[Patient steering from a health economics perspective: conditions for effective cost-sharing in a European comparison].

Rising health expenditures and demographic change increasingly challenge the financing and steering of healthcare in Germany. Cost-sharing instruments are recurrently discussed as a means of reducing inappropriate utilisation, most recently in the context of a primary care gatekeeping system. This article analyses the institutional design and empirical evidence on financial steering instruments in four European health systems (Germany, the Netherlands, France, Denmark) and synthesises the findings from a health economics perspective. The effectiveness of copayments emerges as a function of three interrelated conditions: the type of service, the behavioural-economic design and the institutional architecture. Uniform copayments are regressive and disproportionately burden insured persons with low income. Based on the international evidence, a reintroduction of the previous German practice fee (Praxisgebühr) is not advisable. A more promising approach would design copayments as a targeted steering instrument at points where inappropriate utilisation is empirically identified, such as when patients inappropriately bypass a coordinated care pathway. This requires accounting for behavioural-economic effects and income-related differences. Configured in this way, copayments can contribute to improving patient steering without jeopardising access to standard care.