Economization and marketization in the German healthcare system: how do users respond?

VerfasserEwert, Benjamin

1 Introduction

From an historical perspective, the German corporatist healthcare system appeared for a long time reluctant to proceed with any far-reaching reforms. However, since the 1990s the German healthcare system has been targeted by several modernization processes, characterized by pundits as an "incremental reform" (see Gerlinger/Schmucker in this volume). This article scrutinizes two of its key drivers, economization and marketization, arguing that the two approaches restructure the healthcare system differently and have different consequences for healthcare users' behavior. They share, however, common ground: economization and marketization processes aim at the expert patient as a focal figure. For instance, state-driven agendas of user activation as well as market-based healthcare services emphasize individual responsibility, as well as financial stakes and participation of healthcare users. Simultaneously, there is a differentiation of users' identities, especially against the backdrop of mixed healthcare provision and the establishment of a complementary healthcare market. Users act in different contexts as citizens, patients, co-producers, consumers or community members. In order to do so, there is an increasing need for a specific health knowledge and competence; that means the development of a context-related "health literacy" (Nutbeam 2000).

By analyzing the implementation of economic and market-based elements in the field of healthcare and the differentiation of users' identities--or rather the way they are culturally embedded--this article will give some evidence of opportunities as well as constraints of users' autonomy and self-determination. In the first part, a theoretical distinction between economization and marketization processes within the German healthcare system will be made. Both strategies, superficially viewed as assigned to market principles, stimulate very different users' identities as well as self-governance needs. While an economized healthcare system favors cost containment policies and compliant users above all, the emergence of a healthcare market with various tailored products and services forces users to act as experts on their own behalf, or rather as health consumers.

The second and the third part of the article portray current reforms in the German healthcare system. Illustrative examples of the economization of healthcare (e.g., Disease Management Programs and Diagnosis Related Groups) as well as the marketization of health (e.g., so-called Individual Healthcare Services) will be discussed with a special focus on their consequences for users. The main argument of the fourth part is that ambivalent, and to some extent contradictory, demands emanate from both processes. As it turns out, recent policies are characterized more by controlling users' be-havior and bringing them into the service system in order to contain costs than by positive effects such as more choice and user involvement in market-based healthcare arrangements. Finally, the conclusion outlines individual coping strategies for healthcare users in an economized and partly market-based healthcare system and calls for an appropriate supporting environment.

2 Economization and marketization: Two different approaches of a modern health policy

In the field of health policy, it would be a mistake to limit the process of modernization merely to the implementation of market principles. Instead, a variety of different, but related, changes and dynamics that are taking place at the same time have to be taken into account. From a broader perspective that is related not only to health policy but also to social policy in general, three lines of development are shaping the policy framework:

- First, the reinvention of legitimacy patterns for social policy interventions (Rothgang/Preuss 2008). Efficiency criteria emerging from the paradigm that all social investments must show returns into the future became decisive.

- Second, the adjustment of the notion of citizenship to highlight the active and individually responsible citizen as the modern target of social policies.

- Third, the generation of a political culture and atmosphere that helps to make the revised policy goals and role models for citizens achievable.

- Analyzing the particular changes within the healthcare system, according to Kuhlmann (2006, 6), ?three arenas of change" can be identified:

- a new self-awareness of professionals who increasingly take over the role of citizen professionals;

- new forms of governance, emphasizing the role of the state as a manager and social investor, and

- the emergence of citizen consumers as a new citizenship model.

Without discussing these theoretical frameworks in detail, one commonality seems quite obvious: the introduction of market-based elements in connection with a more active role of citizens and users. Thus, there are ?diverse ways in which citizens engage with policies, which often reflect forms of agency and multiple identities (...)" (Bevir/Trentmann 2007, 3).

For social policy researchers as members of a discipline that, by tradition, invents measures to cure the shortcomings of capitalism and the market economy (Nullmeier 2003, 973), the application of market instruments such as efficiency criteria, standardization and competition in the welfare services sector evokes almost automatically defensive and skeptical reflexes. Hence, with respect to health policies, several publications deal with the interrelations and problems of a marketized healthcare system with regard to solidarity or socio-economic inequalities (e.g. Deppe/Burkhardt 2002; Elsner et al. 2004). Literature that also ascribes positive effects to a partly market-based healthcare system is rarely found among social scientists in the German context. This article argues for a more sensitive analysis of market instruments within the realm of healthcare.

When speaking about market elements in the healthcare system, we do not mean a switch from one system to another, but a limited internal change towards market principles. On a more abstract level, the whole process could be described as the emergence of welfare markets (Nullmeier 2002)--more specifically, a social policy that not only compensates for market effects but produces welfare partly through state-controlled sectoral markets (e.g., care for the elderly).

A careful distinction between the logics of economization and the practice of marketization with regard to their intended effects seems appropriate. While the former aims at better governance of the health sector in terms of a more efficient distribution and application of limited resources, the latter establishes a competition-based healthcare market alongside a system of supply and demand, which is similar to conventional consumer markets. At first glance, both mechanisms share the pursuit of capital allocation: on the one hand through cost containment (economization); on the other hand through profits generated by commercial healthcare services and products (marketization). But where are the significant differences? First of all, the approaches can be distinguished with regard to the degree to which they attach importance to the state. An economized health policy based on the standardization of healthcare, quality management and an ingenious system of cost control depends on a strong and regulative state, consisting of "elements of centralist steering" (Knappe 2007, 6). By contrast, marketization is reducing the impact of the state by initiating competition between non-profit and for-profit providers, the contracting-out of certain services, or the formation of new kinds of contracts that do not include the state as an actor, e.g., contracts between service providers and users (Clarke 2007, 98). In Germany, the secondary healthcare market offers healthcare services that are excluded from the coverage of the German Statutory Health Insurances (SHI).

Another remarkable difference emanates from the rationale behind the composition of the range of health-related services, therapy treatments, and products to be offered. The paradigm of economization strongly implies a kind of reduction or shortage of healthcare services and medical goods. The state rationalizes its resources or restructures the public healthcare system. Every service, product, treatment or public subsidy is judged according to overarching cost-benefit criteria. Therefore, an economized healthcare system is accompanied by various measures of standardization and managerial rationales in order to homogenize the allocation systems. By contrast, healthcare markets are oriented towards consumer needs. The key principles of marketization are all about more: an expansion and pluralization of healthcare services and products by anticipating as well as creating users' needs.

Obviously, there is no clear-cut dividing line between economization and marketization; rather it is the process of outsourcing services and cutting social welfare assistance that forces the marketizing of health. Thus, both processes are simply two sides of a reform policy that applies principles, e.g. efficiency and competition, on a sector that was formerly more or less state-driven.

However, the most important distinction concerns the way healthcare users are addressed by both mechanisms. Pointedly, one can say that users are treated as impersonal cost bearers in health arrangements designed under the logic of efficiency. Cost-calculation and containment (as key principles of the healthcare system) and their restrictive effects prevail over the orientation towards individual needs. By transferring the responsibility of health-related costs to the users, economization strategies release the state of its burden. Hence, state policies operate through frameworks and programs that generate cost awareness among users and force them to optimize their consumption of healthcare services and goods in...

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