1. 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

2. Institute for Health Economics and Clinical Epidemiology Seite 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. Institute for Health Economics and Clinical Epidemiology Seite 3 Characteristics of Primary Care in Germany Physicians in practices Physicians in hospitals Primary care physicians Specialists (outpatient care) Data: Germany, year 2003 118,000 Specialists (inpatient care) 146,00059,000 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. Institute for Health Economics and Clinical Epidemiology Seite 4 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 Membership Contribution 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

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

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

8. Institute for Health Economics and Clinical Epidemiology Seite 8 Integrating Disease-Management Programms into the risk- adjustment scheme (Diabetes Type I) man, 50 y. healthy Expenditure per 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 2002from 2002 2,000€ 4,500€ 1,920€

9. Institute for Health Economics and Clinical Epidemiology Seite 9 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 ~ 1,50074 tsd + 3,864 € (=6,700 €) ~ 20080 tsd + 315 € (=2,300 €) ~ 800722 tsd + 869 € (=4.600 €) Data: Germany, year 2006

10. Institute for Health Economics and Clinical Epidemiology Seite 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. Institute for Health Economics and Clinical Epidemiology Seite 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. Institute for Health Economics and Clinical Epidemiology Seite 12 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 %

13. Institute for Health Economics and Clinical Epidemiology Seite 13 Were Disease-Management Programms effective in Germany? AOK (four regions): Smoking Habits 1. Halbjahr 2004 2. Halbjahr 2004 2. Halbjahr 2003 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Region

14. Institute for Health Economics and Clinical Epidemiology Seite 14 Were Disease-Management Programms effective in Germany? AOK (four regions): HbA1c Clinical Parameter Diabetes 1. Halbjahr 2004 2. Halbjahr 2004 2. Halbjahr 2003 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Region

15. Institute for Health Economics and Clinical Epidemiology Seite 15 Were Disease-Management Programms effective in Germany? AOK (four regions): Diabetes Care Blood Pressure (systolic) 1. Halbjahr 2004 2. Halbjahr 2004 2. Halbjahr 2003 Prozent *Data: 4,800 AOK patients, included in DMP in 06-12/2003 Region

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

17. Institute for Health Economics and Clinical Epidemiology Seite 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. Institute for Health Economics and Clinical Epidemiology Seite 18 Were Disease-Management Programms effective in Germany? Region Nordrhein: Diabetes; Blood Pressure

19. Institute for Health Economics and Clinical Epidemiology Seite 19 Non-included Included in DMP Age Diabetes Mellitus II; Expenditures; Inpatient Care; in € per year

20. Institute for Health Economics and Clinical Epidemiology Seite 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. Institute for Health Economics and Clinical Epidemiology Seite 21 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.

22. Institute for Health Economics and Clinical Epidemiology Seite 22 Thank you very much for your attention! Any questions to DMP or health care in Germany? Luengen@igke.de