The Electronic Health Insurance Card for Asylum-Seekers in Berlin: Effects on the Local Health System

Abstract

Background: In debates on asylum-seekers’ access to healthcare it is frequently claimed that restrictions are necessary to prevent unduly high health service utilization and costs. Within Germany, healthcare provision for asylum-seekers varies across the different states. Berlin’s authorities removed some barriers to healthcare for asylum-seekers by introducing an electronic health insurance card (HIC) in 2016. We used the HIC introduction in Berlin as an opportunity to investigate the effects of improved healthcare access for asylum-seekers on the local health system. Methods: The study applied a mixed-methods design. A cost analysis compared expenses for outpatient and inpatient health services for asylum-seekers before and after the HIC introduction, based on aggregate claims data and information on expenses for humanitarian healthcare provision that were retrieved from the Berlin authorities. Semi-structured interviews with 12 key informants explored organizational effects like administrative workloads and ethical dilemmas for staff. We performed a content analysis and used respondent validation to enhance the accuracy and trustworthiness of our results. Results: The HIC has reduced bureaucratic complexity and administrative workloads; it has enabled unprecedented financial transparency and control; and it has mitigated ethical tensions. All the while, average per person expenses for outpatient health services have declined since the HIC introduction. However, our cost analysis also indicates a rise in the utilization and costs of inpatient care. Conclusion: The HIC introduction in Berlin suggests that the removal of barriers to healthcare for asylum-seekers can create win-win-situations by reducing administrative workloads, advancing financial transparency, and mitigating ethical tensions, whilst cutting the costs of outpatient healthcare provision. Removing barriers to healthcare thus appears to be a more prudent policy choice than maintaining mechanisms of restriction and control. However, high inpatient care utilization and costs warrant further research.

Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers and refugees. Results from a cross-sectional survey in Berlin, Germany

“…Incomplete information about ASRs' medical history and healthcare needs among health service providers may exacerbate such patters, leading to inadequate, insufficient or misguided provision of healthcare (11,12). Discrepancies between healthcare needs and the treatment provided, in turn, are liable to frustrate care-givers and patients and increase costs (13,14). In the long run, inadequate treatment of physical and mental health conditions compromises the wellbeing, quality of life, social relations, and integration of ASR in the host country, and entails economic losses, for example through reduced productivity or resources spent on informal care (9,15).…”

“…Across Germany, ASR may face different modes of healthcare provision, and thus different levels of health service accessibility, because the actual organization of healthcare provision for ASR is at the discretion of the local authorities (36). In Berlin, ASR obtain an electronic health insurance card upon arrival, which, in theory, should allow for access to healthcare providers in a similar fashion as statutory health insurance (13).…”

Sick and Tired—Sociodemographic and Psychosocial Characteristics of Asylum Seekers Awaiting an Appointment for Psychotherapy

“…The treating physicians, on the other hand, have to enter into a reimbursement process that differs from standard care and is less familiar to them [14,15]. Studies suggest that this intentional restriction of access to the health system is ultimately even more costly [16]. Superfluous bureaucracy has to be managed and the threat of chronification complicates treatments.…”

“…Administrative burdens and ethical tensions would be reduced and financial transparency increased. At the same time, the costs for outpatient health care would be reduced [16].…”

Associations between physical and mental health and the utilization of ambulatory and emergency healthcare among asylum-seekers: results from a cross-sectional survey in Berlin, Germany

“…It has been suggested that these patterns are causally related, reflecting and reproducing inequities in healthcare and health: Formal and informal access barriers may make asylum-seekers forgo timely treatment in the ambulatory sector and instead use other, potentially inadequate and more costly emergency health services [ 4 , 9 – 11 ]. Discrepancies between healthcare needs and the treatment provided, in turn, are liable to frustrate patients and care-givers [ 12 , 13 ]. In the long run, inequitable treatment of physical and mental health conditions compromises the wellbeing, quality of life, and social integration of asylum-seekers and entails economic costs, for example through reduced productivity or resources spent on informal care [ 9 , 14 ].…”