Federal Statistical Office (Destatis)

Health-Related Accounting System

Graurheindorfer Str. 198

53117 Bonn

Health care expenditure quantifies the economic resources dedicated to health functions, excluding capital investment. Healthcare expenditure concerns itself primarily with healthcare goods and services that are consumed by resident units, irrespective of where that consumption takes place (it may be in the rest of the world) or who is paying for it. As such, exports of healthcare goods and services (to non-resident units) are excluded, whereas imports of healthcare goods and services for final use are included.
Health care expenditure data provide information on expenditure in the functionally defined area of health distinct by provider category (e.g. hospitals, general practitioners), function category (e.g. services of curative care, rehabilitative care, clinical laboratory, patient transport, prescribed medicines) and financing scheme (e.g. social security, private insurance company, household). For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA sets out an integrated system of comprehensive and internationally comparable accounts and provides a uniform framework of basic accounting rules and a set of standard tables for reporting health expenditure data. The System of Health Accounts - SHA 2011 is a statistical reference manual giving a comprehensive description of the financial flows in health care. It provides a set of revised classifications of health care functions, providers of health care goods and services and financing schemes. The SHA is currently used as a basis for a joint data collection by OECD, Eurostat and WHO on health care expenditure. The manual sets out in more detail the boundaries, the definitions and the concepts of health accounting – responding to health care systems around the globe with very different organisational and financing arrangements.

Accounting period: Health expenditure and financing data pertain to the calendar year (1 January to 31 December).

The time coverage of this Quality report is 2014 to 2016 reference years.

In addition the national health care expenditure data provide information by financing agents on research and development in the health care sector, compensation of health-related implications (e.g. integration support for disabled people for occupational rehabilitation), income benefits (e.g. continued remuneration in case of illness) and capital investment.

Healthcare expenditure is recorded in relation to the international classification for health accounts (ICHA) defining:

• healthcare expenditure by financing schemes (ICHA-HF) — which classifies the types of financing arrangements through which people obtain health services; health care financing schemes include direct payments by households for services and goods and third-party financing arrangements;
• healthcare expenditure by function (ICHA-HC) — which details the split in healthcare expenditure following the purpose of healthcare activities — such as, curative care, rehabilitative care, long-term care, or preventive care;
• healthcare expenditure by provider (ICHA-HP) — which classifies units contributing to the provision of healthcare goods and services — such as hospitals, residential facilities, ambulatory health care services, ancillary services or retailers of medical goods.

1. Household individual consumption on health, including the collective consumption with two exceptions:
i. Occupational health care (intermediate consumption within establishments) minus an estimated share of occupational health in health providers’ and other medical industries net administration;
ii.“Remunerated” unpaid household production in the form of transfer payments (social benefits in cash) for home care of sick, disabled and elderly persons provided by family members.
SHA 2011 Manual recommends following the standard System of National Account (SNA) rules for drawing the production boundary of health care services, albeit with two notable exceptions:
- Occupational health care is included in the national totals of health care spending. In SNA, this item is recorded as ancillary services and part of intermediate production of enterprises,
- Part of the cash transfers to private households for care givers of home care for the sick and disabled are treated as the paid household production of health care.
2. Health care financing schemes: HF1 Government schemes and compulsory contributory health care financing schemes; HF2 -voluntary health care payment schemes;
HF3 - Household out-of-pocket payment; HF4 - rest of the world financing schemes.
3. NACE rev. 2, section Q, human health and social work activities.

SHA concept is the consumption of health care goods and services.
Health care statistics describe the process of providing and financing health care in countries by referring to health care goods and services, its providers and financing. For the collection of the data on health care expenditure the System of Health Accounts (SHA) and its related set of International Classification for the Health Accounts (ICHA) is used. SHA is a tri-axial system in which the financing, provision and consumption dimensions are covered by the ICHA (International Classification for Health Accounts): Health Care Functions (HC), Health Care Providers (HP), Health Care Financing Schemes (HF).
Data are presented in 3 summary (one-dimensional) tables and 3 cross-classification tables (2-dimensional tables).

Summary tables provide data on:

• Current expenditure by provider (ICHA-HP)
• Current expenditure by function (ICHA-HC)
• Current expenditure by financing scheme (ICHA-HF)

Cross-classification tables refer to:

• HC x HP: Health care expenditure by function and provider: data on which type of health care goods and services are supplied by which health care provider;
• HC x HF: Health care expenditure by function and by financing scheme: data on how are the different types of services and goods financed;
• HP x HF: Health care expenditure by provider and by financing scheme: data on from which health care provider and under which particular financing scheme are the services and goods purchased.

Commission Regulation 2015/359 concerns the collection of data on "current expenditure on healthcare" which is defined as the "final consumption expenditure of resident units on health care goods and services".
There is a very close relationship between the concept of "final consumption expenditure" as defined in the System of Health Accounts (SHA) and in National Account and, as a consequence, also between the underlying economic transactions as recorded in the two accounting frameworks.
In National Accounts there are two types of statistical units: institutional units and local kind-of-activity units (KAU). A local KAU groups all the parts of an institutional unit in its capacity as producer which are located in a single site. A local KAU belongs to one and only one institutional unit.
SHA uses the same two types of units for data compilation.
Local KAUs operating as providers of healthcare goods and services to resident units are statistical units in SHA.
Also transactions by institutional units are recorded in SHA, in which framework institutional units are also referred to as "financing agents". More precisely, SHA financing agents are institutional units that manage one or more financing schemes. The transactions are executed by the financing agents, according to the rules of the financing schemes.
Financing agents serve as key statistical units in producing national health accounts. While financing schemes are the key units for analysing how the consumption of health care goods and services is financed, the data concerning the relevant transactions are collected either from the financing agents that operate the different financing schemes or from the providers.
The concept of "healthcare financing schemes" in SHA is an application and extension of the concept of "social protection schemes" defined by the European System of Social PROtection Statistics (ESSPROS):  "a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing ...". The social protection scheme is the statistical unit in ESSPROS. It is an analytical unit that allows describing the complete structure of the social protection financing system:  expenditure and receipts.
According to SHA Manual 2011, "the key concepts for describing the structure of the health care financing system are based on measuring: (a) the expenditure of health care financing schemes, under which goods and services are purchased directly from health care providers, on the one hand, and (b) the types of revenues of health care financing schemes, on the other hand.  
Commission Regulation 2015/359 limits its scope to the collection of data on the expenditure of health care financing schemes.

SHA focuses on the consumption of health care goods and services by the resident population irrespective of where this takes place. This implies the inclusion of imports (from non-resident providers) and the exclusion of exports (health care goods and services provided to non-residents).

The data aims at providing a complete overview of expenditure on health care goods and services consumption of services and goods by the resident population on the national territory of a country.

1992 - 2017.

Not applicable.

Several data sources are used:

-          Surveys/census: 4

-          Public administrative records: 11

-          Financial reports: 6

Survey, Censuses

Public administrative records

Financial reports

Annual.

Data are collected through the joint health accounts questionnaire (JHAQ) that countries submit to Eurostat during the annual data collection exercise. There is a voluntary deadline to send the JHAQ questionnaire for the calendar year T by the 31st of March T+2. The joint health accounts questionnaire (JHAQ) is coordinated in agreement with the World Health Organisation (WHO) and the Organization of Economic Co-operation and Development (OECD). These three international organisations are known collectively as the International Health Accounts Team (IHAT). Countries submit data to Eurostat on the basis of Commission Regulation (EU) 2015/359 of 4 March 2015 implementing Regulation (EC) No 1338/2008 of the European Parliament and of the Council as regards statistics on healthcare expenditure and financing.

The Health Expenditure Accounts is a secondary statistical accounting system that summarizes the data sources available in the healthcare sector at the time of calculation - such as administrative data, sample surveys, annual reports and special evaluations - to calculate total expenditure on health care goods and services. The collection of the national data of health expenditure takes place primarily by the financing agents. The expenses of the different financing agents (for example, statutory health insurance) must be allocated to the types of functions and the providers rendering them. For this purpose, to some extent, appropriate quotas for the distribution of expenditure between the types of functions and the providers of functions are calculated.   

The 2018 JHAQ includes a number of features which allow national data correspondents to perform various quality checks before submitting the data. The embedded programmes allow the verification of:

1- Consistency of the data between tables,
This step checks if the marginal totals reported in each table of the JHAQ are consistent across all tables. For example, for each function (HC), the total across all financing schemes (HF) in the HCxHF table has to be equal to the total across all providers (HP) in the HCxHP table, i.e. the values in the column “All HF” in the HCxHF table have to be equal to the values in the column “All HP” in the HCxHP table. Any detected differences are flagged up in the corresponding row or column in the relevant tables and all inconsistencies are listed in the “Report” worksheet by variable code together with the amount by which the respective variable differs between the two compared tables. A positive value indicates that the first listed table has a higher value for the same variable, and vice versa.

2- Consistency of the data within tables,
Any detected inconsistencies are listed by variable code together with an indication of which total is not equal to the sum of its subcomponents as well as the numerical difference. A positive figure indicates that the total is greater than the reported sub-components, and vice versa.

• The presence of negative values,

Entries in the tables cannot be negative as they refer to the consumption of goods and services.
If an individual data table is checked for internal consistency, the negative values check is performed for the relevant table and then any negative values are highlighted red and crossed out.

• The presence of atypical entries,

The atypical entries check provides information whether the data tables contain values in cells which are – if at all – only reported by very few countries and are thus atypical for health accounting.
If an individual data table is checked for internal consistency, the atypical entries check is performed for the relevant table. In the data tables, any cell containing an atypical entry will be highlighted for national data providers.
Should any atypical entries be identified, compilers should scrutinize in detail the transactions that led to entries in those cells and assess whether the accounting rules of SHA have been correctly applied. If they come to the conclusion that the transactions are recorded in the correct categories of the ICHA classifications, then the corresponding atypical entries represent unique – and correctly accounted for – features of the country’s health system. In this case a short description of the nature of the transactions should be included in the accompanying Metadata file under “II.3. Atypical entries”.
If, on the other hand, compilers come to the conclusion that the transactions are not recorded correctly, then they need to make adjustments in the concerned tables. In case the transactions recorded in a cell do not belong to the boundaries of SHA (e.g. they refer to intermediate consumption) the value of the respective cell should be deleted (and all cells that are affected by this change adjusted accordingly). In case the transactions are misreported and another category of the ICHA classification is more appropriate, the value of the cell should be transferred to the correct cell of the table.

3- The growth rates against the previous year and the magnitude of revisions as compared to previously submitted data. Results are grouped into three different categories:

• Breaks in series (the current questionnaire shows no data for an item that is not null in the other file)
• Newly reported (the current questionnaire contains data for an item that is empty in the other file)
• Differences (all other types of differences)

Some important basic statistics (e.g. long-term care statistics, social welfare statistics, statistics of cost structure in offices of physicians by Federal Statistical Office, national accounts) are subjected to the quality standards of the German official statistics. These basic statistics are subject to the quality control in the relevant specialised departments and are validated there. Other data are first validated internally through the data owner and checked again for completeness and plausibility by the Federal Statistical Office.

Several methods are normally used for estimations:

• Balancing item/Residual method: For example, if data are available from the financing side, which permit accurate estimation of the flows to a provider or function, then an acceptable estimation method is to subtract these expenditure flows from the total revenues, and derive the expenditure flows from the unmeasured financing scheme as a residual.
• Pro-rating/Utilisation key: Typically in the absence of direct spending data, a utilisation key linked to the proportion of resources used can be constructed in order to distribute e.g. aggregate provider spending across functions. For every key a fraction of total utilisation within the cost-unit is assigned: fractions in the key must add up to 100% of all care delivered by the cost-unit. Examples of utilisation keys are admissions, bed-days, contacts, staffing, etc.
• Interpolation/Extrapolation: In the absence of data for the period in question, missing values can be estimated using known data points.
• Or other

Due to a lack of data for household out-of-pocket payments a residual method is used. Starting point of the calculation is the volume of sales of the providers. Volumes of sales that cannot be allocated to health purposes, exports and expenditures of the other financing agents are subtracted. The residual amount is the health expenditure of the private households. Then these expenditures are allocated to functions and providers by means of distribution keys.

The boundary of healthcare goods and services at national level follows the recommended definitions of SHA 2011. The health expenditures are shown three-dimensionally – by financing schemes, functions and providers. The classifications of the three dimensions are harmonized with the International Classification for the Health Accounts.

Authorities responsible for SHA data collection are working to ensure that the statistical practices used to compile national health accounts are in compliance with SHA methodological requirements and that good practices in the field are being followed, according to the methodology underlined in the SHA 2011 Manual and European Statistics Code of Practice respecting professional independence of the statistical authorities. Procedures are in place to plan and monitor the quality of the health care expenditure statistical production process.

General regulations are included in the Federal Statistics Law (BStatG) in Germany. These principles include for example neutrality, objectivity, scientific independence, application of appropriate methods and rules of statistical confidentiality and privacy.  

Generally, sampling and non-sampling errors of the basic statistics integrated into the System of Health Accounts may also be contained in the results. Also, applying estimation methods and extrapolating time series may lead to inaccuracies. But it should be noted, that most of the basic statistics are complete surveys and estimations are only made where reliable data are missing. OOP expenditure data is mostly based on a residual method. Therefore under- or overestimations can exist. A quantification of the overall quality is not possible to identify. Altogether, we expect a good data quality.

National users are especially the Federal Ministry of Health (BMG), the Federal Health Monitoring, research institutes, universities, trade associations, health care companies, the media and also the interested public.

The data of health care expenditure is important for the political community for assessing health policies. Besides health expenditure data form the basis for expert opinions and forecasts.

There is an “expert committee“ every three  years in the field of health. Main users will be informed about the current developments and can give their opinions from the user point of view.

For the compulsory variables of the HF categories the category HF4 “Rest of the world financing schemes (non-resident)” is missing because the data are not available.

For the compulsory variables of the HC categories the category HC.2.2 “Day rehabilitative care” and HC.2.4”Home-based rehabilitative care” is missing and reported either in HC.2.1 or HC.2.3. The category HC.3.3”Outpatient long-term care (health)” is missing and reported in HC.3.4 “Home-based long-term care (health).

For the compulsory variables of the HP categories all data are available.

Table HCxHF=78,6%

Table HCxHP=78,6%

Table HPxHF=100%

The quality of the Health Expenditure Accounts depends significantly on the quality of the basic statistics.  In principle, in the selection of the basic statistics, full surveys have priority before sampling surveys and continuous surveys before single counting in order to avoid methodologically caused breaks in the time series.  Lacks of clarity occur particularly where they are already present in the underlying statistics on which this calculation is based or where appropriate data sources for specific fields are missing (data gap). OOP expenditure is mostly based on a residual method. Therefore under- or overestimations can occur. However, a large part of the basic statistics are full surveys, therefore, the results of the Health Expenditure Accounts show only occasional random errors.

In the survey "statistics of cost structure in offices of physicians" the relative standard error is below 15%. In the survey "statistics of cost structure in dental practises" the relative standard error is below 5 %.

Not available.

Not available.

Health care goods and services by non-residents are excluded from domestic provider revenues.

It is not possible to report the underground/informal/illegal health care goods and services in the data collection and should not be significant relevant in Germany.

Not available.

Not applicable.

Should not be significant relevant.

Not available.

Not available.

Not available.

Not available.

Not available.

Not relevant.

Not applicable.

Revisions are generally applied to all years to assure data consistency across all years. Revisions are carried out every year and are usually due to revisions in our data sources.

2014: Revisions were applied to the complete time series and affected all HF, all HC categories except HC.3.2 and HC.5.1.3 and all HP categories except HP.6.  The revisions were due to the inclusion of new data sources and revisions in the existing data sources.

2015: Revisions were applied to the complete time series and affected in particular HF.2.2. The revisions were due to the inclusion of new data sources and revisions in the existing data sources.

2016: Revisions were applied to the complete time series. The revisions were due to the exclusion of expenditures for people living abroad but are insured in the German social insurance schemes. Furthermore, the financing scheme HF12 was broken down into HF121 and HF122 and there was a minor shifting between the financing schemes HF1 and HF2 due to an improved accounting of the implementation of the 2009 reform on mandatory health insurance. Moreover, HC.7xHF.1.1 based on COFOG is now reported.

Not available.

Member States are required to transmit their data to Eurostat in compliance with the Commission Regulation 359/2015 transmission deadlines.
Data and reference metadata for the reference year T should be transmitted to Eurostat by 30 April T+2.

Germany has sent data according to the transmission deadline.

Germany does not publish first results.

Final national results are published in a release after T+14 month. The release dates are reported to Eurostat after T+15 month.

The deadlines were always met.

The deadlines were always met.

Not applicable at national level.

Not applicable.

Breaks in time series resulting from methodological changes

The number of reference periods is 25 (from 1992 - 2016).

The data are not reconciled with other domains such as ESSPROS.

Not applicable.

As the Health Expenditure Accounts measures the last consumption of health goods and services, there is also a limited reference to the concepts of the National Accounts. A connecting factor results from the classification of the providers in the health care sector into the economic sectors of the National Accounts.  Among other things, there are differences in the concepts used. In the National Accounts applies the domestic concept (inclusion of exports), whereas the Health Expenditure Accounts uses the resident concept (exclusion of exports).

There is a press release every year when the national data is published in February.

The results of the national data were published in "Fachserien" (subject-matter series) until 2015.

National Data can be accessed on the website of the Federal Statistical Office.

National Data and the SHA dataset are available on the website of the Information System of Federal Health monitoring.

Information is not available at the moment.

Not applicable.

Other data dissemination is for example the publication "data of the health care sector" from the Federal Ministry of Health.

An article written by Moritz Mannschreck about the revision of the National System of Health Accounts in 2015 and only available in German language: “Die revidierte Gesundheitsausgabenrechnung", published in the magazine Wista Economy and Statistics.

The quality report for the National System of Health Accounts is only available in German language.

100%

Information not available.

For the production of the health care expenditure data approximately 2,5 FTE are needed.

As the Health Expenditure Accounts is a complete accounting system that processes already existing results from primary, secondary and administrative data sources, there are no additional costs for respondents. Additional costs may arise in the context of data acquisition for the data holders of the basic statistics, who voluntarily provide their results to the Federal Statistical Office. Since the data are not always available in the required form, in some cases it may be necessary to compile special statistical evaluations.

The Regulation (EC) No 223/2009 on European statistics (recitals 23-27, 31-32 and Articles 20-26) applies.

Pursuant to §16 (1) BStatG, German official statistics are obligated to keep individual data. Excluded are data that cannot be assigned to the respondent or have been summarized (aggregated) to such an extent that they are not traceable. The Health Expenditure Accounts uses only aggregated data or data without direct personal reference.  In addition, it is about a macroeconomic consideration.  The results are not personally identifiable and in their presentation related only to the total population. Since only aggregated data or statistics without direct personal reference are used and since this is a macroeconomic consideration, no additional confidentiality procedures are applied.

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