Needs for further improvement: risk adjustment in the German health insurance system.

The German risk adjustment mechanism is used only within the public system. It was introduced in two steps, 1994 and 1995. Because of the income-related contribution, which the insured pay directly to their sickness fund, income of the insured is equalized by the mechanism and causes the biggest part of the payments among the sickness funds. On the expenditure side age, gender, disability and entitlement for sickness allowances are used as risk adjusters. The mechanism is retrospective, calculating average costs for each of the 670 risk cells defined by the risk adjusters and using these "standardized expenditures" as a base for the payment a single sickness fund gets because of its risk structure. There do still exist incentives for risk selection. The experience shows that mostly the young and healthy are willing to change sickness funds motivated by lower contribution rates. This can be used and is used for self-selection. Another cause of risk selection is regional differences. The central suggestion of an expertise on behalf of the German Ministry of Health on experiences and improvement proposals is the change to a direct modeling of morbidity.