Disease Management Program

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A disease management program ( DMP for short ) is a centrally organized treatment program for chronically ill people. It is based on the findings of evidence-based medicine . In the area of statutory health insurance (GKV), these programs are also known as structured treatment programs or chronicler programs . The concept originally comes from the USA .

Disease management programs have existed in the German health care system since around 2002. They are considered as building blocks for other novel concepts such as integrated care and case management .

definition

There is no standard definition for the term disease management . The definition of the Disease Management Association of America (DMAA) in the translation of the German Medical Association is given here as an example :

“Disease management consists of a system of coordinated health care measures and information for patient populations with clinical pictures in which the active participation of the patient in the treatment can lead to substantial effects. Disease management

  • supports the doctor-patient relationship and the treatment regimen
  • aims to prevent disease exacerbation and complications through the use of evidence-based treatment guidelines and patient empowerment strategies
  • continuously reviews the clinical, humanitarian and economic treatment results with the aim of improving the health situation "

aims

Around twenty percent of German citizens suffer from chronic illnesses that last more than four weeks and need continuous medical treatment that includes monitoring and drug therapy. The organization of the German health system is primarily geared towards the therapy of acute illnesses, so that a chronically ill patient can have several contact points for various aspects of his illness. The first point of contact is usually the family doctor , who usually also provides long-term care. If special knowledge or special equipment is required, the patient is referred to a specialist or even to several specialists or admitted to a hospital. However, patients can also consult a specialist directly or seek hospital treatment in emergencies. The acute case is treated there, but there is no preventive long-term care. Patients can also change their general practitioner or specialists as often as they want and visit different hospitals. Sometimes the flow of information between the practitioners stalls, so that there is a lack of coordination of the treatment. With this unsystematic, selective treatment, there is a risk of under-, over- or even incorrect care of the patient. This development is to be corrected through disease management programs by providing long-term preventive support for the chronicler.

With the help of disease management programs you aim to

  • Patients suffering from chronic diseases are protected from secondary diseases through well-coordinated, continuous care and treatment;
  • General practitioners and specialists as well as hospitals, pharmacies and rehabilitation facilities work together in a coordinated manner;
  • the therapy steps must be coordinated according to scientifically proven medical knowledge ;
  • In the medium to long term, the health insurance company's expenditure on benefits can be reduced.

Indications of the disease management programs are in particular so-called lifestyle diseases - for example, coronary heart disease , asthma , chronic obstructive pulmonary disease or diabetes mellitus type II . Due to modern living conditions - poor nutrition, sedentary lifestyle, stress, environmental toxins - these diseases occur frequently and cause a significant proportion of medical care costs. The proportion of diabetics in the adult population in Germany and Europe alone is estimated at 7% to 8%. Accordingly, the accompanying measures of the disease management programs aim to change the behavior of the patient - healthier diet, more exercise, smoking cessation, etc.

Disease Management can also be used for other, non-civilization-related chronic diseases. In Germany there are currently (2019) programs for breast cancer , diabetes mellitus type I , diabetes mellitus type II, asthma, chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD) with a module for chronic heart failure.

Instruments

Disease management programs are not a substitute for therapy by a doctor, but are intended as a supportive and coordinating measure. First and foremost, they are of an informative nature. That is, the patient is fully informed about his illness, its symptoms and significance, treatment options, medication and specialists. Almost all the possibilities of modern communication are used for this:

  • Information brochures;
  • Telephone consultations;
  • Reminders (e.g. of necessary visits to the doctor) by phone, letter, email or SMS;
  • Advice and support for drug therapy in the local pharmacy;
  • Statistical evaluations of the state of health;
  • Training courses;
  • Support from telemedical devices.

variants

In the German healthcare system, there are two types of DMPs:

  • Disease management programs according to RSAV (DMP according to RSAV or RSA-DMP);
  • Free Disease Management Programs.

DMP according to RSAV / DMP guidelines

The disease management programs according to RSAV (Risk Structure Adjustment Ordinance) were introduced with the law on the reform of risk structure adjustment in statutory health insurance of December 10, 2001. This corresponded to a proposal from a report by Karl Lauterbach and Eberhard Wille for the associations of statutory health insurance. They are reserved for the statutory health insurance funds (GKV), as the number of patients participating in the DMP affects the calculation of the risk structure compensation . For registered (i.e. participating) insured persons, separate profiles were created between 2003 and 2008 in addition to the other insured persons, on the basis of which a separate compensation takes place , taking into account the average benefit expenditure of this group of insured persons. As a result, the health insurances for such enrolled insured persons were assigned the average expenses of these groups of insured persons from the RSA and not only the significantly lower allocations that arose on the basis of age and gender. Since the GKV Supply Structure Act (GKV-VStG) came into force on January 1, 2012, the G-BA has been mandated to issue its own guidelines for the DMP.

The indications for which DMP can be carried out according to RSAV are determined by the legislator . In detail, these are currently:

Further indications (such as chronic back pain , osteoporosis , rheumatoid arthritis , depression , heart failure ) are in preparation; however, it is not yet clear whether they will actually be implemented.

If a statutory health insurance company wants to carry out a DMP according to RSAV, it first develops a program concept and concludes contracts with the statutory health insurance associations , medical networks, hospitals or individual doctors for its implementation. Since there are currently 17 KV areas in Germany , a national health insurance company must conclude at least 17 contracts in order to guarantee nationwide coverage. These contracts are then submitted to the Federal Social Security Office (BAS) for review. If the contracts meet the legal requirements, they are accredited by BAS, i. This means that consideration in the risk structure adjustment is approved.

In order to ensure the quality of the treatment programs and to define the care goals for a patient, the doctor and the insured person must regularly fill out a documentation sheet together during the program. This documentation sheet contains a data set with important parameters that are used to evaluate the program. The following values ​​are recorded on the documentation sheet - depending on the indication :

  • Important laboratory parameters or their change;
  • Investigations;
  • Concomitant and secondary illnesses;
  • Relevant Drugs;
  • Recommended and conducted training courses;
  • Administrative data (treating doctor, creation date, etc.).

With the help of these documentation sheets, the health insurance company can support the course of the program and the effect can be evaluated.

Participation of the insured

The participation of a patient is voluntary, but is often supported with bonus measures. If a patient wishes to participate in a DMP, he must first select a doctor who will participate in the program. The doctor declares his participation to the Association of Statutory Health Insurance Physicians, which confirms participation after checking the structural requirements. Together with the doctor, the patient then fills out a declaration of participation and the initial documentation (electronically). The completed documents are forwarded in paper form and electronically (by data carrier or remote data transmission ) to a data center. The data center must check the data record for plausibility , completeness and timely transmission using defined criteria . If data needs to be supplemented or corrected, she will request this from the doctor.

The collected data is transmitted with pseudonymized insured person data to the joint establishment of the health insurances carrying out the DMP and the KV. The data is also completely passed on to the health insurance company. The health insurance company must ensure that not every employee has access to the data in the documentation. The documentation is subject to special data protection and may only be viewed and processed for the purposes of DMP.

quality control

Part of the DMP contracts are goals that are to be achieved with the disease management programs, as well as specific trigger algorithms based on the parameters documented on the documentation sheets. It is determined whether the doctor should receive information from the health insurance company or the insured person from their health insurance company. This means e.g. For example, insured persons participating in the DMP Diabetes mellitus type 2 who have not received an annual referral to the ophthalmologist for an examination of their eyes should be informed by the health insurance company about the importance of this examination.

"Reminding"

“Reminding” is understood to mean reminder systems for both the doctor and the patient. The doctor's attention is drawn to the documentation to be prepared in the quarter. The health insurances inform their insured persons in case of missing documentation, missed training courses or other diagnosis-specific occasions.

Termination of Participation

Furthermore, the health insurance company takes on the so-called "case clearing". This means that the health insurance fund controls the fulfillment of the program on the basis of defined rules and, if necessary, notifies the patient. H. program participation ends. In the indication of breast cancer for example, the bid must be made when the initial manifestation - that is the first appearance - the disease dates back more than ten years and the patient recurrence is. Further reasons for the announcement are insufficient participation in the program - usually missing or late arrival of documentation sheets or training sessions that have not been taken - as well as death or change of fund.

Conceptual criticisms

  • The definition of the medical guidelines for the state of health and the methods of therapy are not undisputed in the medical community, but represent the majority opinion.
  • Some doctors feel that their freedom of treatment is restricted because they should orient themselves to the guideline in their treatment. The initially strong resistance from the doctors has now subsided. Most statutory health insurance physicians in Germany take part in the RSA-DMP.
  • The connection with the risk structure compensation of the health insurance companies has in the past meant that as many patients as possible were enrolled in a program in order not to be financially disadvantaged. Due to the link to the risk structure compensation, the focus was more on the quantity of insured persons than the quality of care for high-risk patients. At present there is only reimbursement of the average expenditure, which in some cases is not enough to cover the costs of the programs.
  • The documentation was too bureaucratic and too complicated and was in some cases drastically changed during the ongoing proceedings (data versions 1 and 2 according to RSAV 7th version and RSAV 9th version).
  • Due to the federal structure of the doctors' representatives, DMP procedures had to be negotiated individually for each KV district. Contracts with different contents were concluded here.
  • By engaging the Federal Insurance Office as the approval and testing institution, the process was significantly bureaucratised and led to high administrative costs for the health insurance companies. Some points are not clearly regulated or were not taken into account in the definition of the programs and therefore leave room for interpretation. A binding test catalog was only available in 2006, which was agreed between the state testing services and the Federal Insurance Office. Previously, there had been disagreements for years regarding individual questions of interpretation. For the health insurance companies, the test catalog is an essential instrument for their DMP organization.
  • Due to the interpretation of the law by the BVA, the conception of DMP programs according to RSAV was awarded exclusively to public-law institutions in the health care system. Private providers of DMP programs were therefore only able to help design and implement the programs as a service provider for the cash register.
  • Through the i. d. As a rule, uniform regional conclusion of the DMP prevented the health insurance companies from being able to offer different programs (e.g. more patient-oriented). Thus it is not possible to implement different approaches and concepts and to test their effectiveness and efficiency .

Practical difficulties with the DMP data

  • In the years 2003–2005, great difficulties arose in practice, particularly with the introduction of the DMP according to RSAV.
  • The permanent adjustments of the process design and the documentation sheets lead to a considerable additional effort in the administration for all involved: patients, doctors but also health insurance companies etc. a.
  • The DMP contracts with the individual KV districts are structured differently, so that the program participant must be assigned to a KV district. However, it is not the place of residence of the insured person that is decisive for the assignment, but the branch of the attending doctor's practice, which can lead to difficulties.
  • Due to the federal structure of the statutory health insurance physicians in 17 KV districts, there is no nationwide uniform list of accredited doctors. DMP providers must therefore bring together accreditation lists in a wide variety of formats.

eDMP - electronic DMP

Starting in 2005, the eDMP was introduced in all KV regions, i.e. H. the electronic transmission of documentation between the doctor's practice and the data center. The data from the previous documentation sheets are transferred to a floppy disk, a CD or a secure online process. At the same time, the doctor's signature is required on an "accompanying note" or a "dispatch list", as there is not yet an approved electronic doctor's signature. By July 1, 2008 at the latest (depending on the federal state), eDMP is mandatory for all contract doctors. In exceptional cases, it was possible to document breast cancer by July 1, 2009.

Scope of the amounts distributed via DMP in the RSA

In the RSA annual adjustment 2005, of the 70.1 million insured years, approx. 1.7 million for insured years with registration in a DMP, so only approx. 2.4 out of a hundred. Since those enrolled usually have above-average cost-intensive illnesses, the DMP expenditure as a proportion of all expenditure taken into account in the RSA amounts to 7.9 billion euros of 129.2 billion euros. 6.1 per cent. (Data can be downloaded from the Internet at the Federal Insurance Office: www.bundesversicherungsamt.de, there under "Special Information, Risk Structure Adjustment, Annual Adjustments".)

Recent developments and outlook

In 2008, the requirement of a doctor's signature on the follow-up documentation from the GKV Competition Strengthening Act (GKV-WSG 2007) was dropped . Furthermore, on April 1, 2008, electronic documentation became mandatory.

On January 1, 2009, the previous risk structure compensation was replaced by a morbidity-oriented RSA (Morbi-RSA). Within the new Morbi-RSA, there is no separate reimbursement of the increased medical costs of DMP participants to the health insurance funds - it is now carried out for 80 selected disease groups. However, the health insurance companies continue to receive a program fee per month for each insured person enrolled in a DMP (2009: 15 euros / month, 2012: 12.76 euros / month). The attractiveness of the DMPs for the health insurance companies has been significantly reduced by the change in the RSA.

With the GKV-VStG, the requirement for a doctor's signature on initial documentation was also abolished on January 1, 2012. By then, the doctor had confirmed the accuracy of the information on the documentation with his signature.

In 2013, revisions to the DMP Breast Cancer, Asthma and COPD will come into effect on July 1, 2013. All DMP participants will be informed of the changes by the health insurance companies and the doctors. Changes result in particular from the medical progress in the breast cancer DMP.

Free DMP

A free disease management program is any DMP that is developed and carried out without RSA coupling and BVA supervision. First and foremost, these are the DMPs of private health insurances (PKV), but there are also statutory health insurances that carry out such free DMPs, then i. d. Usually as a model project or integrated care project . The design of the free DMP is patient-centered and in some cases more extensive than that of the RSA-DMP. Regular consultations take place here too, during which relevant data is collected. Info brochures and statistical evaluations of the state of health are also part of the medical DMP. Furthermore, self-compiled reports and telemetric devices support the care program. Depending on their state of health, patients are often cared for at different levels of intensity. Indications are similar to the RSA DMP mainly lifestyle diseases such as diabetes, osteoporosis, heart diseases asthma, hypertension, etc. Also, preventive programs for. B. for nutrition are offered as part of free DMP. The basic process is divided into three phases, similar to the RSA-DMP: selection, acquisition and support. The focus here is less on the quantity and more on the quality of the care, as the DMP initially mean increased administrative costs for the health insurance company and the cost savings are not generated across the board from the quantity of enrolled patients, but from the targeted care of high-risk patients and seriously ill patients. When implementing the free DMP, some practical difficulties also arose:

  • Insured person's unwillingness to cooperate. With heart disease and diabetes in particular, patients are usually very old and have had a long history of suffering. It is quite difficult to motivate this group to change their behavior or to wrest a positive attitude towards the program from them. In addition, private health insurance customers in particular are often high earners or people who are quite high in the social ranking who have already achieved a lot in their lives and bear a lot of responsibility. This group does not like to be persuaded into their way of life, as their professional success can hardly be reconciled psychologically with a “poor” private life.
  • The medical profession is usually even more skeptical of the free DMP than the RSA-DMP, since neither their own representatives (e.g. associations of statutory health insurance physicians) nor higher-level institutions such as the legislature are involved. This creates an even greater feeling that they are being deprived of responsibility for the patient.

Evaluation

Although the concept of disease management is still quite young in Germany, there are already initial evaluations of its success from the area of ​​free DMP and from other countries. These studies show that disease management programs bring about significant improvements, especially in severe conditions such as heart failure or diabetes. The content of the studies is usually a comparison of the course of the disease or the cumulative costs per patient with and without DMP. The frequency of symptoms, secondary and concomitant illnesses and, consequently, the number of hospital admissions are recorded. The results show a continuous reduction in hospital stays (and thus a main cost factor) - usually by between 20% and 30%, sometimes by over 80%. {{ Evidence missing }} One of the latest studies from Germany ( KKH , heart failure ) shows savings from an average of 1,400 euros to over 5,000 euros. {{ receipts missing }} However, the savings must also be compared with expenses for program implementation and medical interventions. Although the focus of all studies is usually on the monetary aspect, it can be assumed that the quality of life of the patients also improves when there are fewer acute cases.

Nonetheless, there are considerable deficits in the definition of the evaluation conditions by the Federal Insurance Office, which hardly allow meaningful assessments of possible successes of DMP in Germany.

Examples of studies on disease management programs:

  • Jaan Sidorov, Robert Shull, Janet Tomcavage, Sabrina Girolami, Nadine Lawton, Ronald Harris: Does diabetes disease management save money and improve outcomes? In: Diabetes Care . 25 (4), April 2002, pp. 684-689.
  • DP Holst, D. Kaye, M. Richardson, H. Krum, D. Prior, A. Aggarwal, R. Wolfe, P. Bergin: Improved outcomes from a comprehensive management system for heart failure. In: Eur J Heart Fail. 3 (5), October 2001, pp. 619-625.
  • GC Fonarow, LW Stevenson, JA Walden, NA Livingston, AE Steimle, MA Hamilton, J. Moriguchi, JH Tillisch, MA Woo: Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. In: J Am Coll Cardiol . 30 (3), Sep 1997, pp. 725-732.

literature

  • Kerstin Raczek, Jens Bölscher, Johann-Matthias Graf vd Schulenburg: Disease Management in Diabetes Mellitus . Cuvillier Verlag, Göttingen 2000, ISBN 3-89712-846-2 .
  • Viviane Scherenberg: Patient Orientation - Compliance and Disease Management Programs . Publishing house for science and culture, Stuttgart 2003, ISBN 3-936749-43-4 .

Web links

Individual evidence

  1. ↑ Definitions for Disease Management. ( Memento from September 13, 2014 in the Internet Archive ) German Medical Association, accessed on September 13, 2014.
  2. ↑ Karl Lauterbach, Eberhard Wille: Model of a fair box office competition. Immediate program "changer component and solidarity reinsurance" taking into account morbidity. Final report. Expert opinion on behalf of the Association of Salaried Health Insurance Funds eV (VdAK), the Arbeiter-Ersatzkassen-Verband eV (AEV), the AOK Federal Association (AOK-BV) and the IKK-Federal Association (IKK-BV). Cologne and Mannheim 2001.
  3. ^ DMP guideline - Federal Joint Committee. In: www.g-ba.de. January 7, 2015, accessed October 27, 2015 .
  4. ↑ Press releases - Federal Joint Committee. Retrieved June 5, 2019 .
  5. ↑ G-BA: Guideline research on the diagnoses of chronic heart failure, rheumatoid arthritis, osteoporosis and chronic back pain. (PDF) G-BA, August 21, 2014, accessed on October 27, 2015 .
  6. ↑ G-BA: Guideline research on the diagnosis of depression. (PDF) G-BA, August 20, 2015, accessed on October 27, 2015 .
  7. ↑ Afschin Gandjour: A model to predict the cost-effectiveness of disease management programs . In: Health Economics . tape 19 , no. 6 , 2009, ISSN  1057-9230 , p. n / a – n / a , doi : 10.1002 / hec.1503 ( wiley.com [accessed October 31, 2018]).