gms | German Medical Science

Background: The over-indebtedness of citizens in Germany constitutes a public health issue. It is estimated that about 6.7 million citizens in Germany are over-indebted, which means that they have persistent payment failure to legal issues, such as the delivery of an affidavit or a private insolvency proceedings. Major adverse events are leading the ranking of the most important causes of over-indebtedness: 1. unemployment (19.1%), 2. separation, divorce, death of a partner (12.4%), 3. disease, addiction, accidents (12.1%) [1].

While health-related factors may be the cause of over-indebtedness in 12.1% of the cases, it is also known that the over-indebtedness may lead to illness and other health-related issues; psychosomatic stressors, lifestyle changes (such as social withdrawal or changes in the diet) or a reduction in the ability to participate in the social system, in particular to benefit from the health care system [2].

Do over-indebted citizens in Germany experience barriers when redeeming a prescription, due to the co-payment scheme and their financial difficulties? For the first time the study on poverty, debt and health (PDH-study) answered this question.

Materials and Methods: The cross-sectional study was conducted, between July 2006 and March 2007 among over-indebted individuals in Rhineland-Palatinate, in the form of an anonymous survey among clients of debt counselling centres. The survey was carried out in cooperation with 53 centres and with the Expert Debt Advice Centre of the Johannes Gutenberg-University Mainz, a support agency for the above mentioned local centres. The questionnaire was exclusively developed for the PDH-study and contained 58 mainly closed questions on the participant’s health status, his or her debt situation, the structure and quality of their social network and the utilization of the health care system.

A subset of all clients of the debt counselling centres was selected according to certain inclusion criteria. Those selected were informed about the study by one of the debt counsellors and received documents about the study. Inclusion criteria were that participants had to be at least 16 years of age and had made use of a counselling centre at least twice. No exclusion was made with regard to nationality. Only one person per household was interviewed and, if possible, this was the person seeking advice.

In total, 2235 questionnaires were distributed among the 53 centres by the coordinating centre of the study at the Institute for Occupational, Social and Environmental Medicine at the Johannes Gutenberg-University Mainz. Of those, 1876 questionnaires were passed on to clients. All questionnaires completed in written form and arrived at the coordinating centre by the end of March 2007 were collected and checked for plausibility using the Scan-System „Readsoft“.

Results: A total of 666 individuals (51.1% female) aged 18 to 79 (mean 41.0 years; standard deviation 11.2 years; median 41 years) participated in the study. This corresponds to a response rate of 35.5%. About one third was married, 5% was of non-German nationality, and two thirds had only completed basic education or no formal education at all, with 30% not having completed any vocational training.

The majority of all participants stated that they had refrained from buying prescribed medication (65.2%) due to their financial situation, their debts and obligations of co-payment.

There is evidence for a background influence of some socio-economic factors on the utilization of health care services. A significant correlation is found between age and utilization of the health system: the older participants are, the less often they report that they did not purchase medications. Family situation seems to have an influence as well: respondents who have children or are single parents state more often that they are unable to purchase medications.

Conclusion: On the basis of the PDH-study was found that, as a result of their debt situation, the majority of the participating over-indebted individuals refrain from buying prescribed medication. More than 60% reported a limited utilization of the health system.

The German system of co-payment for the purchase of medication leads to discrimination against over-indebted individuals with respect to health care. Because of co-payment, health services are only accessible depending on the financial resources of the individual. Thus, equal opportunities in terms of access to health care are particularly threatened. As already postulated by US scientists in the 80ies [3] and from a socio-medical point of view, co-payment in Germany should be eliminated for poor populations and particularly for those with chronic diseases and burdens. Claims for exoneration from co-payment – which is supposed to avoid discrimination against such groups – should be investigated in more detail.

The PDH-study did not measure to what extent over-indebted individuals avail of the hardship aids offered by the compulsory health insurance. The problem about these aids is that the access threshold refers to the gross income of a person and over-indebted individuals might be disadvantaged, as their financial burden could be underestimated because their payments towards creditors may not be taken into account. Furthermore, heavy bureaucratic efforts are required to apply for hardship aids, since payment receipts have to be collected during the year and a new application has to be filled in every year.

Health system research is urgently needed with particular focus on lower socio-economic groups, in order to prevent socio-economic health inequalities especially in the use of medications.