Integrated care

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Integrated care is the idea of ​​a new "cross-sectoral" form of care in health care . It promotes greater networking between the various specialist disciplines and sectors ( general practitioners , specialists , hospitals ) in order to improve the quality of patient care and at the same time reduce health costs.

history

Since around 1975

Approaches to replacing the sectoral separation in the German health care system with an integrated system have existed since around 1975 (e.g. Economic and Social Science Institute of the DGB ). However, it took more than a generation to implement it: In the meantime, the gaps between service providers and their representatives on the one hand and the cost bearers ( health insurance companies ) and their representatives on the other had become too deep .

The attempt to reform “integrated care” in the 2000 health reform initially had little effect. Integration contracts between service providers and health insurers could only be concluded with the consent of the Association of Statutory Health Insurance Physicians . Here the tendencies towards maintaining the status quo appeared to be dominant, so that collective agreements were not replaced by selective agreements. On January 1, 2004, the red-green coalition created the basis for softening the fronts with the statutory health insurance modernization law . In Sections 140a to 140d of Book V of the Social Security Code (SGB V), newly created for integrated care , it was stipulated that service providers and health insurers can conclude contracts for integration care with one another without the consent of the statutory health insurance associations. On the one hand, this created the basis for individual contracts. Under these regulations, the health insurance funds are equipped with a significant increase in power compared to the formerly superior associations of service providers.

Section 140a Integrated Care (IV) (1) Notwithstanding the other provisions of this chapter, the health insurance companies can conclude contracts for the care of the insured across various service sectors or for interdisciplinary, interdisciplinary care with the contractual partners named in Section 140b (1).

Section 140b Contracts for integrated forms of care (1) The health insurance companies can only enter into contracts according to Section 140a Paragraph 1 with

  1. individual ... doctors and dentists and individual ... service providers ...
  2. Authorized hospitals ...
  3. Organizers of facilities according to Section 95 Paragraph 1 Clause 2 (Medical Care Centers) ...
  4. Organizers of facilities that offer integrated care according to Section 140 a by service providers authorized to care for the insured under Chapter 4 ( management companies ),
  5. Communities of the aforementioned ...

to lock. ... "

Since 2004

In the reform work of 2004, a second important cornerstone for the success of integrated care models was laid: On January 1, 2004, start-up funding of 1% of the total remuneration for outpatient and inpatient services was made available in accordance with Section 140d SGB ​​V in order to avoid the previously hesitant use of new opportunities to accelerate. According to this, a maximum of 680 million euros a year was initially available up to 2006 (220 million euros from contract doctor remuneration and 460 million euros from inpatient care). This period has been extended by another year as part of the current health reform. The start-up financing reduces the budgets of the respective KV districts in which the integration models are located. The start-up financing is only a temporary solution. Clear financing regulations (budget adjustments) are necessary for the long-term survival of integrated care. The start-up funding ended when the health reform came into force in 2009.

Development in the supply landscape in the area of ​​IV contracts: at the end of 2004 there were around 300 integration contracts, in autumn 2005 the mark of 1000 contracts with a remuneration volume of over 300 million euros was reached. At the end of the 1st quarter of 2007, according to the joint registration office for the implementation of Section 140d SGB ​​V (BQS), there were exactly 3,498 IV contracts, which cover a remuneration volume of almost EUR 611 million. Note: The number of contracts does not allow any conclusions to be drawn about the service providers cooperating in the service chain.

The public health insurance issued in 2008, 41% more money compared to 2007 for integrated care. A large part of this goes to the participating hospitals.

While the health insurances have other services checked by the Medical Service of the Health Insurance (MDK), Integrated Care is currently only regularly entrusted by the MDK with the assessment of integrated care contracts in individual parts of the country (e.g. by the MDK North Rhine).

Since 2011

As of January 1, 2011, the list of potential contractual partners in SGB V was expanded with the Statutory Health Insurance Supply Structure Act. Now u. a. pharmaceutical companies or manufacturers of medical devices act as direct contractual partners. Since then it has been specifically stated in Section 140b (1) SGB V:

The health insurance companies can only conclude contracts in accordance with Section 140a (1) with individual doctors and dentists who are licensed to provide statutory medical care and individual other service providers who are authorized to care for the insured under this chapter or with their communities,

  1. Providers of approved hospitals, insofar as they are entitled to care for the insured, providers of inpatient preventive and rehabilitation facilities, insofar as there is a supply contract with them in accordance with Section 111 (2), providers of outpatient rehabilitation facilities or their communities,
  2. Sponsors of facilities according to Section 95 (1) sentence 2 or their communities,
  3. Providers of facilities that offer integrated care according to Section 140a by service providers authorized to care for the insured under Chapter Four,
  4. Long-term care insurance funds and approved long-term care facilities on the basis of Section 92b of Book Eleventh,
  5. Communities of the aforementioned service providers and their communities,
  6. Practice clinics according to Section 115 Paragraph 2 Clause 1 No. 1,
  7. pharmaceutical entrepreneurs,
  8. Manufacturers of medical devices within the meaning of the law on medical devices

to lock.

In 2015, with the Statutory Health Insurance Care Strengthening Act, the innovation fund was adopted as an instrument to promote integrated care and health services research in Germany. Starting in 2016, it will fund innovative, cross-sectoral forms of care and health care research with an annual amount of 300 million euros.

Contract drafting

Most IV contracts according to Section 140a SGB ​​V relate to specific indication areas, but it is also possible to conclude so-called population-based contracts for entire population groups. Often, family doctor-centered care is embedded in IV contracts according to Section 73b SGB ​​V. The aim of the contracts for family doctor-centered care is to strengthen the role of the family doctor as a coordinator in the health system. This is intended, among other things, to avoid double examinations and unnecessary hospital admissions. Structuring the treatment process is also intended to improve the quality of care. A scientific study by the Universities of Frankfurt am Main and Heidelberg in 2014 showed that patients in Baden-Württemberg are better cared for as part of family doctor-centered care.

Indication-specific IV contracts correspond to the classic case management , in which a case of illness is treated within a defined period and remunerated in a standardized manner (e.g. complex flat rate). Since operative indications such as If, for example, hip endoprostheses in osteoarthritis have a correspondingly clear scope of services with a calculable risk due to their high level of standardization, there are particularly many contract examples for such indications. In this context, critics like to speak of "IV light" or "old wine in new bottles". However, since this involves completely new, cross-sectoral cooperation structures, indication-specific IV models are to be understood as a "training field" for the actors involved. In this way, one will approach more complex models that treat more complex indications.

In contrast to indication-specific care, population-based care means that the service providers are remunerated via capitation or health premiums per registered insured person, possibly limited to a certain region. In their pure form, as practiced in the USA, such contracts are still in the pilot stage in Germany, but doctor networks and nationwide family doctor-centered care models (AOK Saxony, Barmer family doctor contract for certain areas in Germany) represent the first steps in this direction.

The long-term trend is from simple, indication-related contracts to more complex contracts that span several sectors, contain more difficult indications and develop entire care landscapes. According to the principle “money follows performance”, which is often neglected in the German health care system, success-oriented remuneration structures will also be established to a greater extent in the future, which promise to measure the progress of recovery with the help of medical guidelines. The discussion about guideline-based medicine is not over in German society.

Some service providers make the content of the contracts they have concluded freely available on the Internet. On the other hand, the insurers usually do not publish contracts with reference to non-compete obligations or a lack of disclosure. There is a database at the registration office, which was operated by the BQS Institute for Quality & Patient Safety until the start-up funding expired in 2008. Data on contract development in the following years can only be found in the 2012 annual report of the German Advisory Council on the assessment of developments in the healthcare sector . Patients can get information from their health insurer about contracts, contract contents and contractual partners.

Related forms of contract

Integrated care can be viewed as a partial component of a modified managed care system based on the US model. In contrast to the German Bismarckian health insurance model, this is primarily designed to be economical and serves more to maintain health (see Health Maintenance Organization (HMO)) than to insure damage to health that has already occurred.

Other managed care components that were initiated with the 2000 health reform in Germany are Disease Management Programs (DMP) and Diagnosis Related Groups (DRG). Together, these measures aim to offer standardized treatment at standardized prices. The aim is to create transparency through better comparability of the services provided.

From quantity to quality model

The three approaches to the so-called indication-based IV described below show, by way of example, how one can go beyond the model of quantity scaling for a price discount, which has since been described many times, and instead introduce monetary quality elements into IV contracts.

  1. Case management : If several doctors are involved in the treatment of chronic diseases, coordination problems and incidentally distorted incentives can arise. Traditional solutions such as standardized treatment pathways , case conferences etc. reach their limits when itcomesto long and variable courses with recursive elements. A case manager can be used for such indications, who regularly visits immobile patients on an outpatient basis or invites mobile patients to his office hours. He is responsible for the entire process and monitors the measures of all therapists involved. For patients as well as for the service providers involved in the IV contract, case management can play a central role in the quality of care and collaboration. (see also: Evaluation results IV model "Endoprothetik Münster" )
  2. Modular complex flat rates : For complex, lengthy treatments across outpatient and inpatient sectors (e.g. cancer), a modularization of the complex flat rates for reimbursement makes more sense than pricing heterogeneous cases with average values. The aim is to offer an incentive for shorter hospital stays through suitable remuneration modules. So you can z. B. through higher-priced admission and discharge modules with corresponding follow-up offers for inpatient and outpatient care to include the home environment more closely and at the same time activate the patient.
  3. Complete packages : Complete packages are useful for inhomogeneous indications that are similar in the therapeutic process. You could e.g. B. in outpatient surgery according to EBM 2000plus include the preoperative standard diagnostics, follow-up care , complication management and a time-limited quality guarantee.

In addition to these three indication-oriented variants, there is also the population-based form of integrated care. In this, the complete care or a group of essential forms of care is provided by a service provider community against a morbidity-adjusted head lump sum.

literature

  • Volker E. Amelung / K. Meyer-Lutterloh / E. Schmid / R. Seiler / R. Lägel / JN Weatherly: Integrated care and medical care centers . 2nd edition with CD-ROM, Medizinisch Wissenschaftliche Verlagsgesellschaft, Berlin 2008, ISBN 978-3-939069-57-7 .
  • P. Schönle, U. Egner: Rehabilitation and Integrated Care - Claim, Reality, Future. Interdisciplinary writings on rehabilitation, Vol. 16, Gentner Verlag, Stuttgart, 1st edition
  • Tobias F. Beck: Managed Care in inpatient service provision; Innovative integrated care as an opportunity for hospitals . IGEL Verlag GmbH, Hamburg, 2008. ISBN 978-3-86815-051-3
  • Mathias Fünfstück / Kristin Richter: Nursing in integrated care. A concept development based on a survey of health insurance companies . VDM Verlag Dr. Müller , Saarbrücken 2008, ISBN 978-3-639-05042-4 .

Web links

Individual evidence

  1. ↑ IV report BQS: 1st quarter 2007 (PDF file; 1.7 MB)
  2. ↑ Bundesverband Managed Care eV Information on the innovation fund
  3. ↑ http://www.aok-bw-presse.de/presseinfos-91.php?mode=detail&id=1563&move=seach&from=search&moveFrom=list&scriptNameFrom=presseinfos-91
  4. ↑ Integrated care: Not all gold that glitters , accessed on September 18, 2017.
  5. ↑ Results of a survey on integrated care according to § 140a-d SGB , Chapter 7.6 in the Special Report 2012 of the Expert Council on the Assessment of Developments in the Health Care System