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How payers could meet the challenges – A German approach

Dr. Cornelius Erbe, DAK, Germany

OPEN DAYS European Week of Regions and Cities

Brussels, October 7, 2008

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Our figures. Our facts.

One of Germany's largest statutory health insurances

Experts in health care since 1774

Over 6 million customers

Nationwide network of 750 branches

Around 14,500 competent and friendly staff

Annual expenditure [2007]: EUR 13.8 billion in health insurance EUR 1.4 billion nursing insurance

Test winner – many awards for quality of treatment and service

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In Germany, growing problem from demographic change and increasing medical cost for chronic patients

Costs

PROBLEM Effect on

Quality & customer satisfaction

Source: Sachverständigenrat für die Konzertierte Aktion im Gesundheitswesen III p208/209

Growing proportion of older and chronically ill Germans

Costs for patients suffering from chronic diseases are on average twice as high as for those without chronic diseases

Costs associated with chronic diseases rise as a function ofco-morbidity on average more than threefold compared to those without chronic illness

Transfer of morbidity-related risks from care providers to German Statutory Health Insurances (SHI) in 2009

Decreasing transparency of SHI-specific care options for members and service providers

Introduction of Health Fund/possible supplementary premium requires offering special rates, e.g. for chronic patients

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Which objectives do we want to achieve with regard to managing chronic patients?

CUSTOMERSATISFACTION

Accompaniment and guidance of the insured through the health care system across sector boundaries

Development of an understanding of the insured taking into account his/her overall environment (co-morbidity, social environment, etc.)

Offer of superior service quality

QUALITY Improvement of compliance/basis for participation of the patients

Transparency concerning customized treatment options

Improvement in quality of life

COST CONTROL

Prevention of co-morbidity and thereby over-proportional cost increases

Prevention/avoidance of hospitalization Long-term condition management performed

according to specified guidelines

DAK OBJECTIVES

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Providing qualified support for chronic patients will help us to achieve our objectives

Objective of support

Support motivates the insured to engage in a healthy lifestyle

Stabilization of the disease, prevention of co-morbidity and avoidance of further demand for care services

RESULT

Increased cooperation of the patient improves the doctor-patient relationship

Cooperation of the insured in his/her therapy and acceptance of personal responsibility

Level of information held by the insured gives him/her a more active role as a patient

Indirect motivation of the GP and other service providers to optimize care

Providing support to the chronic patient leads directly or indirectly, via the service provider, to the achievement of our objectives

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This is the DAK approach: frequency and type of support depend on the severity of the illness

Few Patients

Highest Risk

Most Intense Intervention

Many Patients

Lower Risk

Less IntenseIntervention

LEVEL

1

2

3

Telephonic High Risk Care Management Intensive one-to-one nurse/patient care management for the highest-

risk, most complex of the population Highly trained Care Managers well informed about community resources Social and family-wide intervention; caring for the caregiver As risk for hospitalization is reduced, patients are transferred to Level 2

Telephonic Disease Management Care management for all diseases and co-morbidities Nurse team intervention model with care managers with optional remote

patient monitoring Adherence to standards of care, medications, promotion of behavior

change, lifestyle modification and self management skills Doctor-directed care plan integration Risk reduction leads to transferal to Level 1

Supported Self-Care Ongoing relevant and personalized patient mailings Web-based patient wellness portal Healthways in-bound health coach line and assessment tools Optional self care solutions and programs

Source: Healthways

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Pilot in Bavaria and Baden-Wuerttemberg: Over 200,000 candidates included, approx. 40,000 already enrolled

Enrollment process

First Contact

Contact by Letter Flyer Consent form

Motivation Call

First telephone contact: Informing the candidates about the advantages of participation in the program

Consent

Waiting for incoming consent forms of the candidates

In the case of no response, second motivation call

The program can start only with candidates' consent!

Start of program

Welcome call Gathering

Information Classification

with Embrace®

(predictive modeling)

Classifying the patients by their individual support level

Results

Approx. 40,000candidates enrolled

• In Bavaria 22,600

• In Baden-Wuerttemberg17,400

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

week 1 week 27

19,000

25,000

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In addition to the economic assessment an independent evaluation is undertaken

Key data

Approx. 10% sample

Collected in pilot region

Chosen at random

Assessment of quality of life using the EuroQol instrument

Basis for analysis: Cost of ambu-latory care, hospital care, pharmaceutical spendings, etc.

Challenges

Additional acquisition of 5,000 extra participants

Problem to win over members of the control group

Coordinating the design of the survey with the scientific institute

Side effects compromise statutory RSAV-DMP

Contractor

Prestigious institute of health economics at a well known German faculty of medical science

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Lessons learned: Five key success factors

Health care policy and legal framework need to be supportive

Adaptation of the program to the specific cultural context is crucial

Integration of all stakeholders (patients, GPs, politicians, authorities, professional associations, etc.) needs attention (and time!)

Public reaction is not always positive but don't give up too early

Don't lose sight of your customers' needs and interests

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We look forward to creating a win-win situation for our members, the doctors and our company

DAK

Increase of loyalty of our members

Improvement of our brand image

Avoidance of over-proportional cost

increases

PATIENTS

Increase of quality of life

Reduction of long-term complications

Experience of a superior medical service

DOCTORS

Improvement of doctor-patient

relationship

Increased cooperation of the patients

Reduction of administrative work compared to DMPs

win

win