2009 Annual Research Meeting
Incentives for Care Coordination in Germany 2002-2008: what about their impact on
quality and cost?
Sophia Schlette, MPH
June 28, 2009
Main system features –
Challenges in the German health care system
 Many actors, fragmentation, complexity
 Over- under-, and misuse in health care (Advisory Council report to
MoH, 2000/2001 +)
- Inefficiencies (waste estimated at 30%)
- Coordination deficits (CMWF survey data, rank 4/8)
- Quality disparities, lack of transparency (CMWF survey data, rank 3/8)
 High physician density but regional disparities
 Cottage industry, paper industry
 “Eminence” vs. evidence-based medicine
 Inertia, turf, and reluctance to change
 Unhappy doctors (why?)
Delivery system challenges –
Sectoral and geographical divide
 Separation of hospital and ambulatory care
 West: private solo practice model
 West: double specialty care infrastructure
 East: multispecialty polyclinics model, 1950-1990
 Reemergence of “polyclinics” since 1995 (medical care
centers)
Policy responses since 2001:
Proactive legislation in 2004 and 2007 to promote
 Efficiency
- value-based purchasing based on evidence and comparative effectiveness
 Financing/funding
- pooling premiums in a national health fund, morbidity-adjusted allocation of
moneys to 190+ sickness funds
 Transparency
- mandatory QM, public reporting, patient empowerment, decision-making
 Care coordination
- GP gatekeeping, DMPs, selective contracting, polyclinics, LTC one-stopshops
Governance:
Steps toward Delivery System Reform
 Political endorsement for primary care
 New contractual freedoms, easing horizontal integration
and cooperation:
- integrated care contracts
- medical care centers
- ambulatory surgery
- hospital outpatient care
 Financially incentivised new forms of care coordination
 New mandatory offers: Disease Management Programs
Governance:
Steps toward Delivery System Reform
 Political endorsement for primary care
 New contractual freedoms, easing horizontal integration
and cooperation
 Financially incentivised new forms of care coordination
- Medical Care Centers
- GP models/gatekeeper models
- Integrated care contracts (selective contracting)
- LTC coordination centers
- Disease Management Programs (mandatory 2004-2008)
DMPs – highly controversial at time of introduction
Positions and Influences at a glance
DMPs in numbers
 ~14.800 DMPs (~2.500 per indication)
 >5.5 mio patients (March 2009)
-
> 2.7 mio in Diabetes II DMPs
-
1.2 in CHD DMPs (April 2008)
 75% of GPs participate “voluntarily”
DMP implementation 2002-2008
 Six Conditions – determined by Federal Joint Committee
-





Diabetes type I & II
CHD
COPD
Asthma
Breast cancer
Run by sickness funds
Certified by Federal Insurance Authority
Primary care providers‘ participation voluntary
Patient enrollment voluntary
Requirements for certification and participation
Six key requirements for each condition
1
Evidence-based
guidelines
Treatment according to evidence-based guidelines with
respect to the relevant sectors of care
2
Quality
measurements
Choice of accredited QM tool to ensure adequate
quality assurance
3
Conditions of
enrolment
4
Health education
and CPD
5
Documentation
6
Evaluation
Requirements and procedure for enrolment of insured,
including duration of participation
Education and information of providers and patients
Documentation of data for evaluation, quality assurance
and patient information
Evaluation effects on clinical outcomes and costs
DMP incentives 2002-2008
– balancing rights and responsibilities
For Payers

Extra funds for each DMP eligible member that enrolls – incentive to select „bad
risk“ and treat them well
For Providers

Compensation for additional workload (admin, documentation, evaluation
requirements)
For Patients

Lower or no prescription drug co-pays and/or waived office visit fees
Do DMPs improve health care delivery and quality?
multiple
studies
quality
measurements
patient
surveys
mandatorye
valuation
Several large scale evaluations show positive effects on
quality of care, quality of life, and patient experience!
•
•
ELSID, Evaluation of large scale implementation of disease management programs for patients
with type 2 diabetes, www.klinikum.uni-heidelberg.de
KORA, GSF, Forschungszentrum für Umwelt und Gesundheit, Munich, www.gsf.de/KORA
Ex: Diabetes II DMPs
– evaluation results six years into practice
 DMP participants show more multimorbidity profiles, are sicker and have been
diagnosed longer than non-participants (Barmer)
 Participants slightly better educated (49% vs. 45% with mid/higher grade)
 Improved care process
 Improved clinical outcomes (all studies)
 Less complications
 More early-stage hospitalizations for DMP participants vs. emergency
hospitalizations for non-participants
 Higher patient satisfaction: self-reported higher quality of life and better
(mental) health status
 Growing acceptance among participating physicians
 „Cross-fertilization“ as a welcomed side-effect
Improving health and cost outcomes
Clinical measures
-Lower HbA1c
-Lower blood pressure
-Less hyper- and Hypoglycemia
Process measures
-Fewer hospital admissions
-Fewer emergency visits
-More blood glucose monitoring
-More eye exams
Patient feedback
-Higher satisfaction
-Better quality of life
Economic measures
-Lower cost
 Evidence shows that no single intervention works best;
DMPs have to work on several components simultaneously
Process: Hospitalization data per 1000 BEK diabetes
standard population based on diagnoses and procedures
Men
Total #
hospitalization
s
Total LoS
Total hospital
costs in mio €
(rounded)
Women
DMP
Non-DMP
DMP
Non-DMP
513
608
509
634
3.674
4.564
3.787
5.202
1,43
1,7
1,23
1,7
Source: BARMER 2007
la
n
dPf
Br alz
em
e
Be n
W
es Ha rlin
tfa mb
u
le
n- r g
Th Lip
ür pe
in
ge
n
Rh
ei
n
Process: More frequent eye examinations
89
72
76
80
77
32%
74
Outcome: Overall cholesterol level reduction in CHD DMP
participants in 2 years
205
mg/dl
202,10%
200
198,01%
196,88%
195,90%
195
1 (Eintritt)
2
3
Halbjahre der Teilnahme
Source: Mandatory Evaluation, federal survey of AOK-DMPs
for DMP-CHD enrollees. n = 73.531 in mid-2004.
4
Patients: Increased self-confidence
The Coronary Heart Disease DMP helps me better
manage the disease
CHD DMP*
50
34
9
Very true
7
Rather true
Rather not
true
The Diabetes DMP helps me better manage the
disease
Type 2 Diabetes
DMP**
57
0
10
20
30
Not at all true
33
40
50
60
Figures as percentages
* Evaluation CHD DMP, SUZ 2006, n = 960,
** Evaluation Type 2 Diabetes DMP, psychonomics 2005, n = 981
70
8
80
90
2
100
Prospects: Further development of DMP

Modified DMP incentives since January 2009

Integration of elements for multiple conditions


Development of modules for co-morbidities, e.g. Heart Failure in DMP CHD
Reduce costs of documentation in DMP

Switch to only electronic data exchange

Reduce number of documented data

Simplify administrative processes

Special care for high risk participants (case management)

DMP as part and parcel of a primary care strategy
Federal elections 27 September 2009
Further readings

Blümel, Miriam, Busse, R. "Disease Management Programs. Time to evaluate.“Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/de/a13/2

Blum, Kerstin. "Care coordination gaining momentum in Germany". Health Policy Monitor, July 2007. Available at www.hpm.org/survey/de/b9/1

Busse R (2004): Disease Management Programs in Germany's Statutory Health Insurance System. In: Health Affairs; 23(3):57.

Busse, Reinhard. The health system in Germany. Eurohealth 14(2008)1

Busse R, Schlette S (eds.) (2004): Health Policy Developments Issue 3: Focus on Accountability, (De)Centralization, Information Technologies. Gütersloh, Bertelsmann
Foundation Publishers. www.hpm.org/Downloads/reports/HPDs/HPD3_engl.pdf

Elkeles, Heinze, Eifel: Healthcare by a DMP for Diabetes mellitus Type – Results of a survey of participating insurance costumers of a HI company in Germany. Journal
of Public Health 15 (2007) 6

ELSID, Evaluation of large scale implementation of disease management programs for patients with type 2 diabetes, www.klinikum.uni-heidelberg.de (Szecsenyi 2007)

Gapp O, Schweikert B, Meisinger C, Holle R (2008): Disease management programmes for patients with coronary heart disease - An empirical study of German
programmes. In: Health Policy; 88(2-3):176-185.

Hilfer, S, Riesberg, A, Egger, B (2007): Adapting social security health care systems to trends in chronic disease. Report for the ISSA Technical Commission on Medical
Care and Sickness Insurance. Bonn.

Lisac, Melanie. "Health care reform in Germany: Not the big bang". Health Policy Monitor, November 2006. Available at www.hpm.org/survey/de/b8/2

Lisac, Melanie, Henke, K.-D., Reimers, L., Schlette, S. Access and Choice – Competition under the Roof of Solidarity in German Health Care. An analysis of health
policy reforms since 2004. Article accepted for publication, Health Policy, Economics, and Law, forthcoming.

Mattke S, Seid M, Ma S (2007): Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment? In: The American Journal of Managed Care;
13(2):673-675.

Nagel, H, Baehring, T, Scherbaum, W (2006): Implementing Disease Management Programs for Type 2 Diabetes in Germany. Managed Care November: 50-53.

Schlette, Sophia, Lisac, M., Blum, K.. Integrated Primary Care in Germany – The road ahead. International Journal on Integrated Care. April 2009. Available at
www.ijic.com

Zimmermann, Melanie, reviewers: Reinhard Busse, Sophia Schlette. "Health financing reform idea: health fund". Health Policy Monitor, June 2006. Available at
www.hpm.org/survey/de/b7/1