German Health Care Gerlach

8/9/2019 German Health Care Gerlach

1/26

Professor Ferdinand M. Gerlach, MD, MPH

Primary health careand family medicine in Germany

Current status and recent policy developments

Washington, April 2010


2/26


Overview:German health care system


3/26

Institute of General PracticeJohann Wolfgang Goethe-University, Frankfurt am Main

Universal: for entire population

Europe's oldest universal health care system

Origins dating back to Otto von Bismarck's Sociallegislation, which included the Health Insurance Bill of1883, Accident Insurance Bill of 1884, and Old Ageand Disability Insurance Bill of 1889

Mandatory health insurance

These bills originally applied only to low-income workersand certain government employees

Their coverage, and that of subsequent legislationgradually expanded to cover virtually the entirepopulation


4/26


Two main types of health insurance

Universal multi-payer system with two main types ofhealth insurance: statutory and private

Germans are offered three mandatory health benefits,which are co-financed by employer and employee: healthinsurance, accident insurance, and long-term careinsurance

Currently 90% of the population is covered by a basichealth insurance plan provided by statute, which providesa standard level of coverage

The remainder (10%) opt forprivate health insurance,which frequently offers additional benefits (open for self-employed and individuals with income above a relatively high threshold)


5/26


Funding of health care systems in Europe


6/26


Some characteristics Number of sickness funds in 2010: approx. 160

(early 1990s: more than 1.000)

General contribution rate: 14.9%

Distribution employer/employee: 50/50

All sickness funds: not-for-profit entities under public law Subject to control by government or entitled agency

Classic example of enforced self-regulation


7/26


Novel forms of care

Integrated care programmsDesigned to better coordinate:

care between general practitioners (GPs) and specialists,

across inpatient and outpatient sectors,

rehabilitation and pharmacies (in some cases)

Insurers are allowed to contract directly and selectively since 2004 with

providers from different sectors and specialisations.

General Practitioner centred models (HZV)Promoted since the healthcare reform of 2004 which obliged insurers to offer

such programs to their patients:

GPs will direct patients through treatments, avoiding costly multiple treatment or diagnosis,

improving the flow of information between different healthcare providers,

thus improving cost efficiency


8/26


Novel forms of care (II.)

Health care reform of2007: aims at strengthening GPcentered models further

It obliges social insurers to offer GP-centred models

Members who wish to enrol in such a program (withgatekeeping by GPs) would bind themselves to limittheir free choice of phycisians for one year


9/26


Distinguishing features of theGerman health system


10/26


Doctor patient contacts(Grobe et al. 2008, 1.6 mln insured persons at Gmnder ErsatzKasse)

92.6% of the population consult an ambulatory doctorin a single year

17.9 doctor contacts/year/person

of which 7.1 contacts to a GP Utilization over the last four years:

up 7% (despite introduction of practice fee)

Average Monday: almost 8%, on peak days

(e.g. 01.10.2007) 11.75% of the German population(= 9.7 million persons)


11/26


Population average per person/year (2007):25.8 (ICD-)Billable diagnoses.

Adjusted for duplicate diagnoses etc.:9.3 require further clarification/treatment

Despite questionable validity of diagnosis that led to bill:

- Medical care appears to be fragmented

- Indications oflack of cooperation and ofpriority setting

Diagnoses per patient(Grobe et al. 2008, 1.6 mln insured persons at Gmnder ErsatzKasse)

I tit t f G l P ti


12/26


Short consultation times and long working days

Doctors consultation times: per patient, 30% lower inGermany than the European average and thus theshortest in Europe.

Nevertheless, German doctors have longer workingdays (IQWiG 2008).

Facit: German doctors (and their patients) feel like

a hamster on a treadmill

I tit t f G l P ti


13/26


International comparison(Koch et al. 2007, 6088 GPs from 7 countries)

Institute of General Practice


14/26


Primary carephysicians versus

specialist

Jahr

Hausrztliche Versorgung Fachrztl iche Versorgung

Allgemein-/Praktische rzte, Alle anderen Facharztgruppen

Internisten, Kinderrzte

Anzahl Anteil Anzahl Anteil

1991 44.521 60,1% 29.542 39,9%

1992 45.831 59,3% 31.445 40,7%

1993 62.375 59,7% 42.181 40,3%

1994 62.340 58,7% 43.900 41,3%

1995 62.477 58,1% 45.020 41,9%

1996 59.828 54,8% 49.290 45,2%

1997 60.244 54,6% 50.151 45,4%

1998 59.120 52,5% 53.563 47,5%

1999 59.188 52,4% 53.746 47,6%

2000 59.601 52,3% 54.418 47,7%

2001 59.555 51,6% 55.890 48,4%

2002 58.844 50,7% 57.221 49,3%

2003 58.718 50,3% 57.977 49,7%

2004 58.837 50,3% 58.153 49,7%

2005 58.698 49,9% 58.849 50,1%

2006 58.602 49,5% 59.675 50,5%

2007 58.304 49,1% 60.554 50,9%

since 1993: plus East Germany

Kopetsch 2003, 44;Gesundheitsberichterstattung desBundes 2008, SVR own calculations

1993 to 2007:

Specialists: +43,6%PCP: -6,5%



15/26


Coordinating care: how are we doing?

Services often poorly coordinated betweenambulatory and hospital, between acute and long-termcare

Limited sharing of clinical information betweenprofessionals at different sites

No information system to oversee flow of patientsthroughout the system



16/26


Barriers to care coordination (Bodenheimer)

Overstressed primary care physician Uninformed, passive patient

Lack of computerized records that link different sitesof care

Dysfunctional financing

Lack of integrated systems of care



17/26


Hamster Care

Across the globe doctors are miserable because they feel like

hamsters on a treadmill. They must run faster just to stand still

The result is a reduction in the quality of care and an increase inburnout among doctors.

Morrison and Smith, BMJ 2000;321:1541

Professor Ferdinand M Gerlach MD MPH


18/26


Future approachtowards coordinated medical careon a regional basis

Recommendations

2009 report of the Advisory Council on the Assessment ofDevelopments in the Health Care System

Sachverstndigenrat zur Begutachtung der Entwicklung im Gesundheitswesen



19/26


Core aims

Gear towards demographic change, shift in themorbidity spectrum

Strengthen sustainability and prevention

Reduce unnecessary contacts/workload:Get off the hamster treadmill!

Overcome inefficient competition (between differenthealthcare providers): better coordination

Structure altered to take account ofneeds of careproviders

Attractive working conditions forfuture doctors

...



20/26


Selected strategies

EU-concept on primary care Patient-Centered Medical Home

Bellagio-Model of population-oriented primary care

Roadmap by the Royal College of General Practitioners

Chronic Care Model to provide comprehensive medicalcare for the chronically ill

Cooperation with other professions(AGnES, MoPra, VERAH)

Managed Care (using systematic review)



21/26

Johann Wolfgang Goethe-University, Frankfurt am Main

From sectoral to population-oriented medical care

Professor Ferdinand M Gerlach MD MPH


22/26


Future approach:Implementation using example of

primary care practice



23/26


Primary care practicesFeatures: launching pads for change

Developed organizations

Relatively large sizes: 4-6 doctors, specializedhealthcare assistants and nurses

Registration model: Defined population

Team approach: Involvement of non-physician personnel

Liaison: with specialists from hospitals/practices

GPs as coordinators/facilitators with ultimateresponsibility

Longersurgery opening times, flexible working hours



24/26


Systematic analysis/stratification according to riskfactors in patient population (e.g. diabetes)

Special healthcare services (e.g. vaccination reminders)for various groups of patients

Separate surgery hours assigned for structured,interdisciplinary health services

Case management, long-term monitoring, training ofchronically ill by healthcare assistants

Involvement of chronically ill in their therapy

Communication channels: eMail, telephone consultationhours

Primary care practicescharacterized by multifaceted healthcare services



25/26


Continuity in doctor-patient relationship!?

Trial involving 284 general practices in 10 Europeancountries (including Germany): Patients feel themselves

to be significantly better looked after in smallpractices than in larger-scale practices with severalcontact persons and/or employees(Wensing et al. 2008)

Teamlet-Model (Doctorplus healthcare assistant)(Bodenheimer and Laing 2007)

Primary care practicesProblem



26/26


Next health reform? Consider Cheng Sung Meiscosmic law of health care

1. At any time, anywhere in the world, people willwhine about their health care system.

2. The decibel level of whining is only weakly relatedto how much a country spends on health care.

3. At any time, anywhere on the globe, there will becalls for a major health reform.

4. At any time, anwhere on the globe, the last healthreform will be said to have failed.

(Uwe Reinhard, Princeton University, 2006)

Documents

German Health Care Gerlach