According to a study by the Robert Koch Institute*, around one million people in Germany suffer from dementia. Taking into account an incidence of 200,000 new cases per year and the continuing rise in the average age of the population, the projection for 2050 is over two million people with dementia. The health policy importance of dementia will therefore continue to increase in the coming years, not least because Alzheimer's dementia is one of the 80 clinical pictures defined in the morbidity-oriented risk structure compensation (Morbi-RSA).

>> Alzheimer's dementia makes up the largest proportion of dementia diseases at over 70 percent. Currently - minus the patients insured under private health insurance - there are around 640,000 people insured under statutory health insurance who are suffering from Alzheimer's dementia. The supply of medicines to these Alzheimer's patients will be examined in more detail below.
The therapy recommendation of the Drug Commission of the German Medical Association provides for a guideline-based therapy of Alzheimer's dementia using the active substance groups of AChE inhibitors and NMDA receptor antagonists (memantine) (AkdÄ, Therapy Recommendations of the Drug Commission of the German Medical Association, 3rd edition 2004).
Although the volume of prescriptions for these drug groups has risen continuously in recent years and will continue to rise in 2008 (Fig. 1), a more differentiated view at patient level still reveals a significant undersupply of drug therapy for Alzheimer's dementia in the statutory health insurance market.
The Alzheimer's prescriptions for 2007 correspond to a volume of 54.7 million daily therapy doses (DDD, Defined Daily Dosage), of which 34.5 million DDD are for AChE inhibitors and 20.1 million DDD are for NMDA receptor antagonists. This corresponds to an increase of 12.3 percent compared to the previous year and represents - with therapy according to guidelines - 149,700 years of therapy. This prescription volume is therefore sufficient for the guideline-based therapy of around 150,000 Alzheimer's patients over a year, which would only correspond to around 23 percent of those with GKV insurance who suffer from Alzheimer's dementia.
However, based on the anonymized patient data available to INSIGHT Health, there were 298,700 GKV insured people who were actually treated with anti-Alzheimer's medication in 2007, among whom the prescription volume is distributed.
This results in an average supply level of 183 daily therapy doses for each Alzheimer's patient actually treated - a quantity that, with therapy in accordance with the guidelines, is only sufficient for a therapy duration of around six months! It can be observed that both the number of patients treated and the therapy intensity (in average DDD per patient) increase over time and the care situation thus improves (Fig. 2).
In view of the nationwide low level of care in the Alzheimer's market, the question arises as to whether this applies equally to all regions and - against the background of Morbi-RSA, which is expected to come into force in 2009 - what differences there are between the individual health insurance companies.

Expenditure comparison: Anti-Alzheimer's preparations by health insurance region/cash register

According to INSIGHT Health, the GKV had gross expenditure on the anti-Alzheimer's market in the period from August 2007 to July 2008 totaling 249.3 million euros - around 19 percent more than in the same period last year.
While this increase in expenditure of 15 to 23 percent was almost uniform across all regions of the statutory health insurance associations (KV), a comparison of expenditure per GKV insured person reveals considerable regional differences (see Fig. 3).
The new federal states are without exception significantly above the national average when it comes to per capita spending on anti-Alzheimer's drugs. The northern old federal states, on the other hand, can all be found at the bottom of the spending list.
What is particularly striking is the difference between the city state of Bremen and the federal state of Saxony. In the KV Saxony, more than six times as much is spent per capita in this pharmaceutical segment than in the KV Bremen. But a comparison of the large states also reveals clear differences: Compared to the new federal states, the KV Schleswig-Holstein only spent around half per capita on drug-based anti-Alzheimer therapy. This shows that purely demographic explanations would fall short (Fig. 3).
In addition to the regional consideration, from a health policy perspective, a comparison between the individual health insurance companies is of utmost interest, as the funds are redistributed based on the Morbi-RSA, which took effect in 2009. A comparison of selected health insurance companies (Fig. 4) also reveals huge differences here: In the AOK Brandenburg, expenditure on anti-Alzheimer's medication is more than six times as high as at the Techniker Krankenkasse (TK).
But there are also clear differences within the types of health insurance that cannot be explained solely by the age structure: AOK Hessen spends more than 50 percent more on anti-Alzheimer medication per insured person than AOK Rhineland/Hamburg. The per capita expenditure of the Taunus BKK, which is also mainly active in Hesse, is now only 40 percent of the expenditure of the German BKK.
These prescription numbers already give a first impression of the effects that the Morbi-RSA will have on the cash register landscape. Similar and further analyzes are now to be developed for the other 79 clinical pictures of Morbi-RSA.

Conclusion: Around 340,000 insured without appropriate therapy

The market development of anti-Alzheimer drugs is characterized by a continuous increase in both the absolute number of patients treated and the intensity of therapy per patient. Nevertheless, in 2007, less than half of the 640,000 people insured by the GKV who suffered from Alzheimer's dementia received any drug therapy with a medication that complies with the guidelines, and around 340,000 people insured remained without appropriate therapy.
For treated patients, the average prescription volume now reaches 50 percent of what the corresponding guidelines stipulate. There is also a very strong regional and health insurance-specific differentiation in Alzheimer's therapy, which cannot be explained solely by the population or insured person structure. <<