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
Institute for
Health Economics
and Clinical Epidemiology
Institute for Health Economics and Clinical Epidemiology
 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
 Luengen@igke.de
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Characteristics of Primary Care in Germany
Physicians
in practices
59,000
118,000
Primary care
physicians
Access without referral.
Copayment 10 € per visit
Nearly no gate-keeping
function
No single contracting
Fee-for-service scheme
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Physicians
in hospitals
Data: Germany, year 2003
Institute for
Health Economics
and Clinical Epidemiology
59,000
146,000
Specialists
(outpatient care)
Specialists
(inpatient care)
Access without referral.
Copayment 10 € per visit
..........................................
..........................................
No single contracting
Fee-for-service scheme
Access mostly with referral.
Copayment 10 € per day
...............................................
...............................................
No single contracting
DRG scheme
Institute for
Health Economics
and Clinical Epidemiology
Key elements of the German health care system
Insured/
Patient
Membership
Contribution
• unrestricted access
• no preferred provider
• gate-keeping only by 10€
fee per visit in 3 month
Nobody really does
coordination of care in Germany
Provider
prescription
Pharmacy
(Drugs)
payment
200 Health Insurance Companies
(statutory health insurance only, about 90% of inhabitants)
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Institute for
Health Economics
and Clinical Epidemiology
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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Institute for
Health Economics
and Clinical Epidemiology
How was Disease Management introduced in Germany?
Primary Care
Physicians
Includes
into DMP
Insured
Contribution
Fee-forService
Disease-Management
Program
Payment
For Insured
Management
Initiates
Health Insurance Companies
(health plans)
Federal Social-Insurance
Authority
Quality-Certification
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Pool of all contributions
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Health Economics
and Clinical Epidemiology
Coordination of care in Disease-Management Programs
in Germany
Patient
Shows diabetes
inclusion criteria
Gets reminder from EMR
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Primary Care
Physicians
Includes patient
Health Insurance Compani
(health plans)
No care
managers
needed
Gets reminder from EMR
Provides service
Gets quality report
Pays management fee to
physician
Gives information to
service organisation, EMR
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Health Economics
and Clinical Epidemiology
Integrating Disease-Management Programms into the riskadjustment scheme (Diabetes Type I)
before 2002
Expenditure
per year €
Mean
of all
insured
from 2002
4,500€
2,000€
marginal
expenditure
for
diabetes I
marginal
expenditure
for
diabetes care
1,920€
man, 50 y.
healthy
man, 50 y.
healthy
man, 50 y.
healthy
 Redistribution for healthy was reduced.
 Redistribution for chronically ill was raised.
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man, 50 y.
healthy
Mean of
chronic ill
diabetes
Mean of
„healthy“
insured
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Health Economics
and Clinical Epidemiology
Four diseases were selected first for re-distribution,
certification etc.
re-distribution
No. of programs
No. of patients
per patient
per year
 Diabetes mellitus Type II
~ 3,000
2.1 m
+ 1,232 €
(=4,600 €)
 Breast Cancer
~ 1,500
74 tsd
+ 3,864 €
(=6,700 €)
80 tsd
+ 315 €
(=2,300 €)
722 tsd
+ 869 €
(=4.600 €)
 Asthma/ COPD
 Coronary Heart Disease
Data: Germany, year 2006
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~ 200
~ 800
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and Clinical Epidemiology
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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Health Economics
and Clinical Epidemiology
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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Health Economics
and Clinical Epidemiology
Were Disease-Management Programms effective in Germany?
Diabetes Care (BARMER Ersatzkasse)
Non-included patients
Included patients
64 %
negotiated therapy goals with physicians
81 %
50%
got yearly training
66 %
64 %
got inspection of feet
89 %
reported better management
85 %
reported better (subjective) health status
15 %
Data: Diabetes Disease-Management Program, BARMER Ersatzkasse,
587 answers, 1 year after program started
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and Clinical Epidemiology
Were Disease-Management Programms effective in Germany?
AOK (four regions): Smoking Habits
Region
2. Halbjahr
2003
11,6
8,5
Hessen
7,2
1. Halbjahr
2004
11,8
9,0
8,5
Mecklenburg-V.
2. Halbjahr
2004
17,7
12,6
12,3
Bremen
9,5
7,0
6,4
Sachsen
0
2
4
6
8
Prozent
10
12
*Data: 4,800 AOK patients, included in DMP in 06-12/2003
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14
16
18
20
Institute for
Health Economics
and Clinical Epidemiology
Were Disease-Management Programms effective in Germany?
AOK (four regions): HbA1c Clinical Parameter Diabetes
Region
7,27
2. Halbjahr
2003
7,09
7,06
Hessen
1. Halbjahr
2004
7,15
7,05
Mecklenburg-V.
2. Halbjahr
2004
6,98
7,13
7,11
Bremen
7,01
6,88
6,73
6,69
Sachsen
6,4
6,5
6,6
6,7
6,8
Prozent
6,9
7
*Data: 4,800 AOK patients, included in DMP in 06-12/2003
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7,1
7,2
7,3
7,4
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Were Disease-Management Programms effective in Germany?
AOK (four regions): Diabetes Care Blood Pressure (systolic)
Region
151
143
142
Hessen
1. Halbjahr
2004
150
141
141
Mecklenburg-V.
2. Halbjahr
2003
2. Halbjahr
2004
151
144
143
Bremen
148
142
142
Sachsen
134
136
138
140
142
Prozent
144
146
*Data: 4,800 AOK patients, included in DMP in 06-12/2003
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148
150
152
Institute for
Health Economics
and Clinical Epidemiology
Were Disease-Management Programms effective in Germany?
AOK (six regions): Eye examinations
95
92
78
78
% 67
 32% of diabetes
patients got regularly
eye examination
before introducing
disease management
programs in Germany.
ür
Br
tt.
an
de
nb
ur
g
Br
em
en
en
-W
Ba
d
He
Me
ss
en
ck
len
bu
rg
-V
.
Rh
ein
Rh
lan
ein
d
lan
dPf
Ni
alz
ed
er
sa
ch
se
n
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73
32%
Region
*Data: AOK patients, reports year 2005
84
90
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Health Economics
and Clinical Epidemiology
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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Institute for
Health Economics
and Clinical Epidemiology
Were Disease-Management Programms effective in Germany?
Region Nordrhein: Diabetes; Blood Pressure
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Diabetes Mellitus II; Expenditures; Inpatient Care;
in € per year
Non-included
Included in
DMP
Age
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Institute for
Health Economics
and Clinical Epidemiology
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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Institute for
Health Economics
and Clinical Epidemiology
Key messages
1.
Germany has a authority-managed money pool to reward evidencebased, certified Disease-Management Programs.
2.
Because of the financial incentive for including patients into the
programs, primary care physicians are important partners of the health
plans.
3.
4.
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.
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Institute for
Health Economics
and Clinical Epidemiology
Thank you very much for your attention!
Any questions to DMP or health care in Germany?
Luengen@igke.de
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