Managed care

from Wikipedia, the free encyclopedia

Managed care is a management model in healthcare . The free choice of doctor and the market mechanisms are restricted in favor of planned, contractually regulated processes in order to reduce costs and improve the quality of care. Patients can voluntarily join a managed care system, for example to receive reduced contributions, or they can be insured by their employer in a Health Maintenance Organization (HMO) ( common in the USA, for example ). Service providers are also contractually bound to a managed care system. Often they do not receive an individual performance fee, but a fixed budget, and / or they receive a share of the costs and profit.

In Germany and Switzerland the legislators want family doctor networks with budget responsibility: in Germany since 2009 family doctor-centered care [HzV] (Section 73b SGB V, revised with the law on the further development of organizational structures in the statutory health insurance ), in Switzerland since 1996 (health insurance law) . A number of GPs conclude a joint selective contract (i.e. outside the budget of the KV ) with one or more insurers, in which a cost framework is set for all insured persons included in this contract. If the costs are not reached, the network receives a bonus, if the costs are exceeded, a penalty. Those insured who join such a network receive a premium reduction.

In the Dutch health care system, there is also the family doctor as a so-called gatekeeper : Patients must always first go to a family doctor assigned to them based on the area they live in. The number and locations of these basic providers are strictly regulated. The basic providers only have a small amount of equipment - neither a practice laboratory nor an X-ray - and can provide further information if necessary. In Germany this is only regulated on a voluntary basis when participating in individual disease management programs .

Solved and unsolved problems

There is less supply and less reserve capacity. In the case of business managers of a managed care system, there is a tendency to keep the capacity as tight as possible in order to achieve high utilization. This results in cost savings, but also a waiver of reserve capacity, which is often expressed in long waiting times. (In the Netherlands, for example, one to two weeks for a blood sample, for non-vital operations up to several months.) Since the patients are often limited or unable to work during these waiting times and the long-term consequences of late treatment cannot be ruled out, such savings can be made in the healthcare system lead to societal costs that are difficult to calculate.

There is a reverse incentive system. If service providers are rewarded not for providing, but to a certain extent for avoiding services, there is a tendency - more or less unconsciously - to save services that are actually necessary. This must be compensated for by appropriate quality control mechanisms. Accordingly, the temptation to over-treatment, to unnecessary and too expensive therapies and to waste must be combated in traditional models.

Current importance in Switzerland

In Switzerland on January 1, 2004 there were almost 500,000 (out of a total of approximately 7 million) insured in managed care models, 100,000 of them in HMOs , 400,000 in family doctor networks . When insurers offer family doctor insurance, 30 to 50 percent of those insured usually join them. There are fewer at HMO, as the doctors are not already known here.

On June 17, 2012, the Swiss people voted on a bill that would increase the proportion of those insured in integrated care models to 60 percent. The SP , SVP and BDP spoke out in favor of the rejection , while the other parties announced the yes slogan. This proposal was rejected with a participation of 38.0 percent with 76 percent votes against (1,480,889 against to 466,996 yes). With over 91 percent no votes, the canton of Vaud was the largest rejection of the bill, ahead of the canton of Ticino (87.5 percent) and the canton of Geneva (87 percent). Since so far a proposal that came from parliament ( National Council and Council of States ) has rarely been rejected with so many no votes, the result is surprising.

Current importance in Germany

Disease management programs and integrated care are the first approaches to implementing managed care in German statutory health insurance . A significant expansion is being discussed in connection with a switch to the purchasing model for inpatient and outpatient care.

literature

  • VE 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
  • Jürg Baumberger: How Managed Care works. Thieme, 2001, ISBN 3-13-128391-2
  • 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
  • Daniel Finsterwald: Managed Care - Pioneer Country Switzerland / Managed Care - La Suisse pionnière. Publishing house Switzerland. Society for Health Policy SGGP, Zurich, 2004, ISBN 385707753
  • Peter R. Kongstvedt: The Managed Health Care Handbook, Jones and Bartlett Publishers, 2000, ISBN 0-8342-1726-0
  • Hansjörg Lehmann: Managed Care. Rüegger, 2003, ISBN 3-7253-0732-6
  • Managed Care. Manfred Haubrock u. a. Hans Huber, 2000, ISBN 3-456-83312-1
  • Managed Care - New ways in health management. Volker E. Amelung, Harald Schuhmacher. Gabler, 2004, ISBN 3-409-31500-4
  • Managed Care - Causes, Principles, Forms and Effects. Michael Arnold et al. a. Schattauer, 2001, ISBN 3-7945-1747-4
  • Managed Care in Switzerland and transfer options to Germany. Monika Steininger-Niederleitner u. a. Health Economics Research Center, 2003, ISBN 3-936863-00-8
  • Michael Wiechmann: Managed Care. German University Press , 2003. ISBN 3-8244-7803-X

Web links

Sources and individual references

  1. ↑ Switzerland adopts the Managed Care Act: in future, 60 percent of the Swiss should be enrolled in integrated care! In: Health adhoc. Retrieved June 17, 2012 .
  2. ↑ A massive no to the managed care template. In: Neue Zürcher Zeitung . Retrieved June 18, 2012 .