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Disease Management Programs: Big Bucks in the Game
The treatment programs for the chronically ill have established themselves in standard care. Their effectiveness and their connection with the risk structure compensation are still controversial.
The excitement has given way to a certain lack of passion. "Nobody is really enthusiastic, but everyone participates," says general practitioner Martin G., who runs a family doctor's practice in the Lower Rhine region. We are talking about the disease management programs (DMP), the structured treatment programs for the chronically ill that have now been launched for diabetes mellitus type 1 and 2, for breast cancer, coronary artery disease (CHD) and COPD / asthma. G. believes that it was not medical conviction, but the fear of losing patients to the “competition”, that prompted many doctors to take part in the DMP. Since the programs were launched in 2002, they have not only been massively advertised by politicians - above all by Federal Health Minister Ulla Schmidt - but also by large health insurance funds such as the AOK.
Around 1.7 million insured persons nationwide have now enrolled in the DMP Diabetes mellitus type 2. In the opinion of GP G., however, one cannot speak of a “dramatically improved care”. “The treatment of diabetics in my practice has not fundamentally changed. We have already done a lot of things beforehand in the way the treatment guidelines now provide. ”The advantage is that the prescribed procedures raise awareness in some areas and, for example, examine the feet of diabetics more frequently. In addition, formal involvement in a program could have a positive effect on patient compliance. “But there are always patients who cannot be reached even with the best DMP,” G. points out. “Unless coercion and sanctions are introduced, which nobody really believes to be justifiable.” At the moment, nobody can say in any case whether expensive long-term consequences can actually be avoided through the chronicler programs. It's too early for that. “If that's the case, then I'm happy about it,” says G. But a fundamental concern cannot be dispelled by this: “The DMP with its prescribed guidelines and treatment processes are the beginning of increasing standardization in medicine, which is not the case for the individual patient is more fair. "
Officially, people are satisfied with the chronicler programs. The first evaluations are positive. In February, the Association of Statutory Health Insurance Physicians (KV) North Rhine and, on behalf of the health insurance companies, the AOK Rhineland presented the “Quality Assurance Report 2004 - Disease Management Programs in North Rhine”. "The report proves that structured care based on treatment recommendations leads to measurable improvements in quality," was the conclusion of KV chairman Dr. med. Leonhard Hansen. The authors analyze the results of the DMP diabetes mellitus type 2 (start: July 2003) and breast cancer (start: March 2003) and provide initial information on the DMP coronary heart disease (start: August 2004).
Because of the short observation period, only minor changes in the metabolic situation could be determined in DMP diabetes. But there were positive developments. The proportion of DMP patients treated for at least six months who initially had a comparatively high HbA1c value (more than 8.5 percent) was reduced from 8.5 percent to 7.9 percent. The blood pressure also improved. The proportion of hypertensive diabetics fell by 4.1 percent. The authors also expect positive effects from the fact that three quarters of all registered diabetics have already attended a training course. On the other hand, there is a need for improvement in the monitoring of secondary diseases. Referrals of diabetics with abnormal foot findings to foot clinics or regular check-ups by the ophthalmologist are documented too seldom.
The results are positive, but not spectacular. Here the assessment of GP G. coincides with that of KV chairman Hansen. In North Rhine-Westphalia, the DMP Diabetes replaced a structural agreement that had been in place for several years. “We were good before. As a result, we cannot record any grandiose improvements through the DMP, ”says Hansen. However, this result proves that the care is better than it was talked about. Hansen's assessment of the four ongoing DMPs - the Federal Insurance Office has not yet received any contracts for the COPD / asthma chronicler program - is sober: “The existing DMPs are being maintained. But the desire for something new is gone. "
The anger of the resident doctors about the bureaucracy associated with the DMP has not gone away, even if the additional fee was able to dampen the displeasure a little. In a non-representative internet survey by the National Association of Statutory Health Insurance Physicians (KBV) in the summer, many doctors complained about the high bureaucratic effort required for enrollment, initial and follow-up documentation and correction of the chronicler programs.
For many, the cause of all the evil is the connection of the disease management programs to the risk structure compensation (RSA) between the health insurance companies. The RSA coupling - also the criticism of some delegates at the KBV representatives' meeting on September 9th of this year - leads to unnecessarily extensive documentation, administrative chaos at the data centers, negligent squandering of insurance contributions and interest-driven manipulation by the health insurance companies. The lawmakers must end the link between DMP and RSA immediately, was the demand.
The Institute for Health and Social Research (IGES) also criticized the fact that this construction of the chronicler programs set wrong incentives in a report that was drawn up last year on behalf of the Techniker Krankenkasse - one of the large so-called RSA payer funds. For health insurers it is of vital importance to invest primarily in a DMP offer that covers the region as possible and in maximizing the enrollment rates. The health care goal of improving the quality of care for type 2 diabetics is taking a back seat. The funding according to the watering can principle - a health insurance company is credited a certain sum in the RSA for each registered DMP insured person - fail to recognize that only some of the DMP patients benefit from participation in the chronicler programs.
If the foot findings are abnormal in diabetics, foot clinics should be involved in the treatment. Photo: Dirk Hoppe
According to the IGES report, around half of all type 2 diabetics will theoretically be able to benefit from behavior-modifying programs. A maximum of one eighth should be able to achieve long-term goals. “Only such patients will be able to use behavior-modifying DMPs in the long term.” According to the expert report, the potential for avoiding heart attacks and strokes is three percent each, while the potential for avoiding amputations, blindness and kidney failure is significantly lower. Against this background, the cost-benefit assessment of the DMP as it is today is also negative. According to the IGES experts, annual savings of 120 million euros can be expected at the moment, compared to expenses of 280 million euros.
Medicine is prescribed
Politicians have now also joined the criticism. At the 60th Bavarian Doctors' Day in Coburg in mid-October, the Bavarian Minister of Social Affairs Christa Stewens (CSU) warned that the DMP would create the wrong incentive structures. Due to the connection to the RSA, there is a tendency to neglect the quality of the programs in favor of the quantity of participation. How the future grand coalition of CDU / CSU and SPD will deal with the connection of the DMP to the RSA is open - at least on the part of the CDU, the demand has occasionally been voiced to break this bond. However, even there one cannot ignore the insight that financial incentives are required for the health insurance companies in order to build up structured treatment programs for the chronically ill across the board.
Nevertheless, with the RSA connection of the disease management programs, a bureaucratic superstructure was created, the meaning of which is not apparent to the doctor in the practice. For example, a large part of the required DMP documentation is used to ensure the flow of money from one health insurance company to another in a legally secure manner. It is demotivating when the doctor gets the impression that his documentation only serves the bureaucracy. The feedback was inadequate, criticized, for example, the chairman of the Federal Joint Committee (G-BA), Dr. jur. Rainer Hess.
It is also difficult to understand why the requirements for guideline-compliant medical treatment of the chronically ill are prescribed by the Federal Ministry of Health - namely in ordinances amending the Risk Structure Compensation Ordinance. DMP critics speak of "state medicine", although basically only that which the statutory health insurance contract partners have previously defined as treatment standards in the federal committee in coordination with the medical specialist societies is implemented. Hess: The G-BA examines guidelines according to strict criteria that enable them to be incorporated into binding instructions, that is, into a statutory ordinance. It goes without saying that the required
medical scope for treatment guaranteed. With this, Hess explicitly turned against the DMP criticism of the President of the German Medical Association, Prof. Dr. med. Jörg-Dietrich Hoppe (see also DÄ, issue 31–32 / 2005).
Bureaucracy in abundance
The coupling of the chronicler programs to the RSA also requires an enormous amount of checking effort beyond the documentation obligation of the doctors with a view to the legal security of the entire RSA. In the Federal Insurance Office (BVA), the authority responsible for the approval of DMP contracts, three units are now dealing with this matter. While more than 2,000 initial DMP applications have not yet been approved, the first notifications of extension are pending for contracts that were approved three years ago.
The Federal Insurance Office was surprised by the flood of DMP applications. Right from the start, unsuccessful efforts were made to persuade the health insurance companies to submit uniform contracts. Many health insurers developed their own programs for each KV area, while the KVs - after it became clear that they could not do without them as a contractual partner - for their part used their negotiating leeway to enforce more advantageous contractual conditions for themselves or the registered DMP patients. As a result, the BVA (as of September 30) has received 3,406 applications for a DMP diabetes mellitus type 2, of which 3 137 have been approved. Of the 485 applications for DMP diabetes mellitus type 1, none have yet been approved. For the DMP breast cancer, 793 of the 2,404 application procedures have been completed, and for CHD 1,930 so far 793. No applications have yet been received for the most recent DMP COPD / asthma. Here the health insurance companies are apparently trying to avoid the mistakes of the past and to orientate themselves closely to sample contracts agreed in advance. As with diabetes and CHD, the general practitioner will be the focus of treatment for DMP asthma. Compared to the DMP type 2 diabetes with 1.7 million participants, the figures for the other programs are modest: 110,000 insured persons are currently enrolled in the DMP KHK, and 31,000 in the one for breast cancer.
For the Federal Insurance Office, the main problems with DMP approval lay in the contractual regulation of quality assurance and the flow of data. They saw themselves bound by the legal requirements and did not want to accept deviating agreements between health insurers and KVen - for example, about the KVen taking over quality assurance. The legal certainty of the multi-billion dollar RSA should be preserved under all circumstances.
KVNo chairman Hansen is also aware that the statutory health insurance doctors do not exactly love the chronicler programs. However, the simplifications in the documentation sheets, the patient signature and, last but not least, the now error-free EDP processing could have dampened the initial annoyance. In a self-critical manner, Hansen reminded the Deutsches Ärzteblatt of the vote by the KBV representatives' meeting on the implementation of the disease management program in Rostock in May 2002: "With the request for a double signature, we ourselves rode into the misery of bureaucracy." The related wish of many delegates to let the DMP fail, however, was not fulfilled.
The displeasure with the disease management programs could, however, be alleviated by the fact that the doctors can achieve an extra-budgetary fee with documentation and training. According to Hansen, around eleven million euros per quarter are also paid out to general practitioners and specialized diabetological practices in the KV Nordrhein. An average of around 3,000 euros per quarter was spent on the individual doctor.
A flaw in the system for Hansen is the connection of the DMP to the risk structure compensation. It promotes a registration competition among the health insurance companies instead of a competition for the best quality of care. However, the KV chairman does not see an alternative - without the RSA coupling, the chronicler programs would be doomed to failure.
A design flaw in the original risk structure compensation is responsible for this development. The financial equalization between the health insurances was introduced as an accompanying measure to the freedom of choice of the GKV insured persons. The then Federal Minister of Health Horst Seehofer (CSU) laid the foundation stone for more competition in the healthcare system in 1992. The aim of the financial transfer was to compensate for the historically very different distribution of risks in the individual health insurance companies and thereby prevent distortions of competition. Without statutory health insurance-wide compensation payments, some health insurance companies would not have had a chance of a competitive contribution rate from the outset. The catchphrase of “solidarity competition” has been making the rounds ever since.
RSA connection as a problem
The compensation payments have been flowing between the health insurance companies since 1994, and according to the Federal Insurance Office, they now amount to around 15 billion euros annually. The so-called recipient funds include above all the local health insurance funds, with traditionally many low-paid and chronically ill people, as well as the federal miners' association. Payment funds are in particular the substitute and company health insurance funds.
In a complex process, the RSA compensates for differences in the income of the health insurance companies and in the health expenditure. Up until the RSA reform in 2002, the income of the insured, the number of family members insured free of charge, age, gender, occupational disability and sickness benefit were all taken into account. Until then, the actual morbidity of the insured did not play a role in the financial equalization. A calculation example by the AOK Federal Association illustrates the problem that arises: It did not matter whether health insurance company A pays an annual treatment cost of € 2,500 for a 35-year-old diabetic or whether health insurance company B has to pay for a dental check-up once a year for an insured person of the same age. Since the risk structure compensation only knew the criterion “man, 35 years old”, both health insurances received the same amount in the RSA - the average expenses for a man of this age. The result: The financial equalization between the health insurance companies creates incentives for risk selection. It is financially worthwhile for a health insurance company to recruit as many good risks as possible, i.e. young, healthy and well-paid insured persons. "The RSA generated its own risk strategies," confirms Dr. Dominik Graf von Stillfried, responsible for the fundamental issues department at KBV. "The RSA criteria were too rough."
The RSA reform wanted to correct these undesirable developments. The health insurance fund competition for healthy people should be replaced by competition for better care for the chronically ill, as Federal Health Minister Ulla Schmidt emphasized when she presented her reform plans in August 2001. The law provided for the following step-by-step plan: As of 2002, as part of the risk structure compensation, the so-called standardized service expenditures were compensated in every accredited DMP - with all the resulting distortions. Keyword: registration competition. A risk pool was set up from 2003 to offset particularly high expenses.
From 2007 the risk structure compensation is to be carried out completely morbidity-oriented.To this end, around 72 million GKV insured persons have to be assigned average morbidity surcharges based on their illnesses, which are taken into account in the risk structure compensation. Experts on behalf of the Federal Ministry of Health propose an American model as a classification system that records the morbidity of the insured via drug prescriptions and hospital diagnoses. According to experts, the data required for this is available to the health insurance companies in sufficient quality. The risk pool and DMP compensation should then be omitted. The fate of the chronicler programs should thus be sealed. Unless the legislator takes up the suggestion of the expert opinion to provide a GKV-uniform flat rate for the promotion of the disease management.
These plans for a further development of the current RSA in the “payer cash registers” are met with strong criticism. The BKK Federal Association fears a massive increase in costs, bureaucracy and new distribution injustices if the so-called
te Morbi-RSA become a reality. Even today's financial equalization is a bureaucratic monster, warned the CEO of Techniker Krankenkasse, Prof. Dr. Norbert Klusen. If the Morbi-RSA were to be introduced, "all health insurers and all doctors in this system would only be interested in documenting and treating as much disease as possible."
In contrast, in May of this year, AOK, Barmer and KBV jointly appealed to the federal government to introduce the Morbi-RSA on time. Efficient patient care will thus become a competitive goal for doctors and health insurance companies in the future. Today's RSA is forcing the health insurances to seek healthy instead of sick insured persons. At the moment, a favorable contribution rate is not an expression of good management performance, but rather reflects the different distribution of sick and healthy people in the individual health insurance funds. With the Morbi-RSA, which also only compensates for average costs, there is a real incentive for competition for the quality and cost-effectiveness of medical care.
If the grand coalition does not determine a new route, the wish of the Morbi RSA proponents should come true. A spokeswoman for the Federal Ministry of Health told the Deutsches Ärzteblatt that the regulation for the introduction of the Morbi-RSA could be initiated as soon as the coalition negotiations were concluded. Among other things, it defines the criteria for classification and data collection.
There is also support from the Federal Constitutional Court. It has in a resolution dated July 18, 2005
the regulations of the risk structure equalization are judged to be constitutional. The RSA serves the social balance in the statutory health insurance "in accordance with the general principle of equality across all health insurers and nationwide". In the opinion of the court, there are also no concerns about the introduction of a morbidity-oriented risk structure compensation. "The legislature is pursuing legitimate goals, because it wants to improve the solidarity balance between healthy and sick and in particular to avoid risk selection at the expense of the chronically ill," it says as a justification. Thomas Gerst, Heike Korzilius
Disease Management Programs: Big Bucks in the Game
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