Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment

Abstract

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.

Cardiac Rehabilitation in German Speaking Countries of Europe—Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH—Part 2

“…Similar findings were reported from other European countries [ 317 ]. Unlike migrants who reside in Germany for many years, newly arrived refugees and asylum seekers, without a residence status, encounter additional barriers to accessing health care because, initially, they are only entitled to a limited set of services [ 318 ].…”

Does Facilitated and Early Access to the Healthcare System Improve Refugees’ Health Outcomes? Evidence from a Natural Experiment in Germany

“…Since 1993, refugee access to healthcare in Germany has been regulated by the German social welfare law for asylum-seekers (Asylbewerberleistungsgesetz, AsylbLG, para.4), which restricts refugee access to the healthcare system for the first 15 months of their stay (Wenner et al 2020). During this time, refugees, including those with pending asylum applications and those whose applications were rejected but whose stay in Germany is tolerated (Duldung), are only eligible for the primary, basic treatment of acute illnesses and pain and for further time-sensitive interventions (i.e., pregnancy) (AsylbLG, para.4).…”

“…During this time, refugees, including those with pending asylum applications and those whose applications were rejected but whose stay in Germany is tolerated (Duldung), are only eligible for the primary, basic treatment of acute illnesses and pain and for further time-sensitive interventions (i.e., pregnancy) (AsylbLG, para.4). If they require a doctor's visit, refugees must request it, either from the local authority for foreigners or the responsible social assistance office (Wächter-Raquet 2016;Wenner et al 2020). Such decisions on medical treatment claims are made by employees without specific medical training; therefore, in many cases, a medical treatment requires a consultation with the local health authority beforehand, which can sometimes take months.…”

“…In addition to the pronounced health risks that refugees face, they also encounter several limitations in their access to healthcare services in Germany (Wenner et al 2020). Specifically, refugees whose asylum application was either rejected or is still being processed cannot receive medical treatment in Germany during the first 15 months of their stay, without the consent of nonmedically trained personnel from social and immigration offices, who act as so-called gatekeepers (Kroneman, Maarse, and Zee 2006;Rolke, Wenner, and Razum 2019).…”

Inequalities in access to healthcare by local policy model among newly arrived refugees: evidence from population-based studies in two German states

“…Qualitative studies suggest that the HVs are difficult to handle for healthcare users and providers and thereby hamper access to health services [18][19][20][21]. Quantitative studies provide further evidence for the disadvantages of the HV and of the entitlement restrictions during the 18-month waiting period; for instance, in terms of higher medical costs [22][23][24][25]. So far, there is no quantitative evidence of inequalities in access to healthcare among ASR who are subject to the three different access models.…”