Family doctor-centered care
Family doctor-centered care (HzV) describes a form of medical care in Germany in which the family doctor, as the first point of contact for the patient, coordinates all treatment steps. He thus performs the function of a pilot. Health services research thus combines two goals: on the one hand, the patient should be better cared for, and on the other hand, overall coordination can save money.
The statutory health insurance companies in Germany are obliged to offer their insured persons a HzV. Many health insurance companies have concluded contracts with groups of doctors and enable their insured persons to participate in family doctor models or family doctor programs. Participation is voluntary for the insured and family doctors. The insured person undertakes to consult his family doctor first in the event of health problems for at least one year. Exceptions are mostly emergencies and visits to the gynecologist, ophthalmologist, dentist, pediatrician and adolescent doctor as well as illnesses outside the geographic area of activity of the family doctor. The family doctor takes care of the treatment, transfers to other specialists or hospitals if necessary and ideally has a comprehensive overview of the patient's medical history and the treatments carried out. The "pilot function" is intended to avoid multiple examinations and treatments, avoidable drug interactions, interpretation errors by specialists working in isolation as well as unnecessary visits to other doctors and unnecessary hospital admissions.
Before the introduction of the health insurance card had with the medical certificate until the family doctor each be visited, which optionally transfers exhibited as a specialist. The introduction of the chip card led to more changes of doctor and thus to higher costs.
In total, almost 17,000 family doctors and around four million insured persons take part in the HzV in Germany.
Legal position
The provisions for GP-centered care in the public health insurance resulting from § 73b SGB V . According to this, health insurance companies have to offer their insured persons comprehensive HzV contracts. Contracts can be designed either as full supply contracts or as add-on contracts. In full care contracts, the primary care area is comprehensively regulated via the HzV contract, while additional services are agreed in add-on contracts and otherwise the primary care services are billed as part of the standard care via the EBM.
The contractual partners are free to design the content of their contracts, taking into account the statutory provisions, so that the conditions of the HzV contracts of different health insurances sometimes differ.
According to § 73b SGB V, participation is voluntary for both insured persons and doctors. A declaration of participation is therefore a prerequisite for participating in HzV contracts. The degree of participation of general practitioners differs greatly in the individual regions.
A controversial regulation of § 73b SGB V can be found in Paragraph 4:
- "In order to ensure comprehensive coverage of the offer according to paragraph 1, health insurance companies alone or in cooperation with other health insurance companies have to conclude contracts with communities by June 30, 2009 at the latest, which represent at least half of the general practitioners in the district of the Association of Statutory Health Insurance Physicians. If the contracting parties cannot reach an agreement, the community may request the initiation of arbitration proceedings in accordance with paragraph 4a. "
Communities that meet said quota have the right to request the initiation of arbitration. In this case, the arbitrator determines the content of the contract. In addition to general practitioners, general practitioners and paediatricians also participate in general practitioner care (Section 73 (1a) SGB V). You are entitled to participate in HzV contracts, but will not be taken into account when it comes to the question of whether it is a privileged community within the meaning of Section 73b (4) SGB V. Occasionally, statutory health insurance associations or various medical organizations are contractual partners in the existing models . The German Association of General Practitioners and its regional associations have now implemented their own contracts in most regions. Funds partially oppose the legal obligation because they fear the considerable additional costs.
Development of the contracts according to § 73b SGB V
In order to strengthen family doctor activity, medical care was divided into general and specialist medical care on December 20, 1988 by the new version of Section 73 SGB V within the Health Reform Act (GRG). Although this did not introduce a real primary doctor system, it was nevertheless first specified.
With the Statutory Health Insurance Modernization Act on January 1, 2004, the actual regulations on family doctor-centered care according to Section 73b SGB V were introduced. In addition to his regular treatment activities, the general practitioner was installed by the legislature as a coordinator on the treatment pathways. With the entry into force of the GKV Competition Strengthening Act (GKV-WSG), Section 73b SGB V was fundamentally reformed and expanded on April 1, 2007. The requirements for the design of family doctor-centered care were specified and the health insurance companies were expressly obliged to offer their insured persons a HzV. At the same time, it expands the insurance companies' contractual competence.
As a result of the further development of the organizational structures in statutory health insurance (GKV-OrgWG), the health insurance funds were obliged to conclude contracts with communities that represented half of the doctors in a KV district who took part in primary care by June 30, 2009. The GKV-OrgWG also introduces the possibility of initiating arbitration proceedings if no agreement can be reached with the health insurance companies.
The law on the financing of statutory health insurance funds (GKV-FinG), which came into force on January 1, 2011, made new contracts concluded after September 22, 2010 subject to the stable contribution rate (Section 73b (5a) SGB V ). In addition, the self-financing requirement was strengthened (Section 73b (8) SGB V) and an obligation to submit documents and the authorities' right to object (Section 73b (9) SGB V) was introduced.
The patient rights law (PatRechtG) enshrined a right of withdrawal (Section 73b, Paragraph 3, Clause 3–4, SGB V) and obliged the health insurance companies to include provisions in their statutes for submitting the participant's declaration (Section 73b, Paragraph 3, Clause 8, SGB V).
The 14th SGB V Amendment Act (14th SGB V-AmendmentG) has deleted the refinancing clause from Section 73b (5a) SGB V and replaced it with quality features that are contractually agreed.
Advantages of the family doctor model
The health insurance companies can grant the insured one or more advantages, for example reduced co-payments in pharmacies or additional preventive services at the doctor (e.g. laboratory values, risk advice, early skin cancer screening, PAD screening, drug therapy optimization, basic geriatric assessment and much more depending on the insurance company). In addition, the practices participating in the HzV often offer additional early and evening consultation hours for working HzV insured persons and also agree to limit the waiting time of the patient participating in the HzV to a maximum of 30 minutes.
The general practitioner can provide and bill additional services for the patient (e.g. the above) and usually receives a higher basic flat rate (flat rate for all treatment occasions occurring in a quarter), which compared to regular, statutory insurance with the same insurance premium for the patient Thanks to the better remuneration structure, it makes a contribution to maintaining rural general practitioners' practices and thus also providing comprehensive medical care. This is particularly relevant as the number of general practitioners required to care for patients is decreasing, especially in rural areas, but also in structurally weak urban areas, as the German Advisory Council on Health Care (SVR) confirms in a report. The relationship with the general practitioner and family doctor is strengthened. The family doctor has known the patient for years, sometimes for decades, which enables him to incorporate essential aspects of psychosocial care (so-called hermeneutic case understanding) into his treatment.
“Doctors' tourism” is reduced, which avoids incorrect treatment (e.g. due to drug interactions or ignorance of relevant previous findings), double examinations or over-therapy (e.g. operations that are too early, so-called general practitioners, quaternary prevention). Collecting and saving the findings in one place also ensures that the treating family doctor can keep track of all necessary examinations and treatments.
Since general practitioners finally clarify at least 80 percent of the cases in their practices, the specialists can concentrate on more serious diseases in their area, which ensures patients in need a faster specialist appointment.
Services such as post-inpatient transfer management also improve the coordination of the disciplines required for further treatment after discharge from the hospital. Even suboptimal hospital treatments can often be recognized at an early stage thanks to precise patient knowledge and corrected by the family doctor.
Thanks to the simple structure of the remuneration system with individual services, flat rates and surcharges, the practice bureaucracy can be reduced, leaving the family doctor more time for patient care. The HzV remuneration is paid out in the middle or at the end of each month, depending on the fund. In addition, the use of a “care assistant in the family doctor's practice” ( Verah ) as part of the contracts for family doctor-centered care is regularly accompanied by an extra remuneration .
In order to participate in the HzV, general practitioners have to meet a number of requirements, including qualification and quality requirements. This includes the authorization to provide psychosomatic services as well as the authorization for advanced training in “General Practitioner Geriatric Basic Assessment”. In addition, they are usually also obliged to actively participate in disease management programs (DMP) relevant to general practitioners. General practitioners enrolled in the HzV must also take part in general practitioner-specific training courses. This includes the annual participation in several structured family doctor quality circles for drug therapy. Further training courses on special topics relevant to general practitioners are also to be attended as part of the training obligation during the HzV contract participation. These include patient-centered conversation, basic psychosomatic care and palliative medicine. The advanced training points collected in the course of the special HzV advanced training are counted towards fulfilling the above-mentioned statutory advanced training obligation in accordance with Section 95d SGB V. The aim of these quality requirements is to ensure that the family doctors participating in the HzV are up to date with the latest medical knowledge.
Disadvantages of the family doctor model
The right to a free choice of doctor is restricted by being tied to the family doctor. It also makes it more difficult to obtain comparative examinations and differentiated therapy recommendations (“third and fourth opinions as so-called doctor hopping”) from different specialists. Obtaining a second opinion from a specialist is usually explicitly possible after consultation with a general practitioner, especially in the case of more complex diseases.
Some critics doubt that the qualifications of general practitioners are sufficient for such a complex task, although the training requirements within the framework agreement for HzV participation explicitly provide them with quality-assured training.
Since a separate invoice must be created for each health insurance company and there are different accounting numbers for the health insurance companies, the bureaucratic effort is greater than for doctors who only settle accounts with the Association of Statutory Health Insurance Physicians. This is in contradiction to the “simple structure of the remuneration system” propagated by the family doctor association.
If not all GPs take part, the patient who wants to participate in the program is forced to change GPs.
Patients who have enrolled in a family doctor model may only be treated by other family doctors who themselves participate in the family doctor model when their own family doctor is on vacation or sick. This can definitely lead to patients having to go to a neighboring town for treatment if no other family doctor is participating in the family doctor model in their own place of residence.
Investigations
The Bertelsmann Foundation surveyed a total of 9,000 citizens between 2004 and 2007 and concludes from their answers that the family doctor models have so far not had the desired effect. The patients did not feel better cared for than usual, and the visits to the specialist physician actually increased instead of decreased. Only 59 percent of the participants report an improvement in their state of health; However, 68 percent of non-participants stated this. Apparently, the models do not give the family doctor a better, but rather a worse pilot function. The AQUA Institute for Applied Quality Promotion and Research in Health Care for Applied Quality Promotion and Research in Health Care published a study at the beginning of 2008 on the behavior of those insured with alternative health insurance in family doctor models and found that the proportion of specialist visits by family doctor model participants with referrals remained the same between 2005 and 2006, while he declined in the control group.
An evaluation of family doctor-centered care in Baden-Württemberg by the universities of Frankfurt a. M. and Heidelberg, which was carried out between 2013 and 2016, showed that the number of hospital admissions and double specialist visits are reduced and that patients feel better cared for.
Family doctor models in the countries
Baden-Württemberg
In Baden-Württemberg, the first contract for family doctor-centered care between the family doctor association, the Medi-Verbund and the AOK Baden-Württemberg was concluded in May 2008. This contract, which was mutually extended in 2015, has over two million insured persons (as of 01/2016).
The contract contains numerous elements that, according to the proponents, should improve the care of the participating insured persons, including qualification and training obligations for the participating doctors, mandatory online connection to electronic billing and regular updates of the drug module, introduction of general practitioner treatment guidelines and special offers ( e.g. evening consultation for working people). There is no additional payment for registered patients if they are prescribed medication for which the AOK Baden-Württemberg has concluded a discount agreement. The contract regulates the medical remuneration independently of the Uniform Assessment Standard (EBM) of the KV system with flat rates and a few individual services, as well as “quality-dependent” additional remuneration. It should therefore be a "full supply contract" (in contrast to so-called "add-on" contracts).
By the end of 2010, contracts for family doctor-centered care had been concluded in Baden-Württemberg between the two medical associations and practically all health insurance companies, partly as voluntary contracts (with the IKK Classic, the Techniker-Krankenkasse and numerous company health insurance funds), partly in arbitration by the former judge on Federal Social Court Klaus Engelmann (including the other replacement and company health insurance funds). In the meantime, a study by the universities of Frankfurt / Main and Heidelberg from Baden-Württemberg is available, which shows that the form of family doctor-centered care represents significantly better care for patients: more than 4,500 hospital admissions, especially chronically ill patients, can be in the HzV pro Year in Baden-Württemberg.
Bavaria
In Bavaria, with the exception of a few company health insurers, all health insurances terminated their family doctor contracts in December 2010.
The background to this was the recommendation of the Bavarian Association of General Practitioners to general practitioners to collectively refrain from licensing by a contract doctor. The Bavarian Association of General Practitioners sought care contracts that are no longer within the scope of the Social Security Code. However, the majority of the general practitioners decided against a return of the health insurance approval in the vote on the collective exit from the system.
After the system exit failed, the chairman of the Bavarian Family Doctors' Association Hoppenthaller resigned from his position. Bavaria's Minister of Health, Markus Söder, had previously called for Hoppenthaller's resignation. The BHÄV needed a "new start in terms of content and personnel" and an "unencumbered interlocutor".
Since the beginning of 2012, the statutory health insurances in Bavaria have been offering their insured persons participation in family doctor-centered care (HzV) again. Most family doctor contracts, however, did not come about through contractual agreement between the respective health insurance company and the Bavarian Association of General Practitioners, but were determined by an independent arbitrator by means of an arbitration award (according to Section 73b (4a) SGB V).
As of April 1, 2015, AOK Bayern will again be offering its insured persons a family doctor contract. Significant innovations here include, among other things, the significant expansion of preventive benefits for younger patients, e.g. B. a skin cancer screening every 2 years from the age of 19.
See also
Web links
- The glossary on health reform: General practitioner: General practitioner-centered care
- News and comments on the family doctor model
- Text of § 73b SGB V
- Association of Substitute Funds fears the cost of GP contracts (April 6, 2009)
Individual evidence
- ^ Opinion of the Expert Council in Health Care
- ↑ Quoted from Medical Tribune , January 18, 2008, p. 18
- ^ Result report of the evaluation
- ↑ Text of the contract and other documents ( memento of the original from October 20, 2013 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Archived copy ( memento of the original from October 20, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Quoted from the Ärzte Zeitung
- ↑ Hoppenthaller resigned basket closed , Hartmannbund
