Health crowdfunding challenges in Germany, EU countries

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This study aims at mapping unmet health care needs manifested in medical crowdfunding campaigns in a healthcare system with universal health coverage.

In particular, we explore the most common condition, disease or disorder which prompted individuals to turn to crowdfunding in Germany, where universal coverage is provided through statutory and private health insurance. In addition, we reveal the type and size of health-related expenses that individuals aim to finance via crowdfunding. This study is exploratory in nature; it allows a glimpse into the unmet health care needs of residents in a healthcare system with universal health coverage.

The German healthcare system

In Germany, health insurance is mandatory for all; residents may choose between statutory health insurance and substitutive private health insurance [13]. In Germany, the share of GDP allocated to health spending was 11.7% in 2019 in comparison with an OECD average of 8.8% [14]. Germany spent the equivalent of USD 6646 per person on health in 2019, compared with an OECD average of USD 4224 [14]. In 2019, public sources accounted for 85% of overall health spending, the third highest among the (Organisation for Economic Co-operation and Development) OECD countries [14]. In 2018, Germany was ranked 12th among 35 European countries when measuring the consumer friendliness of the health system by the Euro Health Consumer Index [15].

German statutory health insurance offers comprehensive health care coverage to 90% of the population (73 million people) [16]. Residents earning less than 62.550 euros per year are automatically enrolled in the statutory health insurance system [17]. Only individuals earning more than 62.550 euros per year, self-employed and civil servants can choose which type of health insurance they prefer [18].

In 2020, the statutory health insurance system is administered by 105 non-profit organisations known as Krankenkasssen (sickness funds) [19]. These sickness funds are obliged to provide the same minimum level of care and they are not allowed to refuse anyone as a member [20]. In 2020, all sickness funds charge a basic rate of 14.6% of an employee’s gross salary with a monthly ceiling of 4687.50 euros in 2020 [21]. Statutory health insurance covers treatment such as hospital treatment, visits to general practitioners and specialists, rehabilitation (home care and physiotherapy), health checks from the age of 35, cancer screening, medicines, therapies and aids (hearing aids and wheelchairs, dental check-ups, dentures and crowns, orthodontic treatment up to age 18 [18]). In order to avoid overusing the system and to cover some costs of the statutory healthcare system, co-payment charges apply. Most importantly, patients are expected to cover 10% of prescription costs (minimum 5 euros and maximum 10 euros), 10 euros per day for hospital stays (up to a maximum of 28 days per year), 10% of home help costs (minimum 5 euros and maximum 10 euros per day) and 10% of travel costs (minimum 5 euros and maximum 10 euros per journey) [22].

Depending on the provider, individuals may also be charged an additional contribution of up to 1.1%, on average [21]. This additional contribution may entitle individuals to extra treatment not covered by statutory health insurance, such as additional dental care (professional tooth cleaning or dentures), flu and travel vaccinations, cancer screening under 30, osteopathy, homoeopathy, in vitro fertilisation, contraception [18]. Individuals can easily compare the coverage and extra treatments offered by sickness funds by visiting the website of Krankenkassen Deutschland or Tarifcheck [23, 24].

Moreover, individuals may purchase additional private insurance from health insurance providers to supplement the care they receive under statutory insurance [25]. These supplementary services, depending on the provider, might cover travel health insurance, additional sickness benefits, additional long-term care benefits, better hospital treatment (private hospital rooms, higher fees), additional dental care and alternative medication [18].

Unmet medical needs

According to the subjective method, unmet medical needs are present if individuals perceive that they have not received the care they needed [26]. According to the objective approach, unmet medical needs are present if it is clinically proven that individuals did not receive the necessary care [27]. In this research, we follow the subjective method and assess both unmet medical needs (e.g., medication, surgery, rehabilitation, treatment-related travel costs) and unmet health-related needs (e.g., difficulties in covering living expenses, given poor health status) self-reported in medical crowdfunding campaigns. In 2012, 3.4% of the EU population reported unmet medical needs according to information extracted from the European Union Statistics of Income and Living Conditions [28].

In the literature, unmet medical needs are explained by two factors: the characteristics of the healthcare system and the attributes of individuals seeking care [29]. The former factor, among others, includes availability of health care services, waiting times before being scheduled for a procedure, referral patterns, and the booking system [29, 30]. Patient co-payments might also create barriers to health care access and thus generate unmet needs, especially given the rising co-payments for pharmaceuticals and outpatient care in several European countries [28, 30]. Fjær et al. [30], using data from the European Social Survey, report that two-thirds of unmet needs for health care can be explained by two factors: waiting lists and appointment availability [30].

The association between unmet medical needs and the characteristics of individuals seeking care is widely researched. In general, studies report that young people, women, individuals with low socio-economic status (e.g., unemployed, homeless, drug users), those with low income and financial constraints, individuals with secondary and tertiary education, and individuals in poor health have a higher likelihood of reporting unmet medical needs [29,30,31,32,33,34,35,36,37,38,39,40]. Several studies assess unmet medical needs in specific subpopulations, for example, among young adults [41], the unemployed [31], homeless women with children [42], or the elderly [36]. Some other studies map the unmet needs of particular patient groups such as individuals with disabilities [43], patients suffering from cancer [44, 45], people with multiple sclerosis [46] or dementia [47].

Empirical evidence shows that the prevalence of self-reported unmet medical needs varies greatly in Europe [34, 48,49,50]. Using data from the 2008 European Social Survey, Cylus and Papanicolas [48] show that respondents from Germany report similar levels of perceived barriers to care as respondents from Denmark, France, Poland and Slovenia. Data from the European Union Statistics on Income and Living Conditions (EU-SILC) 2009 survey show that the rate of unmet medical needs in Germany is comparable to that of Denmark, Finland, Italy, and Iceland [34]. Another study using data from six different EU-SILC surveys (2008–2013) documents that the percentage of the population reporting foregone medical care in Germany is similar to that of France, Norway, Slovakia and Sweden [49]. The level of unmet needs in Germany is relatively low when compared to the rest of Europe [34, 48, 49]. For Germany, a study among the elderly also finds that the prevalence of self-reported unmet medical needs for health care is low overall [36].