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

1. Chronic Illiness and the Role of Primary Care in Disease Management in Germany M. Lüngen, PhD Acting Director

2. 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

3. Characteristics of Primary Care in Germany Physicians in practices Physicians in hospitals Data: Germany, year 2003 118,000 59,000 59,000 146,000 Primary care physicians Specialists (outpatient care) Specialists (inpatient care) Access without referral. Copayment 10 € per visit Nearly no gate-keeping function No single contracting Fee-for-service scheme 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

4. Key elements of the German health care system Insured/ Patient Provider • unrestricted access • no preferred provider • gate-keeping only by 10€ fee per visit in 3 month prescription Pharmacy (Drugs) Nobody really does coordination of care in Germany Membership Contribution payment 200 Health Insurance Companies (statutory health insurance only, about 90% of inhabitants)

5. 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).

6. How was Disease Management introduced in Germany? Primary Care Physicians Insured Includes into DMP Contribution Fee-for- Service Pool of all contributions Payment For Insured Disease-Management Program Management Initiates Health Insurance Companies (health plans) Federal Social-Insurance Authority Quality-Certification

7. Coordination of care in Disease-Management Programs in Germany Patient Primary Care Physicians Health Insurance Companies (health plans) No caremanagers needed Shows diabetes inclusion criteria Includes patient Pays management fee to physician Gives information to service organisation, EMR Gets reminder from EMR Gets reminder from EMR Provides service Gets quality report

8. Integrating Disease-Management Programms into the risk-adjustment scheme (Diabetes Type I) before 2002 from 2002 Expenditure per year € Mean of chronic ill diabetes 4,500€ marginal expenditure for diabetes I marginal expenditure for diabetes care Mean of all insured 2,000€ Mean of „healthy“ insured 1,920€ man, 50 y. healthy man, 50 y. healthy man, 50 y. healthy man, 50 y. healthy • Redistribution for healthy was reduced. • Redistribution for chronically ill was raised.

9. Four diseases were selected first for re-distribution, certification etc. re-distribution per patient per year No. of programs No. of patients • Diabetes mellitus Type II • Breast Cancer • Asthma/ COPD • Coronary Heart Disease ~ 3,000 2.1 m + 1,232 € (=4,600 €) ~ 1,500 74 tsd + 3,864 € (=6,700 €) ~ 200 80 tsd + 315 € (=2,300 €) ~ 800 722 tsd + 869 € (=4.600 €) Data: Germany, year 2006

10. 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).

11. 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.

12. Were Disease-Management Programms effective in Germany?Diabetes Care (BARMER Ersatzkasse) Non-included patients Included patients 64 % 81 % negotiated therapy goals with physicians got yearly training got inspection of feet reported better management reported better (subjective) health status 50% 66 % 64 % 89 % 85 % 15 % Data: Diabetes Disease-Management Program, BARMER Ersatzkasse, 587 answers, 1 year after program started

13. Were Disease-Management Programms effective in Germany?AOK (four regions): Smoking Habits Region 2. Halbjahr2003 1. Halbjahr2004 2. Halbjahr2004 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003

14. Were Disease-Management Programms effective in Germany?AOK (four regions): HbA1c Clinical Parameter Diabetes Region 2. Halbjahr2003 1. Halbjahr2004 2. Halbjahr2004 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003

15. Were Disease-Management Programms effective in Germany?AOK (four regions): Diabetes Care Blood Pressure (systolic) Region 2. Halbjahr2003 1. Halbjahr2004 2. Halbjahr2004 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003

16. Were Disease-Management Programms effective in Germany?AOK (six regions): Eye examinations % • 32% of diabetes patients got regularly eye examination before introducing disease management programs in Germany. 32% Region *Data: AOK patients, reports year 2005

17. 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)

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

19. Diabetes Mellitus II; Expenditures; Inpatient Care;in € per year Non-included Included in DMP Age

20. 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.

21. Key messages 1. 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. 2. 3. 4.

22. Thank you very much for your attention!Any questions to DMP or health care in Germany?Luengen@igke.de