Disease Management 2.0 & Morbi-RSA 1.0 – Medical Management for health insurance companies under the conditions of the Morbi-RSA

Disease management programs will take on new meaning with Morbi-RSA, introduced next year. The payers will focus on the medical management of the most important of the 106 defined hierarchical morbidity groups (HMG) that are suitable for this approach.

>> Basically, three different concepts have proven successful for actively managing the restoration of health or the use of services in the event of illness. The first approach, in the case of acute complaints, is demand management via medically trained call center agents. The aim of demand management is to guide the insured person to the right level of care at the right time. The second approach is disease management, also known in Germany as “structured treatment programs”. This concept is about better managing chronic diseases with a prevalence relevant to the healthcare system through coordinated and integrated supply chains. The third approach is "major" and "minor" case management. On the one hand, this involves managing patients who are viewed as so-called “catastrophic cases” in terms of their future course of illness, ie as complicated cases with a serious course and corresponding service expenditure. On the other hand, “minor” case management is used in many cases of illness where it is necessary to guide the patient through different intervention cascades.
All three concepts presented in abridged form have meanwhile become established in the German healthcare system. The DMPs were laid down by the legislature in the SGB V and linked to the risk-structure compensation. The private health insurance companies mostly offer the same DMP indications as in the GKV. More than 4.5 million patients are now treated in the statutory health insurance through DMP programs. Little is known about the quantification of the other two approaches. Due to the possible decoupling of the previous GKV DMPs from the risk-structure equalization, the funds are divided as to the continuation of the DMPs 1.0. The protagonists of the continuation are the Barmer and also the AOK. On the other hand, TC has long been rather critical of the DMP concept in its current form. An evaluation carried out a few years ago in cooperation with the IGES Institute (Häussler and Berger, 2004) clearly showed where the deficits of the German DMPs lie. In principle, no fund or insurance company has a stringent strategy as to how these instruments should be used to greater effect and in a way that is tailored to the respective health burden.
This will have to change with the introduction of the health fund and the morbidity-oriented risk-structure compensation in January 2009, because then the statutory health insurance funds will receive special surcharges for patients in 106 hierarchized morbidity groups (HMG), in addition to those based on age and gender oriented basic amounts, which are intended to compensate for the additional costs caused by illness. Whether insured persons then fall into an illness group relevant to the surcharge depends on the documented outpatient or inpatient diagnoses and on the specific medication prescriptions and their duration.
In the future, the GKV health insurance funds will, on the one hand, need to identify patients who fall under the Morbi-RSA criteria as quickly as possible in order to receive the disease-related compensation amount. As soon as the patients have been identified, i.e. diagnosed, it becomes important for the health insurance company to provide these patients with optimal and cost-effective care. This means that the illness-specific expenses should at most be as high as the compensatory amount. It is better for the fund if it manages to reduce costs below the compensation amount through concepts such as disease and/or case management, because then a financial reserve (surplus) is built up. According to medical experts, of the 106 Morbi-RSA diseases underlying HMGs, around 26 can actually be better managed through specific DMP concepts. So far, the health managers in the health insurance companies, but also the service providers in the DMP and CM sector, have not really recognized the full significance of this. However, this is where the next round of the competition will take place in the future.

Morbi-RSA 1.0: DMP approaches in the new
Morbi-RSA, patients and cost figures

The morbidity-oriented risk structure compensation to be introduced from January 1st, 2009 is based on 80+ diseases (BVA, 2008). These 80 diseases represent an expected additional cost of around 65 billion euros. The illnesses are divided into serious illnesses and chronic illnesses on the other. Disease management is primarily suitable for diseases that are chronic, can be influenced in the course of the disease and have a standardized course of treatment (guidelines and care maps). Based on these criteria, they apply to around 26 diseases in the new M-RSA. Experts estimate the total prevalence in statutory health insurance for the diseases covered by the new M-RSA to be more than 36 million patients. This increases the number of DMP-capable patients recorded in the RSA by around 75 %. Multiple registration due to multimorbidity has not yet been taken into account here. The situation will be similar for private health insurance companies. If they do not expand their DMPs to include additional indications, they will not be able to effectively slow the rise in service expenditures.

Deficits and optimization paths for German DMPs 1.0
For more than 5 years now, DMPs have been introduced in the statutory health insurance for various indications or illnesses in statutory health care. There are also DMPs for those insured with private health insurance, for sometimes different indications, with a different content program and without a link to the RSAV. According to the first evaluations, the situation is ambiguous (Häussler and Berger, 2004; Szecsenyi, 2007). Depending on the perspective of the payer, major successes or rather only small steps towards medical improvement are reported. In particular, the savings promised when the DMP programs were introduced have not yet been realised.
The reason for the lack of effectiveness of the GKV-DMPs is largely a completely missing or incorrect risk stratification of the included patients, caused by the wrong incentives from the RSAV. Only the complicated and severe cases initially benefit from the predominantly medically oriented DMP interventions and not the mild cases of illness, because the cost-benefit ratio is rather neutral to negative.
The structured medical treatment program is drastically reduced or limited in its impact on improving health if the DMP patient continues to smoke, only walks to the car (sedentary lifestyle) and his clothing size suggests a BMI value > 30. In their calculations based on the Federal Health Survey and using the Mellibase® program (Häussler and Berger, 2004), Häussler and Berger have shown that, especially in diabetes mellitus, optimal laboratory values at guideline level achieved under DMP programs only lead to moderate reductions in complications .
So it no longer seems disputed that the full effect of a disease management program can only unfold through the combination of doctor-centered, medical DMP and patient-centered BMP (also called bi-directional DMPs). The German Disease Management Society has also pointed this out several times in its statements. The scientific literature on this topic provides evidence of clearly additive to multiplicative effects. In view of the introduction of the Morbi-RSA, it is now necessary to rework the second generation of DMPs.
In order to make the programs more binding, two different approaches are possible, which can be summarized under the keyword "quality-oriented remuneration": the pay-for-performance and the risk-sharing approach. Both approaches have been piloted in the USA for a number of years and in some cases in the UK and the Netherlands.
Pay for Performance (P4P) means incentivizing process quality and in particular its optimization. Lighthouse projects in the USA are, for example (Institute of Medicine, 2001; O'Kane, 2007):
1. Bridges to Excellence (amalgamation of major employers, insurers, MCQA, MEDSTAT, WebMD Health): programs for diabetes, CHD, case management; Top 10% of the residents are published and receive bonuses from the payers involved;
2. IHA P4P initiative (various IHAs): Evaluation of service providers according to medical quality (50 %), patient satisfaction (40 %), IT (10 %). Medical quality as defined by the NCQA for diabetes, CHD, asthma, cancer screening, child vaccination) and
3. Medicare (hospital-based approach).

Risk sharing relates primarily to the quality of results achieved. This is about hard outcomes and no longer about more or less passable surrogate parameters. A risk sharing agreement for diabetes mellitus would then be about the achieved reduction/avoidance of blindness, amputations, heart attacks or strokes. Depending on the quality of the interventions or DMP programs, a prospective quota is agreed (Fig. 2).
If the quota is reached, the service providers involved receive a bonus (for example 20 % in additional remuneration). If the agreed quota is missed, a percentage penalty will be deducted. However, the medication in the GKV-DMPs mainly consists of standard generics, and with that you won't be able to achieve that much. A rethink is required here. Innovative drugs and new active ingredients belong in effective DMPs, but under the condition of risk sharing.
In addition, DMP patients should be more actively involved in the programs and the treatment chain in the future, for example through targeted bonus and less malus regulations. Only if the patient feels real incentives will he change his behavior in the long term.

Disease Management 2.0 in Holland, an attractive model for the German healthcare system?

Although the health situation in Germany cannot necessarily be compared in every detail with the Netherlands, there are some interesting developments in the area of disease management there that lend themselves to transfer to the German care landscape. The Dutch neighbors noticed three important things:
1. The quality of care does not match the expectations of the stakeholders because it is actually worse.
2. There is a lack of cooperation between doctors and other disciplines.
3. Furthermore, the actors in care are not willing to make the care process and the quality of care provided transparent.
Given this initial situation, the so-called “indication-based chain care programs” were developed in the Netherlands. A chain includes all of the professional providers who care for a specific patient. In the case of diabetes, it is usually the family doctor, the practice assistant, the internist, the diabetologist, the ophthalmologist, the podiatrist, the dietitian and the physiotherapist. But there are also chains in which the pharmacy, the laboratory and other service providers are integrated. The final and irreversible development in Holland is that the patient himself is becoming an active part of the supply chain.
To enable intensive and effective collaboration between providers and patients, specific multidisciplinary clinical software support is necessary. The software ensures the following requirements:
- The medical content of the multidisciplinary software is completely guideline-based. This ensures that everyone involved treats correctly, i.e. according to the best standards, proceeds in an evidence-based manner and delivers high-quality care.
- The cooperating providers all work together in a shared electronic patient record. The individual provider acting in each case is informed about the entire treatment process, he knows all the data and findings that are relevant for the specific patient.
- Cooperation based on data transparency, quality and benchmarking leads to better results and, as a kind of side effect, usually also to better cooperation conditions.
If the patient is actively involved in the chain, then it gets even more exciting because the patient has access to their own data and thus the possibility to check the "quality" of their provider.
Because all those involved work in a common electronic dossier, a transversal and longitudinal database is being set up. This can then be used to evaluate the quality of care provided, the resulting health effects, patient behavior and many other relevant issues.
The newly created transparency makes it possible for cost bearers and service providers to flank the quality, the processes and also the results with innovative remuneration models.
The necessary multidisciplinary disease management software has been successfully developed in the Netherlands. At the same time, accompanying implementation processes were developed and professionalized. VitalHealth Software and Diagnosis4Health are the market leaders in the Netherlands for the development and implementation of this multidisciplinary software. Although VitalHealth is a Dutch company, VitalHealth Software is also a subsidiary of the American Mayo Clinic in the USA. With more than ten years of experience, Diagnosis4Health is fully focused on the implementation of new care processes in clinical practice. For many years, Diagnosis4Health has been using specially trained medical assistants and nurses as well as suitable nursing staff during implementation. They either work directly in the doctor's office or reach the patients assigned to them via telephone (call center approach). The most important element of the software supporting the DMPs is to ensure that the relevant guidelines are followed closely.
The Dutch guidelines say that a COPD/asthma patient should be seen by the doctor every 6 months after diagnosis and that during these visits certain medical areas should be queried or examined. Blood pressure, pulse rate and signs of heart failure (“Vitals”, orange) must be checked at every opportunity. It should also be checked whether there have been signs of worsening of the disease in the past period, what the diet and muscle strength are like (red). Spirometry is only performed once a year. Of course, the software also allows all necessary examinations to be carried out in between and in isolation. But in any case it is ensured that the minimum necessary is carried out at the right time.
In a stable patient, monitoring can usually be carried out routinely because the software ensures exactly what is to be queried and examined, detects abnormal findings and reports directly to the software users. In this way it is quite possible to delegate routine activities, for example to a physician's assistant. The doctor is only consulted if there are findings that require the doctor's direct involvement. The patient also becomes an integral part of the supply chain, with different communication technologies available such as the computer, the television, the cell phone and other special devices (Fig. 2).
Figure 2 shows an electronic medication schedule that helps the patient see which tablet or inhaler puffs they should take or use at what time. The patient can be asked when he actually took the medication. This interactive dialogue can be used to promote compliance and also measure it at the same time.
Figure 3 makes it clear whether the healthcare partners have carried out certain checks in accordance with the guidelines. The traffic light used illustrates the situation: red means that an inspection has not been carried out within the deadlines specified by the guidelines, orange means that an inspection is due soon, green means that everything has been done within the prescribed deadlines. If a patient participates and carries out certain checks themselves or measures performance or laboratory parameters, then what the patient's performance looks like becomes visible. This transparency makes it possible for all those involved to address each other about their respective competences, responsibilities and shortcomings (Fig. 3).
In the future, disease management will focus primarily on patients with multiple illnesses, as this is much more in line with today's reality of care. People with diabetes often have CHD at the same time. The COPD patient gets his rheumatism as he gets older. What will be important here will be to meaningfully network the individual indication-related DM programs with interfaces and via algorithms and data integration. The development department of VitalHealth/D4H is dedicated to these aspects with great commitment. Today's range of DMPs and BMPs on offer goes far beyond that of German providers. The Dutch company has recognized the opportunities in the DMP sector in Germany with the introduction of the Morbi-RSA and will align its future development strategy accordingly.
In Germany, doctors' networks or IV models according to § 140 SGB V could use this software to really credibly document that they deliver a better quality of care. In particular, population-based IV models such as the AOK Baden-Württemberg model project - “Healthy Kinzigtal” - could come a lot closer to the goals we have set ourselves through such an integral approach: the active management of the health of the entire collective. Private health insurance companies, on the other hand, could tie certain innovative tariffs or better reimbursement modalities to the use of the software. The tentative attempts by private health insurance companies to establish PPO models in Germany with parameters that are of little medical relevance could also achieve a different quality dimension through the mandatory use of the software and the professional involvement of non-medical professionals. Thanks to the software's reports and benchmarking reports, the private health insurance companies would finally know what rate of increase they should pay for which quality of care.

Summary and conclusions
The Dutch example shows how care can actually be improved with comprehensive software support, the use of non-medical professionals at different levels of the supply chain and the integration of everyone involved in the supply chain - including the patient. Indeed, this threefold approach appears to be the critical success factor for effective disease management. In addition, disease management programs in the future must be designed to be multi-disease capable instead of just focusing on singular indications.
Under the new framework conditions of Morbi-RSA, a great need for such new, multi-disease-capable DMPs is expected. The providers are called upon to develop novel programs and concepts for the diseases of Morbi-RSA. The payers should accompany these new programs with innovative remuneration concepts such as pay for performance or risk sharing. <<