Inverted risk selection—a structural property of a new population-based integrated care system in Germany

BACKGROUND AND PURPOSE: In the Kinzigtal region in Southwest Germany, a population-based integrative care system has been set up in 2005–2006, organising care across all health service sectors and indications. The system is run by a regional health management company (Gesundes Kinzigtal GmbH) in cooperation with the physicians' network in the region and with two statutory health insurers (among them is the biggest health insurer in Southwest Germany: AOK Baden-Württemberg). Membership is optional for insured persons in the Kinzigtal area. In contrast to many other Managed Care organisations, Gesundes Kinzigtal and its partners have intentionally attempted to prevent a policy of risk selection and to organize a better (integrated) care first of all for the so-called ‘bad risks’ such as older persons and the chronically ill. To determine whether that attempt has been successful, we analyse the administrative data of the concerned health insurers during the building phase of the Kinzigtal system (2006–2008). THEORY: A common critique of Managed Care initiatives holds that while economic and financial goals have come to dominate, a strategy of risk selection—i.e. preferred recruitment of the young and/or healthy—has often been forwarded. To overcome this experience, Gesundes Kinzigtal and its partners have set up a specific system of contractual and financial incentives to realize a kind of inverted risk selection, implying the preferred recruitment of the so-called ‘bad risks’. In the contribution we outline the contractual and economic incentives which are to produce an inverted risk selection and a more efficient care in greater detail. METHODS: To check whether Gesundes Kinzigtal has managed to realize an inverted risk selection, age, social status and morbidity costs of the insured members of the integrated care network are compared with the data of those assureds in the Kinzigtal region who have not (yet) become members. The contribution will focus on the health insurers' administrative data that were collected during the whole building phase of the system (2006–2008). RESULTS AND CONCLUSIONS: The available data show that the Kinzigtal integrated care system has indeed managed to realize an inverted risk selection during its building phase (2006–2008), i.e. its members are considerably older and cause remarkably higher morbidity costs than the non-members in that area. DISCUSSION: The contractual and financial incentives of the Kinzigtal system have obviously been adequate means to realize an inverted risk selection. At the same time, the financial results of the first two years (2006–2007) of the system have turned out surprisingly positive (see other abstract)—thus Gesundes Kinzigtal demonstrates the huge potential of population-based integrated care approaches.