 12 453 million or 14.20/o, followed by diseases of the bones and organs of movement (DM 7042million or 8.l’%)andinjuries(DM 6574million or 7.5%). These four diagnostic groups comprise about 56% of the direct cost of illness in West Germany in the year 1980. In appraising the results in Table 2 it should be borne in mind, however, that total expenditures as well as their distribution by diagnosis are dependent upon the exclusion of expenditures of certain carriers and for certain types of health service respectively. The procedure used here, as much as any alternative procedure, implies an underestimation of direct costs with the degree of underestimation varying between disease categories.
IV. Indirect cost of mortality in the Federal Republic of Germany in the year 1980 1. Background Indirect costs of mortality comprise the estimated cost or value to society of all deaths occurring in West Germany in the year 1980. The estimates presented below constitute total mortality losses taking also into account future losses in output resulting from the deaths in 1980; accordingly no separate estimation of annual mortality costs is carried out. The human capital approach is employed to quantify the value of a human life. Various sets of cross-sectional data are utilized for the estimation. Due to lack of data no value of housewives’ services could be imputed. 2. Estimating
procedure
Four stages in the estimation (a) Number annually by [20]. Every reported on
of mortality
losses can be distinguished.
of deaths The number of deaths by diagnosis, age and sex is record-ed the,German Federal statistical Office in the national mortality statistics death is attributed to one underlying condition, based on information the death certificate.
(b) Total years lost average number of years the mortality conditions deaths by diagnosis are estimated life expectancy
Years lost per person by age and sex are estimated as the of life remaining to a male/female at that particular age given existing in the period 1978/1980 [21]. Total years lost of all the product of the number of deaths by diagnosis and the with age and sex taken into account.
(c) Total man-years lost to productivity
Man-years
lost to productivity
per person
127
by age and sex represent the number of years in the labour force for the average male/female as he/she grows older taking into account again the prevailing mortality conditions. Use is made of 1980 cross-sectional labour force participation rates by age and sex [21]. Total man-years lost of all deaths by diagnosis are obtained by multiplying the number of all deaths by diagnosis and the age- and sex-specific estimates of man-years lost to productivity.
(d) Present value of lifetime earnings
In the estimation of the present value of lifetime earnings by age and sex, labour force years per person by age and sex are multiplied by the corresponding age- and sex-specific annual mean earnings. Here too, 1980 cross-sectional data are used. Two discount factors, viz. 4% and 6% are applied to aggregate earnings. In Table 3, the present values of lifetime earnings by age and sex are given for the two discount factors. Indirect costs of mortality by diagnosis are the product of the number of deaths by diagnosis and the estimates of the present values of lifetime earnings with age and sex taken into account.
3. Findings (a) Number of deaths In 1980, a total number of 714 117 deaths (males: 348 015, females: 366 102 deaths) is reported for West Germany (see Table 4). Diseases of the circulatory system account for the largest number of deaths: 359 503 or 50.3% of the Table 3 Present
value of lifetime earnings,
Age (years)
o-5 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 >90
amount
Males
discounted
at 4% and 6%, by age and sex, in DM Females
4%
6%
4%
6%
248 532 305481 372 560 444 244 495412 507 657 484 568 434 550 371416 300 345 216942 123718 47 608 11355 1636 1068 878 740 646
133 266 180 165 241636 313 559 371920 397 515 39 I 900 361 197 317213 264 355 196 964 115483 45 269 10898 1502 979 819 700 623
116915 143 348 174 699 201336 203 208 185 361 166369 145 780 120 305 91264 59 294 26975 5 694
67510 91016 121978 151606 159 440 148 349 136 266 122825 104 294 81577 54718 25691 5 525 227 122 64 49 42 39
250 134 70 52 45 41
3 192 2672 2 086 748 1528 627 135
4844 4 784 3 580 2831 2 803 1508 443
Calculated
from Ref. 20.
All diagnoses 714117
348015
3 648
7421
128
5 337
10 352
Maternity
5 352
163 669 81556 25 762 23 856 20 321 7520
366 102
128
308
1275 881
2112 1494 2083
1652
3 773
5015
10376
195 834 82 680 16713 15647 16987 9 144
100.0
0.0
0.1
0.4 0.2
0.7 0.5 0.4
0.7
1.0
1.5
2.2
50.3 23.0 6.0 5.5 5.2 2.3
Total
Females
Total
Males
Percent
Amount
15728
1980
Allergic, endocrine, metabolic and nutritional diseases Diseases of the genitourinary system Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Infective and parasitic diseases Certain diseases of early infancy Diseases of the bones and organs of movement Congenital malformations Diseases of blood and blood-forming organs Diseases of the skin and cellular tissue
by diagnosis,
359 503 164236 42 475 39 503 37314 16664
of deaths,
system Diseases of the circulatory Neoplasms Injuries system Diseases of the respiratory Diseases of the digestive system Symptoms, senility and ill-defined conditions
Diagnosis
Number
Table 4
100.0
0.0
0.4 0.2
0.8 0.6 0.2
0.9
1.1
1.5
1.5
47.0 23.4 7.4 6.9 5.9 2.2
Males
100.0
0.0
0.1
0.3 0.2
0.6 0.4 0.6
0.5
1.0
1.4
2.8
53.5 22.6 4.6 4.3 4.6 2.5
Females
129
total. Neoplasms rank second with 164 236 deaths or 23%, injuries third with 42 475 deaths or 6% of the total. These three diagnostic groups, therefore, account for almost 80% of total deaths. Males and females reveal varying patterns of deaths with circulatory diseases being a relatively more important cause of death for females, whereas injuries account for a relatively larger share of deaths among males. (b) Total years lost The deaths in 1980 yield a total loss of 8 804 703 years (males: 4 576 123; females: 4 228 580 years). As can be seen from Table 5, circulatory diseases, neoplasms and injuries still rank first, second and third. Yet their proportions of total years lost have changed to 37%, 23.9% and 13%, respectively, giving a total of approximately 74%. As compared to the number of deaths, diseases of the circulatory system have lost some of their importance due to the fact that deaths from these diseases are dominant among the aged who have a relatively short life expectancy. In contrast, deaths from injuries occur more often among the younger with a relatively long life expectancy causing the proportion of total years lost due to injuries to increase sharply. Here again, sex-specific differences can be observed with respect to circulatory diseases and to injuries, reflecting the relative importance of these causes of death for males and females respectively. A total of 1862 740 man-years are lost (c) Total man-years lost to productivity because of the deaths in 1980 (see Table 6). With males having higher labour force participation rates in each age group compared with females, deaths among males account for 1452 839 man-years lost to productivity, whereas deaths among females result in the loss of 409901 man-years. Comparing the findings summarized in Tables 4 and 5 with those in Table 6 a different picture emerges. Injuries now rank first: 539 224 man-years lost of 28.9% of the total. Diseases of the circulatory system drop to second place with a loss of 355 116 man-years (19.1%) and neoplasms are in third place with 340037 man-years lost (18.3%). These three diagnostic groups account for more than 66% of the total man-years lost to productivity. Injuries and neoplasms show sex-specific variations. Whereas injuries account for almost a third of man-years lost for males, their proportion of total man-years lost for females is only about 20%. In contrast, neoplasms rank highest for females causing about a fourth of the total loss of man-years. (d) Indirect cost of mortality In Table 7, the indirect costs caused by the deaths in the year 1980 are shown. Applying the present values of lifetime earnings discounted at 4% yields a total loss of DM 27.8 billion (males: DM 24 billion; females: DM 3.8 billion). As to injuries, circulatory diseases, and neoplasms, their proportion of total indirect cost, viz. 28.2%, 22.4%, and 20.7%, respectively, is largely equivalent to that of total man-years lost. Here too, the same sex-specific variations can be observed. Indirect costs of mortality decrease to a total of DM 23.1 billion when the present values of lifetime earnings discounted at 6% are applied [4]. The ranking of diagnostic groups remains unchanged,,but for one exception: diseases of the nervous system and sense organs advance to place eight.
Table 5
1980
All diagnoses
Diseases of the circulatory system Neoplasms Injuries Diseases of the digestive system Diseases of the respiratory system Certain diseases of early infancy Symptoms, senility and ill-defined conditions Congenital malformations Allergic, endocrine, metabolic and nutritional diseases Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Diseases of the genitourinary system Infective and parasitic diseases Diseases of the bones and organs of movement Diseases of blood and blood-forming organs Maternity Diseases of the skin and cellular tissue
Diagnosis
Total years lost, by diagnosis,
13 285 47 096 50 149 8 154 8 470
2035
105 289 102 496 90687 28 735 20001 6 191 6 189
4576 123
72 889
142 194
8 804 703
95 609 65 340
1583 083 971929 780 380 310325 231695 141145 134539
182699 181378
3 256 375 2 107516 1 145 496 539210 395 154 252 170 242 923
4 228 580
6 191 4 154
11531
40538 20581
55 400
32 004
69 305
87 090 116038
1673 292 1 135 587 365 116 228 885 163 459 111025 108 384
100.0
0.1 0.1
0.2
1.0 0.3
1.2
1.2
1.6
2.1 2.1
37.0 23.9 13.0 6.1 4.5 2.9 2.7
Total
Females
Total Males
Percent
Amount
100.0
0.0
0.2
1.1 0.2
1.0
1.6
1.6
2.1 1.4
34.6 21.2 17.1 6.8 5.1 3.1 2.9
Males
100.0
0.2 0.1
0.3
1.0 0.5
1.3
0.8
1.6
2.1 2.7
39.6 26.8 8.6 5.4 3.9 2.6 2.6
Females
lost to productivity,
All diagnoses
Injuries Diseases of the circulatory system Neoplasms Diseases of the digestive system Certain diseases of early infancy Congenital malformations Symptoms, senility and ill-defined conditions Diseases of the respiratory system Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Infective and parasitic diseases Allergic, endocrine, metabolic and nutritional diseases Diseases of the genitourinary system Diseases of blood and blood-forming organs Diseases of the bones and organs of movement Maternity Diseases of the skin and cellular tissue
Diagnosis
Total man-years
Table 6
36 306 20 288 17679 8973 2 846 2036
779
41826 28061 25631 12959 4 253 3 275 2027 1372
1452 839
46 282 32 666
61821 43 755
1862 740
456 263 289 748 237 872 108213 79 032 54 597 59 259
539 224 355 116 340037 132 222 113523 81260 76018
409 90 1
2 027 593
1239
1407
3 986
7773 7 952
5 520
15 539 11089
82961 65 368 102 165 24 009 34491 27 023 16759
100.0
0.1 0.1
0.1
0.1
0.7
1.5 1.4
2.2
3.3 2.3
28.9 19.1 18.3 7.1 6.1 4.4 4.1
Total
Females
Total
Males
Percent
1980
Amount
by diagnosis,
100.0
0.1
0.1
0.2
0.6
1.4 1.2
2.5
3.2 2.3
31.4 19.9 16.4 7.4 5.4 3.8 4.1
Males
100.0
0.5 0.1
0.3
0.3
1.0
1.9 1.9
1.4
3.8 2.7
20.2 16.0 24.9 5.9 8.4 6.6 4.1
Females
w
All diagnoses
tissue 27831
22 20
cellular
49
organs of movement Maternity Diseases of the skin and
60
blood-forming organs Diseases of the bones and
of blood and
331 191
and nutritional diseases Infective and parasitic diseases Diseases of the genitourinary
system Diseases
414 306
566 311
24 029
14
37
46
269 155
518 486
693 589
712 711
personality disorders Certain diseases of early infancy Diseases of the nervous system and sense organs Congenital malformations Allergic, endocrine, metabolic
848 117
7 048 5 613 4 586 2 187 867
Males
Females
3 802
22 6
12
14
62 42
152 71
175 103
136 66
807 567 1161 274 132
100.0
0.1 0.1
0.2
0.2
1.2 0.7
2.0 1.4
2.5 2.1
3.0 2.8
28.2 22.4 20.1 8.8 3.6
Total
DM,l980
Total
in million Percent
at 4 percent,
Amount
discounted
ill-defined conditions Diseases of the respiratory system Mental, psychoneurotic and
by diagnosis,
7 855 6 240 5 147 2461 999
cost of mortality,
Injuries Diseases of the circulatory system Neoplasms Diseases of the digestive system Symptoms, senility and
Diagnosis
Indirect
Table 7
100.0
0.1
0.1
0.2
1.1 0.6
1.7 1.3
2.2 2.0
3.0 3.0
29.3 23.6 19.1 9.1 3.6
Males
100.0
0.6 0.2
0.3
0.4
1.6 1.1
4.0 1.9
4.6 2.7
3.6 1.7
21.2 14.9 30.5 7.2 3.5
Females
_
133
V. Indirect cost of morbidity in the Federal Republic of Germany in the year 1980 1. Background Costs of morbidity are the second component of indirect cost of illness. They comprise the estimated loss of output imposed upon society by illness and disability during the year 1980. Again the human capital approach is used to quantify the value of the productive time lost because of morbidity. The estimation is limited in this analysis to indirect costs arising from illness of the currently employed and to indirect costs arising from disability of persons who have been granted pensions on account of disability for the first time in 1980. Thus, morbidity costs could not be estimated for the majority of those unable to work because of chronic illness or disability, for women unable to keep house because of illness or disability, as well as for persons institutionalized because of illness.
2. Estimating procedure (a) Man-years lost due to short-term illness of the currently employed Manyears lost from work associated with acute and chronic conditions comprise absence from work because of temporary illness, industrial accidents as well as absence from work during inpatient rehabilitation treatment. Absence from work by sex is estimated on the basis of respective inactivity rates for workers, employees and public servants [22]. The total number of man-years lost is allocated by diagnosis according to the sex-specific percentage distribution of days of incapacity for work by insurance status and diagnosis as reported by the Federal Association of Local Sickness Funds [17]. The loss of productive time because of industrial accidents is recorded by the statutory accident insurance [23]. Man-years lost for this category are allocated to the diagnostic group “injuries”. Finally, absence from work during inpatient rehabilitation treatment is estimated on the basis of cases of treatment by sex granted from the statutory pension insurance [ 191. Man-years lost are distributed to diagnostic groups according to the (principal) diagnosis recorded for the treatment.
(b) Man-years lost due to disability
Morbidity losses by sex due to disability are estimated for those formerly employed who have been for the first time in 1980 granted pensions on account of disability by the statutory pension insurance [24] and the statutory accident insurance [25]. For the estimation of man-years lost pension figures are divided in half on the assumption that the pattern of cases is approximately symmetrical about midyear. Man-years lost are allocated according to the (principal) diagnosis reported for the pensions by the Association of Pension Insurance Carriers [24]. Man-years lost resulting from pensions granted by the statutory accident insurance are assigned to the diagnostic group “injuries”.
134
(C) Earnings Year-round ries before deductions
full-time earnings (by sex) which include are employed as a measure of output loss.
wages and sala-
3. Findings (a) Man-years lost due to short-term illness of the currently employed
In
1980, 22 337 million dependent employed persons account for a total of 1434 310 man-years lost due to incapacity for work (males: 867 104; females: 567 206). The loss of man-years from industrial accidents in 1980 amounts to 76 685 man-years (males: 57 008; females: 19 677). Absence from work because of inpatient rehabilitation treatment adds another 64212 man-years lost (males: 41481; females: 22731). The total loss of productive time in 1980 due to short-term illness of the currently employed by sex and diagnosis can be seen in Table 8. Diseases of the bones and organs of movement rank highest accounting for 311260 man-years lost or 19.8% of the total. Diseases of the respiratory system are in second place with a loss of 265 077 man-years or 16.8%, injuries rank third with 238 815 man-years lost or 15.2% of the total. These three diagnostic groups constitute more than 50% of the total loss of productive time because of short-term illness. Sex-specific differences can be observed in regard to diseases of the bones and organs of movement as well as to injuries, diseases of these two groups being more often the cause for short-term illness among males than among females. In contrast, diseases of the genitourinary system and neoplasms are more prevalent among females.
(b) Man-years lost due to disabillty In 1980, 146 716 persons (males: 95 330; females: 5 1386) have been for the first time granted pensions on account of disability by the statutory pension insurance, and an additional 417 persons (males: 3 18; females: 99) have been for the first time granted equivalent pensions by the statutory accident insurance. A total of 73 566.5 man-years (males: 47 824; females: 25 742.5) are estimated to be lost in 1980 due to disability. From Table 9, the 1980 total loss of man-years by sex and diagnosis can be obtained. Diseases of the circulatory system and diseases of the bones and organs of movement rank first and second, accounting for 27 211 and 13 466.5 man-years lost or 37% and 18.3% of the total, respectively. Whereas the former diagnostic group is relatively more significant for disability among males than among females, the reverse is true for the second diseases category. (c) Total man-years lost due to morbidity In 1980, a total of 1.65 million
manyears are lost in West Germany due to morbidity (see Table 10). Including the loss of productive time because of disability does not markedly change the picture as compared to the pattern revealed in Table 8, with the exception of circulatory diseases now rking fourth.
(d) Indirect cost of morbidity for males,
In 1980, a man-year lost is valued at DM 27 157 and at DM 18 116 for females. Indirect costs of morbidity are obtained
lost to productivity
All diagnoses
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Diagnosis
Total man-years
Table 8
Females
965 593
177 946 1953
238815 2915 1575 207
33 278
21978
29 607 34641
60 101
89 828 161676 109 381 19648
144 099 265 077 162407 67 237
2 182
44 275
71768
4 645
36321
65621
202 188
1404
3361
311260
33 942 16624 12969
53 036 38 585 22 032
609 614
60 869 962
26 823
2463
109072
29 607 12663
54271 103 401 53 026 47 589
27 493
29 300
1957
19094 21961 9 063
100.0
15.2 0.2
3.8
0.3
19.8
1.9 2.2
9.1 16.8 10.3 4.3
4.5
4.2
0.2
3.4 2.4 1.4
Total
Males
Total
1980 Percent
illness, by diagnosis,
Amount
due to short-term
100.0
18.4 0.2
3.5
0.2
20.9
2.3
9.3 16.8 11.3 2.0
4.6
3.8
0.2
3.5 1.7 1.3
Males
100.0
10.0 0.2
4.4
0.4
17.9
4.8 2.1
8.9 17.0 8.7 7.8
4.5
4.8
0.3
3.1 3.6 1.5
Females
E
lost to productivity
All diagnoses
Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system
Diagnosis
Total man-years
Table 9
1 197 1686.5 1841.5
1910 2152 2 703
47 824
30
79
73 566.5
7 654
13466.5
18885.5 3416 2159 537
27211 4 229 2 823.5 900.5
99
2 029.5
3 148.5
161
3 648
48.5
410.5 3 297 885
6527
80
538.5 6027 1610
25 742.5
465.5 861.5
713
49
5 812.5
62
8 325.5 813 664.5 363.5
1119
2879
31.5
128 2 730 725
100.0
2.9 3.7
2.6
0.1
18.3
0.2
37.0 5.8 3.8 1.2
4.3
100.0
3.5 3.9
2.5
0.1
16.0
0.2
39.5 7.1 4.5 1.1
4.2
7.6
0.1
0.1
8.9
0.9 6.9 1.9
Males
0.7 8.2 2.2
Total
Females
Total
Males
1980 Percent
by diagnosis,
Amount
due to disability,
100.0
1.8 3.3
2.8
0.2
22.6
0.2
32.3 3.2 2.6 1.4
4.4
11.2
0.1
0.5 10.6 2.8
Females
10
lost to productivity
All diagnoses
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Diagnosis
Total man-years
Table
Females
108713.5 165092 111540 20 185
22 077 209 842 2212 34475 179 632.5 3 794.5
171310 269 306 165 230.5 68 137.5 29 607 34 802 324726.5 4 724 62011 240 967 5618
1013417
46 304.5
74916.5
1648 773.5
39 969
1452.5
3441 72 148
34 352.5 19921 13854
53 574.5 44612 23 642
635 356.5
61334.5 1823.5
27 536
2512
114 884.5
29607 12725
62 596.5 104214 53 690.5 47 952.5
28612
32 179
1988.5
19 222 24691 9788
100.0
14.6 0.3
3.8
0.3
19.7
1.8 2.1
10.4 16.3 10.0 4.1
4.6
4.4
0.2
3.3 2.7 1.4
Total
Males
Total
1980 Percent
by diagnosis,
Amount
due to morbidity,
100.0
17.7 0.4
3.4
0.2
20.7
2.2
10.7 16.3 11.0 2.0
4.6
3.9
0.1
3.4 2.0 1.3
Males
100.0
9.7 0.3
4.3
0.4
18.1
4.7 2.0
9.9 16.4 8.4 7.5
4.5
5.1
0.3
3.0 3.9 1.5
Females
6; rl
138
by multiplying the sex-specific loss of man-years and the respective earning figures. In West Germany, 1980 indirect costs of morbidity amount to DM 39 billion (males: 27.5 billion; females: 11.5 billion). The distribution of morbidity costs by sex and diagnosis can be seen in Table 11. As compared to the findings summarized in Table 10, the ranking of diagnostic groups in Table 11 is left almost unchanged. Due to the fact, however, that man-years lost are valued higher for males, those disease categories which account for a larger proportion of man-years lost among males, viz. diseases of the bones and organs of movement, injuries, and circulatory diseases, gain, although only slightly, in importance. The reverse is true in regard to maternity and diseases of the genitourinary system which is/are only respectively more prevalent among females.
VI. Total cost of illness In the Federal Republic of Germany in the year 1980 In Table 12, the various results on the cost of illness, disability and death in West Germany in the year 1980 are joined together. It can be seen that diseases of the digestive system, diseases of the circulatory system, and injuries are the three most costly disease categories to society, comprising 18.8%, 14.8% and 13.2%, respectively of the total of DM 154 324 billion. Together with the diseases of the bones and organs of movement (9.6%), diseases of the respiratory system (8.4%) and neoplasms (6.7%), these six disease categories account for almost three quarters of the total cost of illness in West Germany. These results are strongly influenced by the amount and distribution by diagnosis of direct costs which contribute approximately 57% to total costs. Yet, whereas direct costs concentrate mainly on two diagnostic groups, the inclusion of indirect costs implies that other disease categories come to the fore as well. At this point it seems necessary to recall the limitations of the preceding analysis. Important components of the cost of illness, disability and death could not be estimated due to lack of data. In particular, it is assumed that costs of selected chronic diseases causing lifelong disability are grossly underestimated. Yet, to quote Arrow: “An unsatisfactory solution may be what is needed to provoke the needed information-gathering to produce a better one, while neglect is never productive” [26]. Against the background of increasingly scarce resources in health care [27], the findings of cost of illness studies obtain special significance for the allocation of these resources. In contrast to the status quo which in West Germany is characterized by an uncoordinated health policy of the various participating groups in the health care sector, a disease-oriented approach may provide a more differentiated and rational basis for the ex-ante macro-allocation [28] of health care resources. In the U.S.A., for instance, reference to cost of illness estimates has been made in regard to the so-called “Prevention Profile” [29] for whose triennial preparation legislation was enacted in 1978. Apart from indications as to whether, and if so, as to where to concentrate preventive efforts including medical research, findings from cost of illness studies offer a basis for decision making when the most expensive diseases are to be subjected to cost containment measures.
by diagnosis,
348 447 117 37
933 541 376 39
1281 988 553 76
1257 2953 4 484 3 029 548
600 5 699 60 936 4 878 103 27 521
1775 4087 6 372 4 002 1417 536 830 7 780 106 1435 5989 136 39031
Symptoms, senility and ill-defined conditions
Injuries Miscellaneous
All diagnoses
Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy
11510
1111 33
499
46
2081
536 230
1134 1888 973 869
518
583
Females
Males
Total
1085
organs
DM, 1980
Amount
in million
1668
Diseases of blood and blood-forming
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases
cost of morbidity,
11
Diagnosis
Indirect
Table
0.1
0.2
0.2 3.4 17.7 0.4 100.0
3.7 15.3 0.4 100.0
20.7
2.2
10.7 16.3 11.0 2.0
4.6
0.3
19.9
1.4 2.1
10.5 16.3 10.3 3.6
4.5
3.9
3.3 2.0 1.4
3.3 2.5 1.4
4.3
Males
Total
Percent
100.0
9.7 0.3
4.3
0.4
18.1
4.7 2.0
9.8 16.4 8.5 7.5
4.5
5.1
0.3
3.0 3.9 1.5
Females
c \o
140
141
142
As to the future it seems desirable to enhance the the quality of cost of illness studies. Apart from efforts to develop further the methodological concepts [9-l I], it appears necessary to improve the underlying statistical data so that future cost of illness analyses can consider, for example, population groups, regions, or specific diseases.
Acknowledgement This research has been supported Family, and Health, Bonn.
in part by the German
Federal
Ministry
for Youth,
References 1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16
17
18
Rice, D.P., Estimating the cost of illness, Health Economic Series no. 6, U.S. Department of Health, Education, and Welfare, Washington, DC, 1966. Lindgren, B., Cost of illness in Sweden 1964-1975, Liber, Lund, 1981. Rice, D.P., Feldman, J.J. and White, K.L., The current burden of illness in the United States, Occasional Paper, Institute of Medicine, National Academy of Sciences, Washington, DC, 1976. Henke, K.-D., Schlierf, G., Arab, L. and Behrens, C.S., Kosten ernahrungsabhlngiger Krankheiten, Der Bundesminister fur Jugend, Familie und Gesundheit, Bonn, 1985, in press. Franke, A. and Jokl, S., Die volkswirtschaftlichen Kosten der Arbeitsunfalle, Bundesanstalt fur Arbeitsschutz und Unfallforschung, Dortmund, 1975. Pflanz, M., Was kostet die koronare Herzkrankheit?, Der Klinikarzt, 6 (1979) 679-682. Boschke, K., Sozialokonomische Aspekte der Hypotonie, Institut fur Gesundheitssystemforschung, Kiel, 1981. Cooper, B.S. and Rice, D.P., The economic cost of illness revisited, Social Security Bulletin, 39 (1976) 21-35. Hodgson, Th.A., The state of the art of cost-of-illness estimates, Advances in Health Economics and Health Services Research, 4 (1983) 129-164. Hodgson, Th.A. and Meiners, M.R., Cost-of-illness methodology: A guide to current practices and procedures, Milbank Memorial Fund Quarterly/Health and Society, 60 (1982) 429-462. Hu, T.-W. and Sandifer, F.H., Synthesis of cost of illness methodology, U.S. Department of Health and Human Services, Washington, DC, 1981. Statistisches Bundesamt, Die Struktur der Ausgaben im Gesundheitsbereich und ihre Entwicklung seit 1970, Vertiefende Untersuchung zur Aussagefahigkeit der amtlichen Statistik, Der Bundesminister filr Arbeit und Sozialordnung, Bonn, 1978. Statistisches Bundesamt, Fachserie 12, Gesundheitswesen, Reihe S.2, Ausgaben fur Gesundheit 1970 bis 1980, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Mtiller, W., Ausgaben fur Gesundheit, Wirtschaft und Statistik, 35 (1984) 791-797. Verband der privaten Krankenversicherung, Die private Krankenversicherung, Rechenschaftsbericht 1981, Verband der privaten Krankenversicherung, Koln, 1982. Zentralinstitut fur die kassenlrztliche Versorgung in der Bundesrepublik Deutschland, Studie “Erhebung tiber die ambulante Versorgung durch niedergelassene Arzte - EVaS” 1981/1982, Zentralinstitut fur die kassenarztliche Versorgung in der Bundesrepublik Deutschland, Kiiln, 1985, in press. Bundesverband der Ortskrankenkassen, Statistik der Ortskrankenkassen, Krankheitsarten-, Krankheitsursachenund Sterblichkeitsstatistik sowie Gliederung der Arbeitsunfahigkeitsund Krankenhausfalle nach ihrer Dauer, 1980, Bundesverband der Ortskrankenkassen, Bonn, 1982. Wissenschaftliches Institut der Ortskrankenkassen, Analyse der Struktur und Entwicklung der Arzneimittelausgaben der Krankenversicherung der Rentner aus Daten des GKV-Arzneimittelindex, Vorllufiger Bericht, Mlrz 1983, Wissenschaftliches Institut der Ortskrankenkassen, Bonn, 1983.
143
19
20 21 22 23
24 25 26 27 28 29
Verband deutscher Rentenversicherungstrlger, Die Leistungen zur Rehabilitation und die zusatzlithen Leistungen in der gesetzlichen Rentenversicherung im Jahre 1980, Verband deutscher Rentenversicherungstrager, Frankfurt/M., 1981. Statistisches Bundesamt, Fachserie 12, Gesundheitswesen, Reihe 4, Todesursachen 1980, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Statistisches Bundesamt, Statistisches Jahrbuch 1982 furdie Bundesrepublik Deutschland, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Maib, J., Fehlzeiten, Universitlt Gottingen, Gottingen, 1981. Hauptverband der gewerblichen Berufsgenossenschaften, Ubersicht uber die Geschlftsund Rechnungsergebnisse der gewerblichen Berufsgenossenschaften im Jahre 1980, Hauptverband der gewerblichen Berufsgenossenschaften, Bonn, 1981. Verband deutscher Rentenversicherungstrager, Rentenzugang des Jahres 1980 einschliel3Iich Rentenwegfall/Rentenumwandlung, Verband deutscher Rentenversicherungstrlger, Frankfurt/M., 1982. Der Bundesminister fur Arbeit und Sozialordnung, Die gesetzliche Unfallversicherung in der Bundesrepublik Deutschland im Jahre 1980, Der Bundesminister fur Arbeit und Sozialordnung, Bonn, 1982. Arrow, K.J., The limits of organization, Norton, New York, NY, 1974. Fuchs, V.R., Who shall live?, Basic Books, New York, NY, 1983. Harron, F., Burnside, J. and Beauchamp, T., Health and Human Values, Yale University Press, New Haven-London, 1983. U.S. Department of Health and Human Services, Health United States, 1980, U.S. Department of Health and Human Services, Washington, DC, 1980.
6 (1966) 119-143
119
HPE00086
The economic cost of illness in the Federal Republic of Germany in the year 1980 Klaus-Dirk Department Accepted
Henke and Cornelia S. Behrens of Economics,
24 October
University
of Hannover,
F.R.G.
1985
Summary This paper provides an empirical investlgatlon of the economic cost of illness, disability and premature death in the Federal Republic of Germany in the year 1990. Direct and indirect cost of morbidlty and mortality are estimated and allocated to the disease categories of the ICD-lnternatlonal Classification of Diseases. Against the background of increasingly scarce resources in health care, the findings of cost of Illness studies obtain special significance for the setting of priorities for the allocation of these resources. In comparison to the status quo, a disease-orlented approach may provide a more differentiated and national basis for the ex-ante macroallocatlon of health care resources as well as for the identification of areas for increased efforts in prevention. cost of Illness; resource allocation;
Federal Republic of Germany
I. Introduction Until the present day, numerous cost of illness studies have been carried out mainly in the U.S.A., but also in some European countries, e.g. Sweden [1,2]. Apart from giving an indication of the burden of illness, disability, and death to society, it has been
Addressfor correspondence: Prof. Dr. K.D. Henke, Institut ver, Wunstorfer Strasse 14, D-3000 Hannover 91, F.R.G.
0168-8510/86/%03.50
0 1986 Elsevier Science Publishers
fiir Volkswirtschaftslehre,
B.V. (Biomedical
Division)
Universitlt
Hanno-
120
argued that the measurement of that burden takes on special significance for the setting of priorities for the allocation of scarce resources, and the evaluation of health research and health service programs [3]. Prior to the study [4] the main findings of which are presented below, there existed no comprehensive cost of illness study in West Germany, but rather a small number of analyses which attempted to estimate the cost of selected diseases [5-71. This situation was caused by the lack of appropriate data, in particular, in regard to data on health care expenditures and data on health resources utilization. While, in the meantime, more data have become available in West Germany, detailed statistics as for example are used in American cost of illness studies are still an exception in Germany. Thus, the findings of the present study have to be judged against this background, and to be viewed as a first attempt to develop information on the cost of illness in West Germany.
II. Methodological
background
of the present study
The present study relies on the various methodological concepts developed by Rice [ 1,8], which have a great influence on the state of the art of cost of illness studies until the present day [9-111. Direct costs of illness are estimated on the basis of expenditure data, although it is understood that expenditures may not reflect correctly the true opportunity costs of the resources which are used due to illness. Expenditures for the so-called “core” costs are identified, whereas various add-ons are not included. For the estimation of indirect costs of illness the traditional human capital approach is used. Whereas there are drawbacks of the concept vis-a-vis the alternative willingness-to-pay approach, the empirical development of the latter is yet still in its infancy in West Germany. Psychosocial costs are not estimated. Nevertheless, it may be argued that our estimates include at least some of the psychological and social consequences of illness, disability and death, viz. those which give rise to the consumption of some health care resources (e.g., psychiatric treatment) and/or entail productivity losses. The results presented below are prevalence-based estimates. The International Classification of Diseases (ICD, 1968) is used for the distribution of illness costs by disease categories.
Ill. Direct cost of illness in the Federal Republic of Germany in the year 1980 1. Background In 1976, the German Federal Statistical Office began to lay the theoretical foundation for comprehensive statistics combining the existing estimates ofpublic and private expenditures for health services [ 121. As of writing, annual expenditure data by type of
121
carrier and by object of expenditure or by type of health service are available for the period 1970 to 1982 [13,14]. In 1980, health care expenditures amount to DM 200520 million, including DM 11916 million for various preventive measures, maternity benefits, and nursing home care, DM 116 857 million for medical care treatment, DM 61 350 million for various health-related transfer payments, DM 2909 million for medical education and training, and medical research, DM 7488 million comprising, mainly, net costs of the various insurance carriers. Of these, transfer payments have to be deducted because, as indirect costs are estimated separately, they would imply double counting, leaving a sum of DM 139 170 million. Due to lack of appropriate data the allocation of expenditures by disease is limited in this analysis to a sum of DM 87 462 million (see Table 1 for details), i.e. approximately 63% of the outlay for health and medical care in 1980. The remaining 37% comprise a variety of personal and nonpersonal expenditures includingto name the quantitatively most important categories - public expenditures for nursing home care and for hospital construction, expenditures of the statutory health insurance for various drug sundries and medical appliances, the larger share of health care expenditures of private households, public expenditures for medical education and training, and medical research as well as the net cost of insurance. It can be assumed that due to the exclusion of these expenditure categories, the direct cost, especially of certain chronic diseases, will be underestimated. To enhance the statistical basis is an area for additional research so that (some of) these categories of expenditures can be included in future cost of illness studies in West Germany. 2. Estimating
procedure
For some expenditure categories the distribution by diagnosis is based on the type of (insurance) carrier, whereas other categories of expenditures are distributed by diagnosis on the basis of type of health service or the utilization of the specific type of service respectively. (a) Distribution of expenditures by diagnosis on the basis of type of (insurance) carrier The expenditures of the statutory accident insurance amounting to DM 1836 million are classified in the diagnostic group “injuries and adverse effects of chemical and other external conditions” (subsequently referred to as injuries). The outlays of the private health insurance reaching a sum of DM 5748 million are allocated according to statistics on the distribution of services by diagnosis published annually by the Association of Private Health Insurance Funds [15]. Use of these statistics is also made for the distribution by diagnosis of the expenditures of public employers amounting to DM 4469 million. (b) Distribution of expenditures by diagnosis on the basis of type of health service The expenditures of the statutory health insurance for services of physicians (DM 15 358 million) are allocated on the basis of the percentage distribution of
1
of expenditures
in the estimation
Derived
and calculated
69 386
Total
from Ref. 13.
93
514
3 306
70
1836
22
5 784
4 868
437
766
10
1939
343 2632
12573 1439 7351
906
1716
1734
901
20 876 15 358 5518 25 465
1342
544
Public and private employers
2189
Private households
364
2111
Amount
2189
87 462
12 573 1439 10 583
15679
85351 24 870 15 358 5861 30973 31 3 246
1407
334 3
Private health insurance
334
364
Statutory accident insurance
100.0
(1.6) 12.1
(14.4)
17.9
(0.0) 3.7
(6.7) 35.4
97.6 28.5 (17.6)
1.6
0.4
0.0
0.4
2.4
Percent
All expenditure carriers
and by type of health service, in million DM, 1980
6
3 236
Statutory pension insurance
carrier
6
Statutory health insurance
of direct cost of illness, by type of expenditure
14012
31 31
62
Public households
Type of carrier
included
(2) Medical care treatment ambulatory care physicians dentists hospital care tuberculosis aid inpatient rehabilitation treatment drugs, drug sundries and medical supplies from pharmacies from opticians dental prostheses
(1) Preventive measures and maternity benefits prevention of industrial accidents, first aid health insurance dental examination service measures for early detection of cancer maternity benefits
Type of service
Categories
Table
123
office visits to physicians, according to speciality, by (principal) diagnosis. These data stem from a representative sample of 13 185 office visits during the 4th quarter of 198 1 and the 1st quarter of 1982 [16]. The estimating procedure is based on the assumption that the cost of each office visit, by physician speciality, is the same. The allocation of expenditures of the statutory health insurance for hospital care amounting to DM 25465 million is based on the distribution of days of care by (principal) diagnosis. The data are obtained from a representative sample of cases/ days of hospital care by diagnosis as reported from the Federal Association of Local Sickness Funds [17]. In 1980, approximately 47% of the German population was insured in these funds. Here, the assumption is made that the cost of a day of hospital care for each type of disease is the same. Variations of daily costs are allowed for only in regard to insurance status, a day of hospital care being valued at DM 188.43 in the case of compulsory and voluntary members and their family dependents, and at DM 182.25 in the case of insured pensioners and their family dependents. The expenditures of the statutory health insurance for drugs and drug sundries from pharmacies are allocated by diagnosis on the basis of results from the Statutory Health Insurance Medical Index [ 181. The 1981 percentage distribution of sales in DM by diagnostic group is applied to the 1980 outlays for drugs and drug sundries amounting to DM 12573 million. The allocation of an amount of DM 3236 million for inpatient rehabilitation treatment granted by the statutory pension insurance is based on the distribution of cases of treatment by diagnosis as reported by the Association of Pension Insurance Carriers [19]. Here, it is assumed that the costs per case of treatment are the same for all diagnoses. The expenditures of various carriers for other types of services are classified as follows: - expenditures of public households and the statutory health insurance for maternity benefits (DM 1404 million) in the diagnostic group “deliveries and complications of pregnancy, child birth and puerperism” (subsequently referred to as maternity), - expenditures of the statutory health insurance for medical supplies from opticians (DM 1439 million) in the diagnostic group “diseases of the nervoussystemandsense organs”, - expenditures of the statutory health insurance for the early detection ofcertain forms of cancer (DM 334 million) in the diagnostic group “neoplasms”, - expenditures of the statutory health insurance, the statutory pension insurance and private households for dental services including dental prostheses (DM 15 134 million) in the diagnostic group “diseases of the digestive system”, - expenditures of the public households for tuberculosis aid (DM 31 million) in the diagnostic group “infective and parasitic diseases”. 3. Findings From Table 2 the summarized results for the allocation of expenditures by diagnosis and by type of carrier or by type of service can be obtained. Expenditures for diseases of the digestive system rank highest amounting to DM 22 552 million or 25.8% of the
expenditures
Diseases of the nervous system and sense organs Diseases of the circulatory system
240 563
729
146
24
263 179
55
Public employers
1439
334
31
2 161
1420
571
77
325 628
427
Physicians’ services
4314
1112
2029
148
2 140 987
456
Hospital care
service or by type of expenditure
Other health services*
and by type of health
311
189
Mental, psychoneurotic personality disorders
and
31
340 232
Neoplasms Allergic, endocrine, metabolic and nutritional diseases
Diseases of blood and blood-forming organs
72
Private health insurance
by diagnosis
Statutory accident insurance
- selected categories,
and parasitic
Infective diseases
Diagnosis
Health
Table 2
465
38
389
1
108 145
353
Inpatient rehabilitation treatment
carrier,
4221
387
1015
87
30 915
730
12453
4 941
4 339
368
3 540 3 086
2 124
Amount
14.2
5.7
5.0
0.4
4.0 3.5
2.4
Percent
Total expenditure
DM, 1980 Drugs, drug sundries from pharmacies
in million
for early detection
* Tuberculosis
aid, measures
1836
1836
All diagnoses
Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and illdefined conditions Injuries Miscellaneous 251 72 454 16 4 246 665
325 93 587 20 6 318 345
of cancer,
5 784 medical
4 868
1055 358
1365 463
277
358
supplies
15 358
797 2 268
283
46 4
2 129
616
695 1033
from opticians,
18342
1404
15 134
1878
dental
services,
25 465
2913
1355
223 205
1548
598 665
3 103 1871
1798
dental
3 236
15 168
74
3
1058
13
105 86
215
prostheses,
12573 maternity
3 767
1266
512
1095 304
1241
benefits.
87 462
6 574 3 203
2276
308 219
7 042
2578 1971
22 552 4115
5 767
100.0
7.5 3.7
2.6
0.4 0.2
8.1
2.9 2.3
25.8 4.7
6.6
126
total DM 87 462 million. The dominating position of this disease category islargelydue to the high proportion of expenditures for dental services. Being well recorded in the existing expenditure data, they constitute approximately 19% of the total expenditures included in this analysis, Diseases of the circulatory system are in second place with expenditures of DM 12 453 million or 14.20/o, followed by diseases of the bones and organs of movement (DM 7042million or 8.l’%)andinjuries(DM 6574million or 7.5%). These four diagnostic groups comprise about 56% of the direct cost of illness in West Germany in the year 1980. In appraising the results in Table 2 it should be borne in mind, however, that total expenditures as well as their distribution by diagnosis are dependent upon the exclusion of expenditures of certain carriers and for certain types of health service respectively. The procedure used here, as much as any alternative procedure, implies an underestimation of direct costs with the degree of underestimation varying between disease categories.
IV. Indirect cost of mortality in the Federal Republic of Germany in the year 1980 1. Background Indirect costs of mortality comprise the estimated cost or value to society of all deaths occurring in West Germany in the year 1980. The estimates presented below constitute total mortality losses taking also into account future losses in output resulting from the deaths in 1980; accordingly no separate estimation of annual mortality costs is carried out. The human capital approach is employed to quantify the value of a human life. Various sets of cross-sectional data are utilized for the estimation. Due to lack of data no value of housewives’ services could be imputed. 2. Estimating
procedure
Four stages in the estimation (a) Number annually by [20]. Every reported on
of mortality
losses can be distinguished.
of deaths The number of deaths by diagnosis, age and sex is record-ed the,German Federal statistical Office in the national mortality statistics death is attributed to one underlying condition, based on information the death certificate.
(b) Total years lost average number of years the mortality conditions deaths by diagnosis are estimated life expectancy
Years lost per person by age and sex are estimated as the of life remaining to a male/female at that particular age given existing in the period 1978/1980 [21]. Total years lost of all the product of the number of deaths by diagnosis and the with age and sex taken into account.
(c) Total man-years lost to productivity
Man-years
lost to productivity
per person
127
by age and sex represent the number of years in the labour force for the average male/female as he/she grows older taking into account again the prevailing mortality conditions. Use is made of 1980 cross-sectional labour force participation rates by age and sex [21]. Total man-years lost of all deaths by diagnosis are obtained by multiplying the number of all deaths by diagnosis and the age- and sex-specific estimates of man-years lost to productivity.
(d) Present value of lifetime earnings
In the estimation of the present value of lifetime earnings by age and sex, labour force years per person by age and sex are multiplied by the corresponding age- and sex-specific annual mean earnings. Here too, 1980 cross-sectional data are used. Two discount factors, viz. 4% and 6% are applied to aggregate earnings. In Table 3, the present values of lifetime earnings by age and sex are given for the two discount factors. Indirect costs of mortality by diagnosis are the product of the number of deaths by diagnosis and the estimates of the present values of lifetime earnings with age and sex taken into account.
3. Findings (a) Number of deaths In 1980, a total number of 714 117 deaths (males: 348 015, females: 366 102 deaths) is reported for West Germany (see Table 4). Diseases of the circulatory system account for the largest number of deaths: 359 503 or 50.3% of the Table 3 Present
value of lifetime earnings,
Age (years)
o-5 5-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 >90
amount
Males
discounted
at 4% and 6%, by age and sex, in DM Females
4%
6%
4%
6%
248 532 305481 372 560 444 244 495412 507 657 484 568 434 550 371416 300 345 216942 123718 47 608 11355 1636 1068 878 740 646
133 266 180 165 241636 313 559 371920 397 515 39 I 900 361 197 317213 264 355 196 964 115483 45 269 10898 1502 979 819 700 623
116915 143 348 174 699 201336 203 208 185 361 166369 145 780 120 305 91264 59 294 26975 5 694
67510 91016 121978 151606 159 440 148 349 136 266 122825 104 294 81577 54718 25691 5 525 227 122 64 49 42 39
250 134 70 52 45 41
3 192 2672 2 086 748 1528 627 135
4844 4 784 3 580 2831 2 803 1508 443
Calculated
from Ref. 20.
All diagnoses 714117
348015
3 648
7421
128
5 337
10 352
Maternity
5 352
163 669 81556 25 762 23 856 20 321 7520
366 102
128
308
1275 881
2112 1494 2083
1652
3 773
5015
10376
195 834 82 680 16713 15647 16987 9 144
100.0
0.0
0.1
0.4 0.2
0.7 0.5 0.4
0.7
1.0
1.5
2.2
50.3 23.0 6.0 5.5 5.2 2.3
Total
Females
Total
Males
Percent
Amount
15728
1980
Allergic, endocrine, metabolic and nutritional diseases Diseases of the genitourinary system Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Infective and parasitic diseases Certain diseases of early infancy Diseases of the bones and organs of movement Congenital malformations Diseases of blood and blood-forming organs Diseases of the skin and cellular tissue
by diagnosis,
359 503 164236 42 475 39 503 37314 16664
of deaths,
system Diseases of the circulatory Neoplasms Injuries system Diseases of the respiratory Diseases of the digestive system Symptoms, senility and ill-defined conditions
Diagnosis
Number
Table 4
100.0
0.0
0.4 0.2
0.8 0.6 0.2
0.9
1.1
1.5
1.5
47.0 23.4 7.4 6.9 5.9 2.2
Males
100.0
0.0
0.1
0.3 0.2
0.6 0.4 0.6
0.5
1.0
1.4
2.8
53.5 22.6 4.6 4.3 4.6 2.5
Females
129
total. Neoplasms rank second with 164 236 deaths or 23%, injuries third with 42 475 deaths or 6% of the total. These three diagnostic groups, therefore, account for almost 80% of total deaths. Males and females reveal varying patterns of deaths with circulatory diseases being a relatively more important cause of death for females, whereas injuries account for a relatively larger share of deaths among males. (b) Total years lost The deaths in 1980 yield a total loss of 8 804 703 years (males: 4 576 123; females: 4 228 580 years). As can be seen from Table 5, circulatory diseases, neoplasms and injuries still rank first, second and third. Yet their proportions of total years lost have changed to 37%, 23.9% and 13%, respectively, giving a total of approximately 74%. As compared to the number of deaths, diseases of the circulatory system have lost some of their importance due to the fact that deaths from these diseases are dominant among the aged who have a relatively short life expectancy. In contrast, deaths from injuries occur more often among the younger with a relatively long life expectancy causing the proportion of total years lost due to injuries to increase sharply. Here again, sex-specific differences can be observed with respect to circulatory diseases and to injuries, reflecting the relative importance of these causes of death for males and females respectively. A total of 1862 740 man-years are lost (c) Total man-years lost to productivity because of the deaths in 1980 (see Table 6). With males having higher labour force participation rates in each age group compared with females, deaths among males account for 1452 839 man-years lost to productivity, whereas deaths among females result in the loss of 409901 man-years. Comparing the findings summarized in Tables 4 and 5 with those in Table 6 a different picture emerges. Injuries now rank first: 539 224 man-years lost of 28.9% of the total. Diseases of the circulatory system drop to second place with a loss of 355 116 man-years (19.1%) and neoplasms are in third place with 340037 man-years lost (18.3%). These three diagnostic groups account for more than 66% of the total man-years lost to productivity. Injuries and neoplasms show sex-specific variations. Whereas injuries account for almost a third of man-years lost for males, their proportion of total man-years lost for females is only about 20%. In contrast, neoplasms rank highest for females causing about a fourth of the total loss of man-years. (d) Indirect cost of mortality In Table 7, the indirect costs caused by the deaths in the year 1980 are shown. Applying the present values of lifetime earnings discounted at 4% yields a total loss of DM 27.8 billion (males: DM 24 billion; females: DM 3.8 billion). As to injuries, circulatory diseases, and neoplasms, their proportion of total indirect cost, viz. 28.2%, 22.4%, and 20.7%, respectively, is largely equivalent to that of total man-years lost. Here too, the same sex-specific variations can be observed. Indirect costs of mortality decrease to a total of DM 23.1 billion when the present values of lifetime earnings discounted at 6% are applied [4]. The ranking of diagnostic groups remains unchanged,,but for one exception: diseases of the nervous system and sense organs advance to place eight.
Table 5
1980
All diagnoses
Diseases of the circulatory system Neoplasms Injuries Diseases of the digestive system Diseases of the respiratory system Certain diseases of early infancy Symptoms, senility and ill-defined conditions Congenital malformations Allergic, endocrine, metabolic and nutritional diseases Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Diseases of the genitourinary system Infective and parasitic diseases Diseases of the bones and organs of movement Diseases of blood and blood-forming organs Maternity Diseases of the skin and cellular tissue
Diagnosis
Total years lost, by diagnosis,
13 285 47 096 50 149 8 154 8 470
2035
105 289 102 496 90687 28 735 20001 6 191 6 189
4576 123
72 889
142 194
8 804 703
95 609 65 340
1583 083 971929 780 380 310325 231695 141145 134539
182699 181378
3 256 375 2 107516 1 145 496 539210 395 154 252 170 242 923
4 228 580
6 191 4 154
11531
40538 20581
55 400
32 004
69 305
87 090 116038
1673 292 1 135 587 365 116 228 885 163 459 111025 108 384
100.0
0.1 0.1
0.2
1.0 0.3
1.2
1.2
1.6
2.1 2.1
37.0 23.9 13.0 6.1 4.5 2.9 2.7
Total
Females
Total Males
Percent
Amount
100.0
0.0
0.2
1.1 0.2
1.0
1.6
1.6
2.1 1.4
34.6 21.2 17.1 6.8 5.1 3.1 2.9
Males
100.0
0.2 0.1
0.3
1.0 0.5
1.3
0.8
1.6
2.1 2.7
39.6 26.8 8.6 5.4 3.9 2.6 2.6
Females
lost to productivity,
All diagnoses
Injuries Diseases of the circulatory system Neoplasms Diseases of the digestive system Certain diseases of early infancy Congenital malformations Symptoms, senility and ill-defined conditions Diseases of the respiratory system Diseases of the nervous system and sense organs Mental, psychoneurotic and personality disorders Infective and parasitic diseases Allergic, endocrine, metabolic and nutritional diseases Diseases of the genitourinary system Diseases of blood and blood-forming organs Diseases of the bones and organs of movement Maternity Diseases of the skin and cellular tissue
Diagnosis
Total man-years
Table 6
36 306 20 288 17679 8973 2 846 2036
779
41826 28061 25631 12959 4 253 3 275 2027 1372
1452 839
46 282 32 666
61821 43 755
1862 740
456 263 289 748 237 872 108213 79 032 54 597 59 259
539 224 355 116 340037 132 222 113523 81260 76018
409 90 1
2 027 593
1239
1407
3 986
7773 7 952
5 520
15 539 11089
82961 65 368 102 165 24 009 34491 27 023 16759
100.0
0.1 0.1
0.1
0.1
0.7
1.5 1.4
2.2
3.3 2.3
28.9 19.1 18.3 7.1 6.1 4.4 4.1
Total
Females
Total
Males
Percent
1980
Amount
by diagnosis,
100.0
0.1
0.1
0.2
0.6
1.4 1.2
2.5
3.2 2.3
31.4 19.9 16.4 7.4 5.4 3.8 4.1
Males
100.0
0.5 0.1
0.3
0.3
1.0
1.9 1.9
1.4
3.8 2.7
20.2 16.0 24.9 5.9 8.4 6.6 4.1
Females
w
All diagnoses
tissue 27831
22 20
cellular
49
organs of movement Maternity Diseases of the skin and
60
blood-forming organs Diseases of the bones and
of blood and
331 191
and nutritional diseases Infective and parasitic diseases Diseases of the genitourinary
system Diseases
414 306
566 311
24 029
14
37
46
269 155
518 486
693 589
712 711
personality disorders Certain diseases of early infancy Diseases of the nervous system and sense organs Congenital malformations Allergic, endocrine, metabolic
848 117
7 048 5 613 4 586 2 187 867
Males
Females
3 802
22 6
12
14
62 42
152 71
175 103
136 66
807 567 1161 274 132
100.0
0.1 0.1
0.2
0.2
1.2 0.7
2.0 1.4
2.5 2.1
3.0 2.8
28.2 22.4 20.1 8.8 3.6
Total
DM,l980
Total
in million Percent
at 4 percent,
Amount
discounted
ill-defined conditions Diseases of the respiratory system Mental, psychoneurotic and
by diagnosis,
7 855 6 240 5 147 2461 999
cost of mortality,
Injuries Diseases of the circulatory system Neoplasms Diseases of the digestive system Symptoms, senility and
Diagnosis
Indirect
Table 7
100.0
0.1
0.1
0.2
1.1 0.6
1.7 1.3
2.2 2.0
3.0 3.0
29.3 23.6 19.1 9.1 3.6
Males
100.0
0.6 0.2
0.3
0.4
1.6 1.1
4.0 1.9
4.6 2.7
3.6 1.7
21.2 14.9 30.5 7.2 3.5
Females
_
133
V. Indirect cost of morbidity in the Federal Republic of Germany in the year 1980 1. Background Costs of morbidity are the second component of indirect cost of illness. They comprise the estimated loss of output imposed upon society by illness and disability during the year 1980. Again the human capital approach is used to quantify the value of the productive time lost because of morbidity. The estimation is limited in this analysis to indirect costs arising from illness of the currently employed and to indirect costs arising from disability of persons who have been granted pensions on account of disability for the first time in 1980. Thus, morbidity costs could not be estimated for the majority of those unable to work because of chronic illness or disability, for women unable to keep house because of illness or disability, as well as for persons institutionalized because of illness.
2. Estimating procedure (a) Man-years lost due to short-term illness of the currently employed Manyears lost from work associated with acute and chronic conditions comprise absence from work because of temporary illness, industrial accidents as well as absence from work during inpatient rehabilitation treatment. Absence from work by sex is estimated on the basis of respective inactivity rates for workers, employees and public servants [22]. The total number of man-years lost is allocated by diagnosis according to the sex-specific percentage distribution of days of incapacity for work by insurance status and diagnosis as reported by the Federal Association of Local Sickness Funds [17]. The loss of productive time because of industrial accidents is recorded by the statutory accident insurance [23]. Man-years lost for this category are allocated to the diagnostic group “injuries”. Finally, absence from work during inpatient rehabilitation treatment is estimated on the basis of cases of treatment by sex granted from the statutory pension insurance [ 191. Man-years lost are distributed to diagnostic groups according to the (principal) diagnosis recorded for the treatment.
(b) Man-years lost due to disability
Morbidity losses by sex due to disability are estimated for those formerly employed who have been for the first time in 1980 granted pensions on account of disability by the statutory pension insurance [24] and the statutory accident insurance [25]. For the estimation of man-years lost pension figures are divided in half on the assumption that the pattern of cases is approximately symmetrical about midyear. Man-years lost are allocated according to the (principal) diagnosis reported for the pensions by the Association of Pension Insurance Carriers [24]. Man-years lost resulting from pensions granted by the statutory accident insurance are assigned to the diagnostic group “injuries”.
134
(C) Earnings Year-round ries before deductions
full-time earnings (by sex) which include are employed as a measure of output loss.
wages and sala-
3. Findings (a) Man-years lost due to short-term illness of the currently employed
In
1980, 22 337 million dependent employed persons account for a total of 1434 310 man-years lost due to incapacity for work (males: 867 104; females: 567 206). The loss of man-years from industrial accidents in 1980 amounts to 76 685 man-years (males: 57 008; females: 19 677). Absence from work because of inpatient rehabilitation treatment adds another 64212 man-years lost (males: 41481; females: 22731). The total loss of productive time in 1980 due to short-term illness of the currently employed by sex and diagnosis can be seen in Table 8. Diseases of the bones and organs of movement rank highest accounting for 311260 man-years lost or 19.8% of the total. Diseases of the respiratory system are in second place with a loss of 265 077 man-years or 16.8%, injuries rank third with 238 815 man-years lost or 15.2% of the total. These three diagnostic groups constitute more than 50% of the total loss of productive time because of short-term illness. Sex-specific differences can be observed in regard to diseases of the bones and organs of movement as well as to injuries, diseases of these two groups being more often the cause for short-term illness among males than among females. In contrast, diseases of the genitourinary system and neoplasms are more prevalent among females.
(b) Man-years lost due to disabillty In 1980, 146 716 persons (males: 95 330; females: 5 1386) have been for the first time granted pensions on account of disability by the statutory pension insurance, and an additional 417 persons (males: 3 18; females: 99) have been for the first time granted equivalent pensions by the statutory accident insurance. A total of 73 566.5 man-years (males: 47 824; females: 25 742.5) are estimated to be lost in 1980 due to disability. From Table 9, the 1980 total loss of man-years by sex and diagnosis can be obtained. Diseases of the circulatory system and diseases of the bones and organs of movement rank first and second, accounting for 27 211 and 13 466.5 man-years lost or 37% and 18.3% of the total, respectively. Whereas the former diagnostic group is relatively more significant for disability among males than among females, the reverse is true for the second diseases category. (c) Total man-years lost due to morbidity In 1980, a total of 1.65 million
manyears are lost in West Germany due to morbidity (see Table 10). Including the loss of productive time because of disability does not markedly change the picture as compared to the pattern revealed in Table 8, with the exception of circulatory diseases now rking fourth.
(d) Indirect cost of morbidity for males,
In 1980, a man-year lost is valued at DM 27 157 and at DM 18 116 for females. Indirect costs of morbidity are obtained
lost to productivity
All diagnoses
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Diagnosis
Total man-years
Table 8
Females
965 593
177 946 1953
238815 2915 1575 207
33 278
21978
29 607 34641
60 101
89 828 161676 109 381 19648
144 099 265 077 162407 67 237
2 182
44 275
71768
4 645
36321
65621
202 188
1404
3361
311260
33 942 16624 12969
53 036 38 585 22 032
609 614
60 869 962
26 823
2463
109072
29 607 12663
54271 103 401 53 026 47 589
27 493
29 300
1957
19094 21961 9 063
100.0
15.2 0.2
3.8
0.3
19.8
1.9 2.2
9.1 16.8 10.3 4.3
4.5
4.2
0.2
3.4 2.4 1.4
Total
Males
Total
1980 Percent
illness, by diagnosis,
Amount
due to short-term
100.0
18.4 0.2
3.5
0.2
20.9
2.3
9.3 16.8 11.3 2.0
4.6
3.8
0.2
3.5 1.7 1.3
Males
100.0
10.0 0.2
4.4
0.4
17.9
4.8 2.1
8.9 17.0 8.7 7.8
4.5
4.8
0.3
3.1 3.6 1.5
Females
E
lost to productivity
All diagnoses
Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system
Diagnosis
Total man-years
Table 9
1 197 1686.5 1841.5
1910 2152 2 703
47 824
30
79
73 566.5
7 654
13466.5
18885.5 3416 2159 537
27211 4 229 2 823.5 900.5
99
2 029.5
3 148.5
161
3 648
48.5
410.5 3 297 885
6527
80
538.5 6027 1610
25 742.5
465.5 861.5
713
49
5 812.5
62
8 325.5 813 664.5 363.5
1119
2879
31.5
128 2 730 725
100.0
2.9 3.7
2.6
0.1
18.3
0.2
37.0 5.8 3.8 1.2
4.3
100.0
3.5 3.9
2.5
0.1
16.0
0.2
39.5 7.1 4.5 1.1
4.2
7.6
0.1
0.1
8.9
0.9 6.9 1.9
Males
0.7 8.2 2.2
Total
Females
Total
Males
1980 Percent
by diagnosis,
Amount
due to disability,
100.0
1.8 3.3
2.8
0.2
22.6
0.2
32.3 3.2 2.6 1.4
4.4
11.2
0.1
0.5 10.6 2.8
Females
10
lost to productivity
All diagnoses
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases Diseases of blood and blood-forming organs Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy Symptoms, senility and ill-defined conditions Injuries Miscellaneous
Diagnosis
Total man-years
Table
Females
108713.5 165092 111540 20 185
22 077 209 842 2212 34475 179 632.5 3 794.5
171310 269 306 165 230.5 68 137.5 29 607 34 802 324726.5 4 724 62011 240 967 5618
1013417
46 304.5
74916.5
1648 773.5
39 969
1452.5
3441 72 148
34 352.5 19921 13854
53 574.5 44612 23 642
635 356.5
61334.5 1823.5
27 536
2512
114 884.5
29607 12725
62 596.5 104214 53 690.5 47 952.5
28612
32 179
1988.5
19 222 24691 9788
100.0
14.6 0.3
3.8
0.3
19.7
1.8 2.1
10.4 16.3 10.0 4.1
4.6
4.4
0.2
3.3 2.7 1.4
Total
Males
Total
1980 Percent
by diagnosis,
Amount
due to morbidity,
100.0
17.7 0.4
3.4
0.2
20.7
2.2
10.7 16.3 11.0 2.0
4.6
3.9
0.1
3.4 2.0 1.3
Males
100.0
9.7 0.3
4.3
0.4
18.1
4.7 2.0
9.9 16.4 8.4 7.5
4.5
5.1
0.3
3.0 3.9 1.5
Females
6; rl
138
by multiplying the sex-specific loss of man-years and the respective earning figures. In West Germany, 1980 indirect costs of morbidity amount to DM 39 billion (males: 27.5 billion; females: 11.5 billion). The distribution of morbidity costs by sex and diagnosis can be seen in Table 11. As compared to the findings summarized in Table 10, the ranking of diagnostic groups in Table 11 is left almost unchanged. Due to the fact, however, that man-years lost are valued higher for males, those disease categories which account for a larger proportion of man-years lost among males, viz. diseases of the bones and organs of movement, injuries, and circulatory diseases, gain, although only slightly, in importance. The reverse is true in regard to maternity and diseases of the genitourinary system which is/are only respectively more prevalent among females.
VI. Total cost of illness In the Federal Republic of Germany in the year 1980 In Table 12, the various results on the cost of illness, disability and death in West Germany in the year 1980 are joined together. It can be seen that diseases of the digestive system, diseases of the circulatory system, and injuries are the three most costly disease categories to society, comprising 18.8%, 14.8% and 13.2%, respectively of the total of DM 154 324 billion. Together with the diseases of the bones and organs of movement (9.6%), diseases of the respiratory system (8.4%) and neoplasms (6.7%), these six disease categories account for almost three quarters of the total cost of illness in West Germany. These results are strongly influenced by the amount and distribution by diagnosis of direct costs which contribute approximately 57% to total costs. Yet, whereas direct costs concentrate mainly on two diagnostic groups, the inclusion of indirect costs implies that other disease categories come to the fore as well. At this point it seems necessary to recall the limitations of the preceding analysis. Important components of the cost of illness, disability and death could not be estimated due to lack of data. In particular, it is assumed that costs of selected chronic diseases causing lifelong disability are grossly underestimated. Yet, to quote Arrow: “An unsatisfactory solution may be what is needed to provoke the needed information-gathering to produce a better one, while neglect is never productive” [26]. Against the background of increasingly scarce resources in health care [27], the findings of cost of illness studies obtain special significance for the allocation of these resources. In contrast to the status quo which in West Germany is characterized by an uncoordinated health policy of the various participating groups in the health care sector, a disease-oriented approach may provide a more differentiated and rational basis for the ex-ante macro-allocation [28] of health care resources. In the U.S.A., for instance, reference to cost of illness estimates has been made in regard to the so-called “Prevention Profile” [29] for whose triennial preparation legislation was enacted in 1978. Apart from indications as to whether, and if so, as to where to concentrate preventive efforts including medical research, findings from cost of illness studies offer a basis for decision making when the most expensive diseases are to be subjected to cost containment measures.
by diagnosis,
348 447 117 37
933 541 376 39
1281 988 553 76
1257 2953 4 484 3 029 548
600 5 699 60 936 4 878 103 27 521
1775 4087 6 372 4 002 1417 536 830 7 780 106 1435 5989 136 39031
Symptoms, senility and ill-defined conditions
Injuries Miscellaneous
All diagnoses
Mental, psychoneurotic and personality disorders Diseases of the nervous system and sense organs Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the genitourinary system Maternity Diseases of the skin and cellular tissue Diseases of the bones and organs of movement Congenital malformations Certain diseases of early infancy
11510
1111 33
499
46
2081
536 230
1134 1888 973 869
518
583
Females
Males
Total
1085
organs
DM, 1980
Amount
in million
1668
Diseases of blood and blood-forming
Infective and parasitic diseases Neoplasms Allergic, endocrine, metabolic and nutritional diseases
cost of morbidity,
11
Diagnosis
Indirect
Table
0.1
0.2
0.2 3.4 17.7 0.4 100.0
3.7 15.3 0.4 100.0
20.7
2.2
10.7 16.3 11.0 2.0
4.6
0.3
19.9
1.4 2.1
10.5 16.3 10.3 3.6
4.5
3.9
3.3 2.0 1.4
3.3 2.5 1.4
4.3
Males
Total
Percent
100.0
9.7 0.3
4.3
0.4
18.1
4.7 2.0
9.8 16.4 8.5 7.5
4.5
5.1
0.3
3.0 3.9 1.5
Females
c \o
140
141
142
As to the future it seems desirable to enhance the the quality of cost of illness studies. Apart from efforts to develop further the methodological concepts [9-l I], it appears necessary to improve the underlying statistical data so that future cost of illness analyses can consider, for example, population groups, regions, or specific diseases.
Acknowledgement This research has been supported Family, and Health, Bonn.
in part by the German
Federal
Ministry
for Youth,
References 1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16
17
18
Rice, D.P., Estimating the cost of illness, Health Economic Series no. 6, U.S. Department of Health, Education, and Welfare, Washington, DC, 1966. Lindgren, B., Cost of illness in Sweden 1964-1975, Liber, Lund, 1981. Rice, D.P., Feldman, J.J. and White, K.L., The current burden of illness in the United States, Occasional Paper, Institute of Medicine, National Academy of Sciences, Washington, DC, 1976. Henke, K.-D., Schlierf, G., Arab, L. and Behrens, C.S., Kosten ernahrungsabhlngiger Krankheiten, Der Bundesminister fur Jugend, Familie und Gesundheit, Bonn, 1985, in press. Franke, A. and Jokl, S., Die volkswirtschaftlichen Kosten der Arbeitsunfalle, Bundesanstalt fur Arbeitsschutz und Unfallforschung, Dortmund, 1975. Pflanz, M., Was kostet die koronare Herzkrankheit?, Der Klinikarzt, 6 (1979) 679-682. Boschke, K., Sozialokonomische Aspekte der Hypotonie, Institut fur Gesundheitssystemforschung, Kiel, 1981. Cooper, B.S. and Rice, D.P., The economic cost of illness revisited, Social Security Bulletin, 39 (1976) 21-35. Hodgson, Th.A., The state of the art of cost-of-illness estimates, Advances in Health Economics and Health Services Research, 4 (1983) 129-164. Hodgson, Th.A. and Meiners, M.R., Cost-of-illness methodology: A guide to current practices and procedures, Milbank Memorial Fund Quarterly/Health and Society, 60 (1982) 429-462. Hu, T.-W. and Sandifer, F.H., Synthesis of cost of illness methodology, U.S. Department of Health and Human Services, Washington, DC, 1981. Statistisches Bundesamt, Die Struktur der Ausgaben im Gesundheitsbereich und ihre Entwicklung seit 1970, Vertiefende Untersuchung zur Aussagefahigkeit der amtlichen Statistik, Der Bundesminister filr Arbeit und Sozialordnung, Bonn, 1978. Statistisches Bundesamt, Fachserie 12, Gesundheitswesen, Reihe S.2, Ausgaben fur Gesundheit 1970 bis 1980, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Mtiller, W., Ausgaben fur Gesundheit, Wirtschaft und Statistik, 35 (1984) 791-797. Verband der privaten Krankenversicherung, Die private Krankenversicherung, Rechenschaftsbericht 1981, Verband der privaten Krankenversicherung, Koln, 1982. Zentralinstitut fur die kassenlrztliche Versorgung in der Bundesrepublik Deutschland, Studie “Erhebung tiber die ambulante Versorgung durch niedergelassene Arzte - EVaS” 1981/1982, Zentralinstitut fur die kassenarztliche Versorgung in der Bundesrepublik Deutschland, Kiiln, 1985, in press. Bundesverband der Ortskrankenkassen, Statistik der Ortskrankenkassen, Krankheitsarten-, Krankheitsursachenund Sterblichkeitsstatistik sowie Gliederung der Arbeitsunfahigkeitsund Krankenhausfalle nach ihrer Dauer, 1980, Bundesverband der Ortskrankenkassen, Bonn, 1982. Wissenschaftliches Institut der Ortskrankenkassen, Analyse der Struktur und Entwicklung der Arzneimittelausgaben der Krankenversicherung der Rentner aus Daten des GKV-Arzneimittelindex, Vorllufiger Bericht, Mlrz 1983, Wissenschaftliches Institut der Ortskrankenkassen, Bonn, 1983.
143
19
20 21 22 23
24 25 26 27 28 29
Verband deutscher Rentenversicherungstrlger, Die Leistungen zur Rehabilitation und die zusatzlithen Leistungen in der gesetzlichen Rentenversicherung im Jahre 1980, Verband deutscher Rentenversicherungstrager, Frankfurt/M., 1981. Statistisches Bundesamt, Fachserie 12, Gesundheitswesen, Reihe 4, Todesursachen 1980, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Statistisches Bundesamt, Statistisches Jahrbuch 1982 furdie Bundesrepublik Deutschland, Kohlhammer Verlag, Stuttgart-Mainz, 1982. Maib, J., Fehlzeiten, Universitlt Gottingen, Gottingen, 1981. Hauptverband der gewerblichen Berufsgenossenschaften, Ubersicht uber die Geschlftsund Rechnungsergebnisse der gewerblichen Berufsgenossenschaften im Jahre 1980, Hauptverband der gewerblichen Berufsgenossenschaften, Bonn, 1981. Verband deutscher Rentenversicherungstrager, Rentenzugang des Jahres 1980 einschliel3Iich Rentenwegfall/Rentenumwandlung, Verband deutscher Rentenversicherungstrlger, Frankfurt/M., 1982. Der Bundesminister fur Arbeit und Sozialordnung, Die gesetzliche Unfallversicherung in der Bundesrepublik Deutschland im Jahre 1980, Der Bundesminister fur Arbeit und Sozialordnung, Bonn, 1982. Arrow, K.J., The limits of organization, Norton, New York, NY, 1974. Fuchs, V.R., Who shall live?, Basic Books, New York, NY, 1983. Harron, F., Burnside, J. and Beauchamp, T., Health and Human Values, Yale University Press, New Haven-London, 1983. U.S. Department of Health and Human Services, Health United States, 1980, U.S. Department of Health and Human Services, Washington, DC, 1980.