Open Access Research article

Health care costs in the elderly in Germany: an analysis applying Andersen’s behavioral model of health care utilization

Dirk Heider1*, Herbert Matschinger12, Heiko Müller3, Kai-Uwe Saum3, Renate Quinzler4, Walter Emil Haefeli4, Beate Wild5, Thomas Lehnert1, Hermann Brenner3 and Hans-Helmut König1

Author Affiliations

1 Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistr 52, Hamburg, 20246, Germany

2 Department of Social Medicine, Occupational Medicine and Public Health, University of Leipzig, Leipzig, Germany

3 Divisions of Clinical Epidemiology and Aging Research and Preventive Oncology, German Cancer Research Center, Heidelberg, Germany

4 Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany

5 Department of General Internal Medicine and Psychosomatics, Medical University Hospital Heidelberg, Heidelberg, Germany

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BMC Health Services Research 2014, 14:71  doi:10.1186/1472-6963-14-71

Published: 14 February 2014



To analyze the association of health care costs with predisposing, enabling, and need factors, as defined by Andersen’s behavioral model of health care utilization, in the German elderly population.


Using a cross-sectional design, cost data of 3,124 participants aged 57–84 years in the 8-year-follow-up of the ESTHER cohort study were analyzed. Health care utilization in a 3-month period was assessed retrospectively through an interview conducted by trained study physicians at respondents’ homes. Unit costs were applied to calculate health care costs from the societal perspective. Socio-demographic and health-related variables were categorized as predisposing, enabling, or need factors as defined by the Andersen model. Multimorbidity was measured by the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Mental health status was measured by the SF-12 mental component summary (MCS) score. Sector-specific costs were analyzed by means of multiple Tobit regression models.


Mean total costs per respondent were 889 € for the 3-month period. The CIRS-G score and the SF-12 MCS score representing the need factor in the Andersen model were consistently associated with total, inpatient, outpatient and nursing costs. Among the predisposing factors, age was positively associated with outpatient costs, nursing costs, and total costs, and the BMI was associated with outpatient costs.


Multimorbidity and mental health status, both reflecting the need factor in the Andersen model, were the dominant predictors of health care costs. Predisposing and enabling factors had comparatively little impact on health care costs, possibly due to the characteristics of the German social health insurance system. Overall, the variables used in the Andersen model explained only little of the total variance in health care costs.

Cost of illness study; Cross-sectional study; Health care utilization; Health care costs; Multimorbidity; Elderly; Andersen behavioral model