Background: Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models. Methods: In Germany's largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasiexperiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex. Results: SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC. Conclusion: The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

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IntroductionIn many countries, including Germany, newly arriving refugees face specific entitlement restrictions and access barriers to healthcare. While entitlement restrictions apply to all refugees who seek protection in Germany during the first months, the barriers to access depend on the model that the states and the municipalities implement locally. Currently, two different models exist: the healthcare voucher model (HcV) and the electronic health card model (eHC). The aim of the study is to analyse the consequences of these two different access models on newly arrived refugees’ realised access to healthcare.Methods and analysisThe random assignment of refugees to municipalities allows for a quasi-experimental design by comparing realised access to healthcare among refugees in six municipalities in North Rhine-Westphalia which have implemented HcV or eHC. We compare realised access to healthcare using ambulatory care sensitive conditions and health expenditure as outcome indicators, and use of emergency care, preventive care, psychotherapeutic or psychiatric care, and of therapeutic devices as process indicators. Results will be adjusted for aggregated information on age, sex, socioeconomic structure of the municipalities and density of general practitioners or specialists.Ethics and disseminationWe cooperated with local welfare offices and the statutory health insurance for data collection. Thereby, we were able to avoid recruiting large numbers of refugee patients immediately after arrival while their access and entitlement to healthcare are restricted. We developed an extensive data protection concept and ensured that all data collected are fully anonymised. Results will be published in peer-reviewed journals and summarised in reports to the funding agency.

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Zusammenfassung Ziel der Studie Der Zugang zur gesundheitlichen Versorgung für Geflüchtete wird bundesweit in den Kommunen unterschiedlich organisiert, sowohl im Hinblick auf die Organisation von (sozialarbeiterischen bzw. kommunalen) Unterstützungsangeboten als auch durch die Wahl des Zugangsmodells (elektronische Gesundheitskarte/eGK-Modell oder Behandlungsschein/BHS-Modell). In den letzten Jahren haben einige Bundesländer und Kommunen die Versorgung geflüchteter Patient(inn)en auf das Zugangsmodell mit eGK umgestellt. Wir analysieren auf Grundlage von Daten aus Nordrhein-Westfalen, wie sich der Zugang zur gesundheitlichen Versorgung aus Sicht Geflüchteter gestaltet und welche Rolle das Versorgungsmodell (eGK vs. BHS) dabei spielt. Methodik In 3 Kommunen in NRW (2 mit BHS und eine mit eGK) wurden insgesamt 31 Interviews mit Geflüchteten zu 2 Erhebungszeitpunkten (Aufenthalt in Deutschland ≤ 15 und > 15 Monate) geführt, um den unterschiedlichen Anspruch auf Versorgungsleistungen zu berücksichtigen. Dabei sollte eine maximale Variation der Interviewpartner(inn)en in Bezug auf Alter, Geschlecht, chronische Krankheiten, Schwangerschaft und Elternschaft erreicht werden. Die Interviews wurden mit Unterstützung von Dolmetscher(inne)n geführt. Die Transkripte der Interviews wurden computergestützt (atlas.ti8) durch eine Inhaltsanalyse ausgewertet. Ergebnisse Der Genehmigungsprozess durch das Sozialamt führt in Kommunen mit BHS-Modell zu zusätzlicher Wartezeit für (Weiter-) Behandlungen. Der direktere Zugang durch das eGK-Modell sowie der Wegfall der Leistungseinschränkungen nach 15 Monaten Aufenthalt können den Zugang zur Versorgung besonders für chronisch erkrankte Geflüchtete erleichtern. Der Erstkontakt mit dem Gesundheitssystem erfolgt meist mit Unterstützung von Sozialarbeiter(inne)n, Freund(inn)en oder Familienmitgliedern. Schlussfolgerung Für Geflüchtete mit einem höheren Versorgungsbedarf kann der Zugang durch das eGK-Modell erleichtert werden. Weitere Zugangsbarrieren, wie z. B. die beschränkte Verfügbarkeit von Dolmetscher(inne)n, bestehen unabhängig vom Zugangsmodell.

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Background The municipalities in the federal state of North Rhine-Westphalia (NRW) decide autonomously how to organize access to health care for refugees: either with electronic health card (eHC model) or with health care voucher (HcV model). The eHC model is often expected to facilitate access to health care and to reduce bureaucratic barriers. However, there are only few analyses of how refugees perceive the two models and their corresponding access to health care. Methods A total of 28 problem-centered interviews with refugees were conducted in three municipalities in NRW (two with HcV and one with eHC model). Sampling was purposive, aiming to achieve a maximum variation of interview partners with regard to age, gender, chronic illnesses, pregnancy and parenthood. The interviews were conducted with the support of translators in the language of the respondents’ choice. Interviews transcripts were evaluated by content analysis using the software atlas.ti. Results Refugees using both the eHC and HcV models report mostly positive experiences when seeking care - both in terms of treatment and interaction with physicians or non-medical staff. The first contact with the health care system was rarely organized by refugees themselves in both models, but mostly with the support of social workers, friends, or family members. The main perceived difference between the models was that in the HcV model, urgent treatment required additional waiting time. Conclusions Access to care is assessed similarly well by refugees in all municipalities. The additional approval process for treatment by the social welfare office in HcV municipalities may lead to a delayed treatment. Formal and informal support is particularly important for newly arriving refugees to help them navigate the complex German health system. Key messages The implementation of one access model alone does not facilitate access to health care for refugees. Formal and informal support is necessary for refugees to gain access to the health system.

Background Providing quantitative evidence on structural access barriers to health care for newly arrived refugees constitutes a challenge due to a lack of suitable data. The coexistence of two different local access models in Germany allows for a comparative analysis of the association between access policies and realized access. Our study compares these two models to establish whether they lead to differences in access to care among refugees. Methods Municipalities in Germany’s largest federal state of North Rhine-Westphalia (NRW) have implemented different access models to which refugees are quasi-randomly assigned. We recruited 6 municipalities of which 3 decided to implement the health care voucher (HcV) model and 3 the electronic health card model (eHC) in a natural quasi-experimental study design. Analyses were based on claims data collected from the welfare offices or the statutory health insurance. We compared standardized incidence rates (SIR) based on 3 indicators: emergency service, ambulatory sensitive hospitalization and use of specialized care. Results We included data on health care use of all recently assigned refugees in the 6 municipalities over a period of 7 quarters (2016/17). The average quarterly sample size is n = 9,077 which corresponds to 6.5% of the population of recently assigned refugees in NRW at that time. We find differences in realized access between the models. For emergency care, the SIR differ significantly between municipalities using the HcV model (SIR:1.88; 95%-CI: 1.62-2.18) and eHC model (SIR:1.33; 95%-CI: 1.14-1.55). Conclusions Local decisions regarding the organization of access to health care are associated with differences in realized access to health care of refugees in NRW. The implementation of the eHC model may contribute to a decrease of emergency service. Further analyses should attempt to reduce a possible (self-)selection bias of municipalities which might have led to an underestimation of the difference between models. Key messages The organization of health care for newly arrived refugees on the local level is decisive for their access to care. Local policy makers may use their scope for action to remove access barriers for newly arrived refugees.