The
Pharmaceutical Journal Vol 266 No 7132 p122
Germany recently introduced health care reoforms with a view to broadening the current health care system. One of the main areas of change was the development of integated care. Sonia Sanghani reports on progress
On January 1, 2000, the German health minister, Andrea Fischer, introduced health reforms. These emphasise patient- focused care, innovation and modernisation of health care, and increasing quality assurance and transparency. The main concerns are threefold:
Historically, Germany’s cost-containment policies have tended to be primarily price-containment policies. Previous reforms over the past 20 years have introduced some element of market economics, but in the main, state regulation is the norm. In order to broaden the current health care system the main areas of change include:
The changing demographics of the German population and high unemployment rates,
especially since the reunification, are the main reasons for the reforms. Around
22 per cent of the German population is presently over 65 years old. In the
next 40 years, this level is expected to rise to 35 per cent of the population,
with the average age increasing, leading to more demands on the health care
system. Germany still has a relatively low birth rate and the proportion of
the population in work is decreasing. The unemployed are not in a position to
pay insurance contributions but still require health treatment.
Through integrated care, the German government aims to offer users of the state
health insurance schemes better quality of care and increasing competition between
the different health schemes, thereby leading to better efficiency.
The aim is to co-ordinate ambulatory (generalist) and hospital (specialist) care and eventually to take up responsibility for budgets, costs and performance analysis, as well as undertaking risk calculations. The emphasis is on local level, decentralised decision making.
All professional groups, besides pharmacists, can participate in such groups. Patients can choose whether they want to be treated by the new groups and are informed in detail of group members and services provided.
The Hartmannbund (German Medical Association) feels that pharmacists are not
involved probably because pharmaceutical prices are not subject to negotiation.
In the first pilot schemes, pharmacists were not included even though drug costs
played a role in some models. The pharmaceutical industry has agreed to health
economic evaluations of its products but the pharmacy profession as a whole
wishes to retain the status quo regarding the medicines laws and the pharmacy
laws and has been called inflexible and resistant to change by the insurance
agencies.
There are no such groups working to date, only pilot schemes set up since
the mid-1990s by the health insurance schemes. These include a diabetes group,
general practice (physician) networks, Hippokrates (a group looking at treating
patients in community rather than hospital), a medical quality group (MQR),
as well as groups for homoeopathy, acupuncture, natural remedies, and rehabilitation
of chronically ill patients using complementary therapies, among others.
These first generation models of innovative care are based on the United States
managed care and decentralised health care structures.
There are currently around 300 to 400 informal physician practice networks in
Germany but only 20 to 30 have managed to come to a contractual agreement with
the insurance companies, partly because of poor, untrained advisers. In view
of this, the German pharmacists and physicians will, together with doctors’
associations, found a new “network academy”, where students will be taught law,
ethics, economics, and consultancy. A curriculum is currently under development.
A scientific investigation conducted by the Institute for Social and Communication
Research in Munich has stated that “increased income potential is marginal,
workload reduction is minimal, and the economic effects have yet be proved”.
The lack of a common fundamental goal within the network results in failure.
Arguments centre around organisational problems, eg, technology links, and then
progress to quality of patient care. The networks hardly profit from the attained
savings.
One such practice network in Nuremberg-North is currently, during a five-year
pilot scheme, attempting to integrate 140 community-based specialists with the
local hospital. Important stepping stones for co-operation within the network
and hospital are seen as:
In this pilot scheme, doctors were unable to assume budget responsibilities
because of a lack of important information and data.
One insurance company’s experience with practice networks in Hessen has shown
that the amount of work in the start-up phase is often underestimated. It is
a long road from the idea of a practice network to realisation of integrated
care, and a big paradigm shift is required along the way.
For An example of a successful medical practice network, known
as MQR, is to be found in Schleswig-Holstein. It has been concentrating on asthma
treatment and patient education. Around 250 doctors participate but this number
is expected to rise to over 300. The aim of the group is to ensure that doctors
have a solid position in a competent health system and higher remuneration is
more a long-term rather than immediate goal. The main reason doctors join is
job satisfaction and intensified training options.
Against The health insurance companies have signalled quite clearly
that they want more influence in doctors’ working practices. Some doctors feel
that networks will be the end of professional freedom and a step further towards
rationed care and are distrustful of this new way of working. From experience,
even the doctors within networks could be roughly split into one-third activists,
one-third proactive supporters and the rest as resigned hangers-on.
A study conducted in Munich using the Delphi technique showed that doctors’
motives were varied and the clearer the goals of each player, the stronger the
conflict between the different interested parties. Many thought that they could
change something without having to change themselves. The myth was to join a
few practices together, delegate unwanted tasks to the network and carry on
working as before.
Networks with more than 100 doctors have more power but in practice they are difficult to lead. Those with 20 to 30 doctors are easier to lead but are too small to have any power to achieve much change.
The first networks before the January, 2000, reforms received funding from
the sickness funds for infrastructure, office establishment, etc. Subsequent
groups received no assistance. The experiences of such networks were reported
at the 10th International Congress of Group Medicine, organised by Hartmannbund
and NAV Virchow-Bund in 1997 in Cologne. Attending doctors were of the opinion
that none of these activities was anything special and that they belonged to
ordinary, good health care. There is no real evidence yet that these networks
produce better medical or economic results.
Following the reforms, the new groups can negotiate budgets, together with the
assistance of the doctors’ negotiating committee (Kassenärztliche Vereinigung),
to cover other sectors, eg, hospital care or pharmaceutical products, based
upon existing figures. There is no economic advantage for the participating
doctors. The only advantage is through direct negotiations, thereby gaining
influence, especially in the hospital sector.
Some are calling for a change in the remuneration system towards a more performance/results
oriented payment. This outcomes-oriented, group application approach should
ensure that the networks will be rewarded more, the closer they work together,
and it is thought that certain disease states lend themselves quite nicely to
this methodology. A certain profit orientation is necessary and politicians
are being urged to alter physicians’ remuneration to ensure that integrated
care is sustainable.
The Hartmannbund thinks it is difficult to break doctors’ solidarity. The health insurers can “buy” medical groups and negotiate contracts outside the regional contracts which can, and probably will, divide doctors as well as patients. It says: “We think communication, co-ordination of care, and co-operation are essentials of good medical care and should not be burdened with extra administrative tasks. Electronic networks under construction will help more than the budget holding of doctors or pharmacists.”
The Hartmannbund feels that “budgets are not really adequate for medical care”.
They are “too small and they lead to rationing. In Germany, the first signs
of rationing are occurring as drug costs weigh heavily on a doctor’s budget.”
One insurance company is now experimenting with the second generation of care
models and recognises that although it is necessary to include other health
care providers, it will be a great challenge in practice to integrate these
into the primary care physician models. All service providers should remember
that the patient must be central focus for all their activities.
At the pharmacy conference in Cologne in September, 2000, Hans Guenter Friese,
president of the ABDA (German Pharmaceutical Association) made it quite clear
to the health minister that the original paradigms of the doctor having responsibility
for diagnosis and therapeutic safety, the pharmaceutical industry for product
safety and the pharmacist for safety of usage by the general public should remain
unchanged. Pharmacists agreed with improving co- operation between health service
providers, with drug therapy being recognised as a necessary part of integrated
care. However, this should only take place within the current legal framework
and most importantly the freedom of the patient to use the pharmacy of their
choice should not be restricted. Health insurance companies and hospitals are
experimenting with the drug regulations and he warned against this, as it would
lead to an Americanisation (capitalism) of the system, ie, it would be profit/competition
oriented, and there would be price cutting, hospital closures, unemployed doctors
and restricted distribution of pharmacies. Cost-containment should not dominate
quality control, and co-operation and co-ordination should not necessarily be
labelled a “network” as this could be open to misinterpretation and fraudulent
use. Having two parallel systems, ie, integrated care for some and normal care
for others, was inefficient. Better co-ordination for all should be the goal,
with drug therapy optimisation, and close co-operation with patient and doctor
through pharmaceutical care, rather than budgets to control performance. He
presented the minister with her ready-to-use patient data card which could be
used for electronic prescriptions and as a medication profile passport for over-the-counter
and prescribed medicines and requested her assistance in arranging the legal
framework for its use in telemedicine. Ending his presentation, he stated: “We
want our pharmaceutical knowledge to be of use to others. That is the integration
that we need.”
In support, Dr Frank Diener, of the ABDA’s social/economics department, stated
that by the end of 2001 there should be available a “health professional card”
to ensure confidential communication streams between doctors, pharmacists and
health insurance companies via the internet. Also, data from prescription pricing
bureaux should be available much quicker in order to assist in prescription
analysis. He also suggested setting up locally based drug committees where pharmacists
and doctors could assess therapeutic quality and economic options, supported
by therapy manuals provided by the ABDA. A framework contract between doctors,
complementary therapists and pharmacists should state each profession’s role
within this collaborative work with clearly defined borders. More co-ordinated
out-of-hours services was another aspect of collaboration on offer.
Instead of individually selling their services to the health insurance companies,
Dr Sebastian Schmidt, of the ABDA’s legal department, urged pharmacists to offer
services collectively without singly taking part in the current models of integrated
care. What was important was to prevent an insurance company finalising a contract
with a single pharmacy and thereby cutting other pharmacies out of the picture.
Free pharmacy choice for the consumer should remain the highest priority.
ACKNOWLEDGMENTS
I thank Mrs Regine Kleinert, (AOK Bundesverband), Mrs Merte Bosch (Hartmannbund,
German Medical Association) and Mrs Christina Claussen (economics and social
politics department, ABDA, and Federation of German Pharmacists) for their assistance
with this article.
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Sonia Sanghanu is a pharmacist in Britain and an apothekerin in Germany, where she lives