The current decisions on health policy also affect family doctor-centered care (HZV). The GKV Financing Act provides for grandfathering of contracts that have already been concluded until the end of June 2014 (“Ärzte Zeitung” 2010). However, strict legal requirements apply to contracts that were concluded after the statutory deadline: Proof of economic viability must be provided “ex ante” for additional expenditure compared to the standard supply. In particular, the health insurance companies that adhered to the legal obligation to introduce the HZV and concluded contracts early on pay higher fees to the participating doctors.
> Funds that do not have to charge an additional contribution achieve significant membership additions from health insurance companies with additional contributions (dfg 2010). In the “competition to avoid additional contributions”, it is therefore economical in the short term for health insurance funds to strictly reduce all expenses (Laschet 2010). It is not just integrated care (IV) contracts that fall victim to this (Osterloh/Rieser 2010; Hommel 2010). Investments in other selective contracts, including family doctor-centered care (HZV), have also largely come to a standstill (ÄrzteZeitung 2010).
Even health insurance companies that have “voluntarily” implemented the legal obligation to introduce the HZV across the board since June 30, 2009, have to rethink their care strategy in view of the competitive disadvantages that arise compared to health insurance companies that have not yet complied with the law without being sanctioned (Stoschek 2010; Beneker 2010 ). Additional costs of the HZV arise from the medical remuneration (unconfirmed sources assume 19 euros per insured person per quarter (Glatzl 2010)) as well as from the additional program costs, which are comparable to the effort of the disease management programs (55 euros when introduced, currently 36 euros per year of insured participation (GKV-Spitzenverband 2010). Given the lack of financial sanctions for disregarding Section 73b SGB V for more than a year, the consistent prevention of the HZV is a cost-cutting strategy relevant to competition.
The supplementary, comprehensive specialist medical care programs are particularly affected by the savings constraints of the health insurance companies: contracts that are intended to reduce downstream and induced costs through coordinated medical care in the outpatient sector. Not only is this endangering the economic viability of selective contract care, but the professional situation between general practitioners and specialists is also becoming more critical. Is this the supply competition that the legislature wants?
Politics calls for “more competition, transparency and less bureaucracy”
The selective contracts were introduced as a competitive instrument (including the GKV Health Reform 2000, the GKV Modernization Act 2004; the GKV Competition Strengthening Act 2007 and the GKV Financing Act 2009). Transparency, health care research and management also have a high priority for the current government (MVF 2010). The current §73b SGB V should rightly be assessed critically. The fact that its implementation requires more than 1,800 arbitration proceedings does not really represent a contribution to reducing bureaucracy. But the implementation of the HZV is also accompanied by bureaucratic hurdles. All health insurance companies must agree annually with the responsible association of statutory health insurance physicians to adjust the total remuneration. The billing management of health insurance companies faces new challenges due to the possibility of double billing of medical services (selective contract vs. standard care) (Kriedel 2010; Graf 2009).
For all participating insured persons in selective contracts, multi-page declarations of participation must be obtained that explain data protection and other contract-specific implications. An insured person who takes part in the DMP (CHD and diabetes mellitus), is enrolled in the HZV, would like to take advantage of special specialist medical care from a diabetologist (in the future, possibly other specialist groups) and at the same time use the advantages of the “diabetic foot” IV contract , will rightly be surprised at the high bureaucratic barriers to entry.
The success of the new forms of care and quality efforts achieved in Germany has received international attention (Miksch et al. 2010). The disease management programs (DMP) are established across the board and have a positive influence on care (see also results of the ELSID study at Heidelberg University Hospital; Miksch et al. 2010; Szecsenyi et al. 2008; Schäfer et al. 2010). The use of the extensive routine data available in Germany offers extensive opportunities for applied health care research and targeted care management (Perleth/Hess 2010). Together with the need to prove the economic viability of selective contracts (Section 53 Paragraph 9 SGB V in conjunction with Section 53 Paragraph 3 SGB V) and the effectiveness of medical interventions (Sections 91 Paragraph 3 and 92 Paragraph 1 SGB V in conjunction with Section 2 Paragraph 5 SGB V), routine data in connection with clinical studies will become more important (Mansky et al. 2009).
The efforts of service providers and health insurance companies to bring transparency to the quality of care, as well as the willingness to provide quality-adjusted care, are also increasing (see, for example, www.qualitaetskliniken.de, Rhein-Ruhr Clinic Guide, Weisse Liste, Initiative Quality Medicine (IQM), Project “Quality assurance of inpatient care with routine data” (QSR) as a joint research project of the AOK Federal Association, HELIOS Kliniken GmbH, WIdO and the Research and Development Institute for Social and Health Care Saxony-Anhalt (FEISA).
How can more competition and transparency be created, but less bureaucracy?
In order to create incentives for the reduction in health costs that can only be achieved in the medium term, it is essential to plan the program costs of selective contracts for health insurance companies in the “competition to avoid additional contributions”. Existing structural competitive disadvantages and those resulting from legal changes should be eliminated so that health insurance companies can compete fairly for better care. In addition, other competitive or bureaucratic hurdles must be consistently reduced for effective and efficient supply management. How can this happen?
Proof of economic viability according to a uniform system for supervision
In future, the obligation to prove the economic viability of existing and future selective contracts should be carried out using a single standardized procedure and monitored by the responsible supervisory authorities. The evaluation should be carried out in the same way at the level of the insured person for the various types of selective contractual interventions (including DMP) using all available routine data. It should be considered that the evaluation is carried out, at least temporarily, exclusively by approved institutions, as the required expertise is currently not available to the necessary extent either from health insurance companies or from service providers.
Introduce a supply management program (VMP) flat rate analogous to the DMP flat rate
Funds with selective contracts that have provided proof of profitability ex ante or have to provide proof of profitability ex post for DMP and HZV existing contracts receive an allocation of a care management program (VMP) flat rate per year of participation from the health fund to compensate for the additional financial burden . Similar to the previous DMP flat rate, the VMP flat rate reduces the funds that can be distributed via the fund. Like the DMP flat rate, the VMP flat rate consists of a flat rate for program costs and an allocation for payments to the service providers. The VMP flat rate is paid per year of participation by the insured person and applies to participation in at least one contract for which proof of economic viability (see above) must be provided. If the insured person takes part in several selective contracts, this does not lead to a higher allocation of the VMP flat rate. In the annual calculation of the amount of the VMP flat rate, however, the selective contractual additional costs for all contract forms that must provide the above-mentioned proof of economic viability ex post or ex ante should be taken into account for each insured person. In order to prevent “cannibalization” of the fund allocation by the VMP flat rate, the allocation share can be limited to a defined amount (e.g. 3% of the health fund allocation).
Enable continuous improvement
A uniform methodology for considering profitability also makes it possible to efficiently provide monthly evaluations for controlling by the contractual partners. Only the quality indicator-based, objectified view of the quality of care makes it possible to constructively address the achievement of the objectives of the contract content (Petersen et al. 2006; Schütte/Homscheid 2010; Geß et al. 2008; Diel 2009; ÄrzteZeitung 2009). The use of all available routine data for the purpose of selective contractual control should be clearly permitted under data protection law.
Do not exclude any contractual partners, lower access barriers and regulate data protection
Real competition is only possible under equal market conditions (Wöhe 2005). Both the statutory health insurance associations, which have established contractual partner relationships and administrative processes, as well as the financially strong companies in the pharmaceutical industry, medical technology and other industries can make valuable contributions to innovation in selective contracts.
The essential contents of all declarations of participation for selective contracts are identical in terms of their technical requirements. In the future, it should therefore be possible to effectively obtain consent for all selective contracts to which the tariff applies - after a documented, detailed explanatory discussion - through the declaration of participation in a selective care tariff in accordance with §53 (3) SGB V. The insured person should be free to choose whether they want to fill out this declaration of participation at their local doctor or in conversation with a health insurance customer advisor. This reduces bureaucratic effort, relieves the burden on the doctor-patient conversation and promotes discussion of the insured person's first declaration of participation.
When implementing the HZV contracts, data protection issues are at the center of the political debate (ÄrzteZeitung 2010). Compliance with data protection is a “condition sine qua non” for a responsible health insurance company. However, the fact that the data protection requirements for the implementation of the HZV have not yet been created nationwide leads, in addition to the above-mentioned financial competitive disadvantage, to damage to the image of the “law-abiding” health insurance companies. How should it be made plausible to an insured person and the press that although the HZV has been legally required with the contractual partners for 15 months, the postponement of real operations is still necessary due to unresolved data protection issues with regard to these contractual partners? If it is to be possible to provide care more efficiently and effectively with selective contract offers, trust in this care must not be shaken. Clarity in data protection law and low-bureaucratic processes are the basic requirements of the insured persons that must be met.
Political scope remains
If the legislature wishes to conclude additional family doctor contracts and supplementary selective contracts or relevant enrollments of insured persons in selective contracts/selected care tariffs in accordance with Section 53 (3) SGB V, the VMP flat rate should be set higher (in order to trigger a corresponding incentive). The DMP flat rate is currently 180 euros, and in the future it will be 168 euros per year of participation by the insured person (Pfeiffer 2010). Depending on the political objective, a single VMP flat rate could be set between the actual proven additional costs of all selective contracts and the current DMP flat rate. Since the “advance deduction” of the care management flat rate will proportionately undercover the health fund for other services, no health insurance company can avoid the additional contribution in the medium term without participating in the care competition. The legislator's intention to promote supply competition and efficient structures would have been transformed into a strong incentive for innovation with a single change to the law. <<
from:
Dr. med. Dr. sports science Heinz Giesen, MBA, Dr. med. Karl Liese, MBA
