Primary Care as a Window into a High Performance Health Care System II

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 Seite 2 Institute for Health Economics and Clinical Epidemiology Characteristics of Primary Care in Germany Physicians in practices 59,000 118,000 59,000 Physicians in hospitals 146,000 Primary care physicians Access without referral. Copayment 10 € per visit Nearly no gate-keeping function No single contracting Fee-for-service scheme Seite 3 Specialists (outpatient care) Access without referral. Copayment 10 € per visit .......................................... .......................................... No single contracting Fee-for-service scheme Specialists (inpatient care) Access mostly with referral. Copayment 10 € per day ............................................... ............................................... No single contracting DRG scheme Data: Germany, year 2003 Institute for Health Economics and Clinical Epidemiology Key elements of the German health care system Insured/ Patient • unrestricted access • no preferred provider • gate-keeping only by 10€ fee per visit in 3 month Provider prescription Membership Contribution Nobody really does coordination of care in Germany Pharmacy (Drugs) payment 200 Health Insurance Companies (statutory health insurance only, about 90% of inhabitants) Seite 4 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). Seite 5 Institute for Health Economics and Clinical Epidemiology How was Disease Management introduced in Germany? Primary Care Physicians Fee-forService Includes into DMP Insured Contribution Payment For Insured Disease-Management Program Initiates Pool of all contributions Management Health Insurance Companies (health plans) Seite 6 Federal Social-Insurance Authority Quality-Certification Institute for Health Economics and Clinical Epidemiology Coordination of care in Disease-Management Programs in Germany Patient Shows diabetes inclusion criteria Primary Care Physicians Includes patient No care managers needed Health Insurance Compani (health plans) Pays management fee to physician Gives information to service organisation, EMR Gets reminder from EMR Gets reminder from EMR Provides service Gets quality report Seite 7 Institute for Health Economics and Clinical Epidemiology Integrating Disease-Management Programms into the riskadjustment scheme (Diabetes Type I) before 2002 Expenditure per year € marginal expenditure for diabetes I from 2002 4,500€ Mean of chronic ill diabetes Mean of all insured 2,000€ marginal expenditure for diabetes care 1,920€ man, 50 y. healthy man, 50 y. healthy man, 50 y. healthy man, 50 y. healthy Mean of „healthy“ insured  Redistribution for healthy was reduced.  Redistribution for chronically ill was raised. Seite 8 Institute for 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  Breast Cancer  Asthma/ COPD  Coronary Heart Disease Data: Germany, year 2006 Seite 9 ~ 3,000 ~ 1,500 ~ 200 2.1 m 74 tsd 80 tsd + 1,232 € (=4,600 €) + 3,864 € (=6,700 €) + 315 € (=2,300 €) + 869 € (=4.600 €) ~ 800 722 tsd Institute for Health Economics 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). Seite 10 Institute for 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. Seite 11 Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? Diabetes Care (BARMER Ersatzkasse) Non-included patients Included patients 64 % 50% 64 % negotiated therapy goals with physicians 81 % 66 % 89 % 85 % got yearly training got inspection of feet reported better management reported better (subjective) health status Data: Diabetes Disease-Management Program, BARMER Ersatzkasse, 587 answers, 1 year after program started Seite 12 15 % Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? AOK (four regions): Smoking Habits Region 11,6 Hessen 8,5 7,2 11,8 2. Halbjahr 2003 1. Halbjahr 2004 2. Halbjahr 2004 Mecklenburg-V. 9,0 8,5 17,7 Bremen 12,6 12,3 9,5 Sachsen 7,0 6,4 0 2 4 6 8 10 12 14 16 18 20 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Seite 13 Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? AOK (four regions): HbA1c Clinical Parameter Diabetes Region 7,27 Hessen 7,09 7,06 7,15 2. Halbjahr 2003 1. Halbjahr 2004 2. Halbjahr 2004 Mecklenburg-V. 7,05 6,98 7,13 7,11 7,01 6,88 Bremen Sachsen 6,73 6,69 6,4 6,5 6,6 6,7 6,8 6,9 7 7,1 7,2 7,3 7,4 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Seite 14 Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? AOK (four regions): Diabetes Care Blood Pressure (systolic) Region 151 Hessen 143 142 150 2. Halbjahr 2003 1. Halbjahr 2004 2. Halbjahr 2004 Mecklenburg-V. 141 141 151 Bremen 144 143 148 Sachsen 142 142 134 136 138 140 142 144 146 148 150 152 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Seite 15 Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? AOK (six regions): Eye examinations 95 92 78 78 84 90 73 % 67  32% of diabetes patients got regularly eye examination before introducing disease management programs in Germany. Region 32% ür Br tt. an de nb ur g Br em en Seite 16 Ba d *Data: AOK patients, reports year 2005 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 en -W Institute for 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) Seite 17 Institute for Health Economics and Clinical Epidemiology Were Disease-Management Programms effective in Germany? Region Nordrhein: Diabetes; Blood Pressure Seite 18 Institute for Health Economics and Clinical Epidemiology Diabetes Mellitus II; Expenditures; Inpatient Care; in € per year Non-included Included in DMP Age Seite 19 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. Seite 20 Institute for Health Economics and Clinical Epidemiology Key messages 1. Germany has a authority-managed money pool to reward evidencebased, 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. Seite 21 2. 3. 4. 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 Seite 22