>> If you look for the reasons for the pressure to act that has arisen, the increasing number of inpatient admissions after visits to rescue centers, which cannot be adequately explained by demographic and morbidity developments, is certainly one of them1. By comparing the different remuneration in the outpatient and inpatient sectors (EBM/DRG) for the same service, one can see, for example, in the case of a diagnostic left heart catheterization.
search (inpatient case costs: 1,800 euros / outpatient
lant: 630 euros) the associated enormous cost burden on the statutory health insurance - arose as a result of an unused outpatient redirection potential2.
In 2015, the legislature responded to the increasing direct use of rescue centers - especially in metropolitan areas - with a comparatively high density of care, with regulations in the Statutory Health Insurance Care Strengthening Act on the obligation of statutory health insurance associations to cooperate with approved hospitals in on-call service during non-consultation hours3. In 2016, the legislature intervened again with the Hospital Structure Act and specified its legal requirements with the requirement that on-call practices (also called emergency services practices or portal practices) be set up in or at hospitals or that hospital emergency departments be directly integrated into the on-call service4. In 2016, the Association of Substitute Insurance Funds (vdek) commissioned a report on this topic from the Institute for Applied Quality Promotion and Research in Health Care (AQUA), which describes reform approaches and gives recommendations for action on how to better integrate inpatient and outpatient areas in the acute and Emergency care can be provided. The up to 25 million people who, according to this report, are treated annually and with an increasing trend in hospital rescue centers across Germany were grouped by AQUA according to general medical, surgical and advanced internal diagnostics cases. The results showed that a third of the emergency center cases are acute cases for which the outpatient medical on-call service is available and which therefore require outpatient care5.
Currently, at the beginning of April 2017, another normative instrument has been used following the findings with the introduction of the “clarification fee” in the uniform assessment standard (EBM): This flat rate can be billed for patients who present themselves to hospital rescue centers without a medically justified emergency should be correctly referred to outpatient practices.
In this context, those involved must also clarify the question of how adequate care for acute and emergency patients can be achieved without simply transferring responsibility for misallocation to the other of the three pillars in acute and emergency care ( outpatient, inpatient, emergency services) or to initiate a “behavior change discussion” on the part of the patient and then end with it. Hospital representatives complain that acute outpatient cases tie up expensive hospital resources at the expense of “real” emergencies in the rescue centers. Ultimately, there is a lack of adequate remuneration for the services in the hospital rescue centers.
It is also a fact that the increasing numbers of “hospital self-admissions” were only made possible by the widespread use of rescue centers. In this context, observers of social developments point to the changing demands of patients who increasingly want 24/7 “quick & easy” care – even for a cold on the weekend – and so the rescue centers are the easiest and best-known access to medical care also choose beyond emergencies.
IGiB on-call practice since 2012
Innovative Healthcare in Brandenburg GbR, or IGiB* for short, addressed the challenge of creating suitable care structures for needs-adequate care of acute and emergency patients back in 2011, when it developed the concept of an on-call practice. This preparedness practice can form the basis for a restructuring of acute and emergency care and, if further developed, can even be a blueprint for nationwide solutions in the next legislative period.
The model for setting up and establishing an on-call practice in the form of a start-up practice at the hospital, which was first designed for Brandenburg in 2011 by the IGiB as an upstream point to the rescue center, was first tested under real conditions in real operation in the Potsdam metropolitan area in cooperation with the St. Josefs Hospital. The first on-call practice was launched on January 1, 2012 as the “KV RegioMed on-call practice” for a pilot period of a total of nine months.
The model was based, on the one hand, on linking the KV RegioMed on-call practice to be established with an existing general practitioner's practice at the medical care center at the hospital location, and on the other hand on the infrastructural integration with the hospital's rescue center. Before the start of the pilot phase, the practice was located directly next to the rescue center, but direct access to the rescue center for patients walking to the location was abolished. In a combination of outpatient general practitioner and on-call practice, acute patients could be treated to the medically necessary extent at a central location during consultation hours and also outside of regular consultation hours, and the rescue center could be relieved of acute outpatient cases, as was proven in the course of the evaluation6.
The sustainability of such structures also includes considerations of economic viability and efficiency through shared and existing spatial, technical and human resources. The location of the on-call practice was established in the model project as a central contact point for patients walking in the catchment area and as a structure in front of the rescue center. The core element of the concept is the joint, consistently staffed registration as well as the common waiting area between the practice and the rescue center.
Using agreed decision-making criteria, patients are guided in a targeted manner according to their state of health to the care offered at the location that meets their needs. The location identity is also so important for patients because they tend to misjudge their health problems and they do not know or understand the exact responsibilities of the pillars of acute and emergency care or only do so insufficiently. If you leave it to the patient to decide which “door” to go through, experience shows that he will choose the “door” of the rescue center, even if the “door” of the on-call practice is only a few meters away.
“Plug and Play” approach
The entire standby practice model was designed as a “plug and play” approach in order to be able to carry out a nationwide rollout in Brandenburg if the pilot was successful. The project's objectives of establishing the first KV RegioMed on-call practice at the St. Josefs Hospital in Potsdam by the end of the pilot phase of the IGiB project, running it economically independently and being able to transfer it to standard care, were achieved. In addition, the project initiator IGiB has succeeded in creating uniform contractual bases, regulatory content for service financing and evaluation of the project as well
to make adaptable arrangements for collaboration with each participating hospital in order to lay the foundation for a rollout. However, the combination with the family doctor's practice at the location during consultation hours did not prove to be successful, as this did not correspond to the demand structure. Based on this experience, it seems better to refer acute patients to surrounding doctor's practices during consultation hours than to provide additional resources for this purpose.
The model of the KV RegioMed on-call practice is now firmly established in Brandenburg and has been further developed regionally by the KV Brandenburg. The aim is to implement comprehensive care using such locations in joint responsibility with the doctors as well as in cooperation with the local hospitals and with active participation on the part of the GKV.
Starting in Königs Wusterhausen, KV Brandenburg has also been taking over central patient control for acute and emergency care since April 2017 via the nationwide uniform number 116117 in close cooperation with the Lausitz regional control center. As part of this further development, the on-call practice in Königs Wusterhausen will also remain open at night and will be staffed by a doctor from the hospital from 10 p.m. in a way that conserves resources and meets demand.
The experiences that have been gained since 2012 with the implementation of the model conceptualized in the IGiB and which have since led to various regional forms and further developments in further implementation can now help to develop a cross-sectoral solution approach that can also be used beyond national borders 24/7 acute and emergency care and to implement the necessary changes in a practical, economical and as friction-free manner as possible.
The IGiB has thus once again proven that, with the joint responsibility of corporations and health insurance companies, new paths can be broken and needs-adequate structures can be successfully implemented not only in the conception but also in the implementation through jointly shouldered start-up financing. In order for this to be the case as a rule, there is a clear requirement for legislation: In order to test and establish new structures, it is imperative that the legal framework be created now. It is necessary to build “windows” for comprehensive care and financing models into the social codes V, X and XI, which enable health insurance companies, but also the federal and state governments, to participate in necessary investments and expenses7.
With regard to the topic of outpatient-sensitive services - i.e. hospital cases that could in principle be avoided through proactive outpatient treatment or could have been treated in an established doctor's office - health services research is expected to provide evidence that new, overarching Structures such as the on-call practice designed by the IGiB, as a start-up practice at the hospital, are not only better for patient care, but also more economical than the previous care in the rescue centers and therefore investments in such new structures are well invested. <<
by: Lutz O. Freiberg, IGiB GbR and Harald Möhlmann, AOK-Nordost