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Franz Knieps on disease management programmes

by Lloyd Davis

Background: Director General for Public Health Care, Health Insurance and Long Term Care Insurance,
Federal Ministry of Health Germany
Theme: Role of disease management programmes in overall health care reform

We’re having a difficult time in Germany but today’s a good day as we’ve just had our reforms signed off by the president.

Universal coverage for nearly everyone; in the new system no-one will be excluded.
Wide ranging benefit package; a lot of doubt that everything offered is medically necessary
Free access and consumer choice; you can have the provider you like, no referral required
Pluralism and competition; public and private
Power sharing between government and self administration
Balance between solidarity and self responsiblity is shifting towards strengthening patients
Decentralization; the federal level is the law maker, but everything is managed at a local level.

We’ve had social health insurance for 90% of the poulation where the rich pay for the poor, the healthy pay for the sick, singles pay for the families and the young pay for the elderly. And private insurance for 10% of population - the self eimployed, civil servants, and high income individuals - based on risk-related premiums offered by some 40 private companies.

It’s a pluralistic health care delivery system employing 4.3 million people - the financial resource allocation system is very complicated which means that co-operation often suffers.

There’s a complex organizational framework - state authorities are weak, with the regulation done by associations of providers, professions, funds, and companies. The power of patients and users within the framework is expanding, combining decision making with empowerment. And competition is growing - every one says they support it but in practice, they don’t like it.

The primary challenges: the disintegration of care separation between ambulatory and hospital care, medical, social and nursing care, the lack of communication, coordination cooperation, and a lack of incentives promoting managed care. We put our focus on acute care, disregarding chronic care - the medical view dominates and there is a lack of case of care mangement - it’s not evidence based, but eminence based. Also, risk selection by funds and providers; variations in the quality of care, which gets shrugged off; overuse and undersupply especially in rural areas where most of the elderly live; regulation and bureaucracy - detailed laws that don’t suit healthcare well; lack of transparency - patients don’t get to know anything about the quality of their doctors or hospitals; resistance to change.

Challenges that face us as everyone - aging population and more chronic disease, a lack of human resources, cost containment leading to priority setting and rationing, finding complementary funding sources and investing in the management of care and diseases.

The first attempts in Disease Management programmes were made by regional funds in early 90s, using experience from the former East Germany and the US. The lack of financial incentives led to little progress, with doctors calling it “cook book” medicine. Which led to a state of uncertainty for doctors and patients. A fundamental change happened in 2001 when we introduced a real link between managed care and redistribution of sicknss fund revenues - funds then became increasingly interested. This act also defined categories for risk adjustment.

Some of the criticisms and needs:
Link to risk structure compensation scheme - risk of incentives for doctors to enroll healthy people.
Data protection concerns - we’ve since satisfied the data commissioner
Additional monetary input
Uniform requirements for accreditation and documentation
Focus on ambulatory care

The Future
We’ll include more diseases and address consideration of multi-morbidity. We’ll link with new models of population-oriented and integrated care across the U.S. and Europe. And we want to look at the evaluation results to improve quality, involve patients more, and reflect on evidence-based medicine so that disease management programmes are an important step to evidence-based health policy and improvement across Europe.

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