institute for health economics and clinical epidemiology chronic illiness and the role of primary...

Institute for Health Economics and Clinical Epidemiology

Chronic Illiness and the Role of Primary Care in Disease Management in Germany

M. Lüngen, PhD Acting Director


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Founded 1996, Institute is part of the University Hospital of Cologne.

About 15 scientists (physicians, economists, statisticians). Research:

Health policy. Cost-effectiveness analysis, financing. Public health, equity in health care.

www.igke.de [email protected]


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Characteristics of Primary Care in Germany

Physicians in practices

Physicians in hospitals

Primary carephysicians

Specialists(outpatient care)

Data

: Ger

man

y, y

ear 2

003

118,000

Specialists(inpatient care)

146,00059,000 59,000

Access without referral.Copayment 10 € per visitNearly no gate-keeping functionNo single contractingFee-for-service scheme

Access without referral.Copayment 10 € per visit....................................................................................No single contractingFee-for-service scheme

Access mostly with referral.Copayment 10 € per day..............................................................................................No single contractingDRG scheme


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Key elements of the German health care system

Insured/Patient

200 Health Insurance Companies(statutory health insurance only, about 90% of inhabitants)

Pharmacy(Drugs)

Provider

MembershipContribution

• unrestricted access• no preferred provider• gate-keeping only by 10€ fee per visit in 3 month prescription

payment

Nobody really does coordination of care in Germany


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Why was Disease Management introduces in Germany?

Problems:

Risk selection between health plans: healthy and wealthy insured were preferred due to incomplete measurement of income and morbidity.

No grouper for morbidity was available for Germany (lack of scientists, research programs, and data).

Competition for quality care for chronic ill was set on the political agenda (not competition for good risks and not competition for efficiency alone).


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How was Disease Management introduced in Germany?

Health Insurance Companies(health plans)

Pool of all contributionsDisease-Management Program

InsuredPrimary Care Physicians

Federal Social-Insurance Authority

Contribution

Management

PaymentFor Insured

Quality-Certification

Initiates

Includesinto DMP

Fee-for-Service


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Coordination of care in Disease-Management Programs in Germany

Primary Care PhysiciansPatient Health Insurance Companies

(health plans)

Shows diabetes inclusion criteria Includes patient

Pays management fee to physicianGives information to service organisation, EMR

Gets reminder from EMRProvides service Gets quality report

Gets reminder from EMR

No caremanagers

needed


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Integrating Disease-Management Programms into the risk-adjustment scheme (Diabetes Type I)

man, 50 y.healthy

Expenditureper year €

marginal expenditure

for diabetes I

Mean of chronic ill diabetes

man, 50 y.healthy

man, 50 y.healthy

man, 50 y.healthy

marginal expenditure

for diabetes care

Redistribution for healthy was reduced.

Redistribution for chronically ill was raised.

Mean of all

insured Mean of „healthy“ insured

before 2002 from 2002

2,000€

4,500€

1,920€


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Four diseases were selected first for re-distribution, certification etc.

Diabetes mellitus Type II

Breast Cancer

Asthma/ COPD

Coronary Heart Disease

~ 3,000

No. of programs

2.1 m

No. of patients

+ 1,232 €(=4,600 €)

re-distribution per patient

per year

~ 1,500 74 tsd+ 3,864 €(=6,700 €)

~ 200 80 tsd+ 315 €

(=2,300 €)

~ 800 722 tsd+ 869 €

(=4.600 €)

Data: Germany, year 2006


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How was Disease Management introduced in Germany?Quality assurance

Not the health plan, but physicians (both in offices and hospitals) were allowed to include patients into disease management programs.

Physicians get an additional fee for managing patient within disease management, but no pay-for-performance.

The high redistribution per patient and year made high controls for including patients necessary (gaming).

All disease-management programs must be quality-certified by the „Bundesversicherungsamt“ (Federal Social-Insurance Authority).


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Evaluation: Is there Evidence?

First full evaluation of 3-year-period will be available in summer 2007.

Today:

1-year-results of several health insurance companies.

Limited data of baseline (clinical parameter).

Some control groups (matching).

Patient surveys of subjective health.


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Were Disease-Management Programms effective in Germany?Diabetes Care (BARMER Ersatzkasse)

Data: Diabetes Disease-Management Program, BARMER Ersatzkasse, 587 answers, 1 year after program started

negotiated therapy goals with physicians

got yearly training

got inspection of feet

reported better management

reported better (subjective) health status

64 %

Non-included patients

81 %

Included patients

50% 66 %

64 % 89 %

85 %

15 %


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Were Disease-Management Programms effective in Germany?AOK (four regions): Smoking Habits

1. Halbjahr2004

2. Halbjahr2004

2. Halbjahr2003

6,4

12,3

8,5

7,2

7,0

12,6

8,5

17,7

11,8

11,6

9,0

9,5

0 2 4 6 8 10 12 14 16 18 20

Sachsen

Bremen

Mecklenburg-V.

Hessen

Prozent

*Data: 4,800 AOK patients, included in DMP in 06-12/2003

Region


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Were Disease-Management Programms effective in Germany?AOK (four regions): HbA1c Clinical Parameter Diabetes

1. Halbjahr2004

2. Halbjahr2004

2. Halbjahr2003

Prozent


6,69

7,01

6,98

7,06

6,73

7,11

7,09

7,13

7,15

7,27

7,05

6,88

6,4 6,5 6,6 6,7 6,8 6,9 7 7,1 7,2 7,3 7,4

Sachsen

Bremen

Mecklenburg-V.

Hessen

Region


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Were Disease-Management Programms effective in Germany?AOK (four regions): Diabetes Care Blood Pressure (systolic)

1. Halbjahr2004

2. Halbjahr2004

2. Halbjahr2003

Prozent


142

143

141

142

142

144

143

151

150

151

141

148

134 136 138 140 142 144 146 148 150 152

Sachsen

Bremen

Mecklenburg-V.

Hessen

Region


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Were Disease-Management Programms effective in Germany?AOK (six regions): Eye examinations

%

*Data: AOK patients, reports year 2005

78

92 95

8490

7367

78

32%

32% of diabetes patients got regularly eye examination before introducing disease management programs in Germany.

Region


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Were Disease-Management Programms effective in Germany?Region Nordrhein: Diabetes

66% of all insured with Diabetes were included in DMP.

63% of all primary care physician practices are certified and joined the DMP.

Average of 77 diabetes-patients per practice (250.000 patients)


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Were Disease-Management Programms effective in Germany?Region Nordrhein: Diabetes; Blood Pressure


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Non-included

Included in DMP

Age

Diabetes Mellitus II; Expenditures; Inpatient Care;in € per year


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Germany as a solution?

Health plans should not be punished for managing bad risks. Extra payment from the pool for Disease-Management Programs are foreseen in Germany even after using morbidity oriented risk adjustment schemes (inpatient diagnosis, Rx etc.).

Get physicians as partners, not as subordinates in questions of guidelines, therapies, and design of programs.

Quality oriented programs and budget neutrality.

Reduce bureaucracy. Documentation is main reason for low adherence among physicians and patients.


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Key messages

Germany has a authority-managed money pool to reward evidence-based, certified Disease-Management Programs.

Because of the financial incentive for including patients into the programs, primary care physicians are important partners of the health plans.

Certified primary care physicians get normal fee plus additional payment for managing the patients. Main organisation workload is done by IT partners.

Evaluations today seems to show an increase in quality and decrease in cost.

1.

2.

3.

4.


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Thank you very much for your attention!

Any questions to DMP or health care in [email protected]

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