Selective contracts in special outpatient medical care in accordance with Section 73c SGB V offer health insurance companies the opportunity to get the costs of treating chronically ill patients under control and at the same time to score points with their insured persons with new offers in care management. The new contract options introduced in 2007 with the Statutory Health Insurance Competition Strengthening Act are still only very rarely exploited. However, that could soon change. Selective contracts, which were once despised – often from the perspective of medical representatives – are on the rise.
>> With the health fund and the morbidity-oriented risk structure equalization (mRSA), the challenge for health insurance companies has increased to align medical care more closely than before with the needs of those with chronic illnesses in particular. For example, there are corresponding indications for the six indications anchored in the Risk Structure Adjustment Ordinance (diabetes mellitus types I and II, coronary heart disease, chronic obstructive respiratory diseases, bronchial asthma and breast cancer).
− already standardized – disease management programs. But these are still not sufficiently targeted and work more according to the “watering can principle”. Nevertheless, they offer a basis for providing more optimized care to larger populations of chronically ill patients using structured treatment paths. Against the background of the health fund/mRSA, it is in the interest of the health insurance funds to target more specifically those chronically ill insured people with more specific offers, for whom significant savings can be achieved in the future through targeted care management. Selective contracts are ideal here.
Funds are still hesitant about selective contracts
So far, however, statutory health insurance companies have been rather cautious when it comes to such new contract structures. Since they have to pay at least part of the services of these special care management programs from their own resources in accordance with Section 73c SGB V (advance payment, for example for medical remuneration as an investment), an assessment of “costs” and “benefits” is essential before their implementation. The health insurance companies are faced with the challenge of developing prediction models that enable a reliable forecast of the development of expenditure for the defined chronic diseases in the future. At the same time, it is important to select the “right” insured persons. However, the available figures on the development of health insurance-specific morbidity are not considered valid enough by many health insurance companies.
Positive response to the KBV contract workshop's concept for selective contracts
But the statutory health insurance companies know that if costs are not to get further out of control in the coming years, expenses must be reduced with the help of innovative care programs. They are therefore increasingly open to selective contracts. This is also shown by the response to the concept for “quality-assured outpatient care for patients with heart failure” developed at the end of last year by the authorized workshop of the National Association of Statutory Health Insurance Physicians (KBV). Several statutory health insurance companies are currently working together, for example with medical associations or with the state statutory health insurance associations, to adopt this concept and even further develop it.
The focus is on the goal of precisely controlling insured people suffering from heart failure. The care program is to be offered to selected groups in addition to the disease management programs (DMP) that have already been introduced. Participation is voluntary. The concept is based on structured collaboration between general practitioners and specialists and focuses on treatment paths based on evidence-based guidelines. Further developments of the concept also include solutions for high-cost case management and the targeted use of telemonitoring.
Doctors who want to take part in this program must, among other things, care for a certain minimum number of heart failure patients and provide evidence of regular training. You will receive guidelines on drug therapy and the specific treatment steps. For example, if the doctor notices that a patient has gained weight by a certain percentage, he is obliged to refer him to the clinic. The practice may also receive targeted information from a telemedicine center.
The aim of the program is to improve the health of the insured, increase the quality of life and reduce the number of hospital admissions. At the same time, we strive to address patients intensively and personally. The doctors involved should take more time for the insured people taking part in the program and also foster greater exchanges with each other. Funds are currently considering expanding the concept to include sick pay case management. The goal: to enable chronically ill insured people suffering from heart failure to return to work quickly. For the first time, service providers should also be held responsible. The plans envisage particularly close cooperation between general practitioners and specialists. Specifically, this includes, for example, better appointment management or the quick exchange of treatment reports. Doctors should be relieved of the often high bureaucratic effort involved in caring for patients who are unable to work, but in return they should make suggestions to the health insurance companies for targeted support for the insured, for example with regard to the initiation of professional reintegration or medical rehabilitation.
Due to the multimorbidity of patients with heart disease and psychological suffering, the next step will be to expand the offer to include psychotherapeutic treatment. Here, too, the treatment paths should be structured based on evidence-based guidelines, inpatient admissions should be avoided and drug therapy should be optimized. In addition, it is planned to offer an online program to support certain groups of insured people. In addition to self-surveys, for example behavioral
contain tips or recommendations for taking medication. These groups are defined based on the routine data from the health insurance company and the assessment of further morbidity development using a prediction model by experts from the health insurance company and the contracted doctors and psychotherapists.
Understanding of each other has grown
Although there are still no final decisions from health insurance companies to introduce corresponding selective contracts, the interim conclusion is positive. The close collaboration between the health insurance company's specialists and the responsible doctors during the development of these concepts has already led to a significantly improved understanding on both sides. The newly created acceptance for the different perspectives of service providers and service providers promotes the development of patient pathways that both further structure and simplify medical care and ensure more sustainable economic care from the perspective of the health insurance company.
In the controversial discussion of collective versus selective agreements, health insurance companies and doctors are aiming to strengthen the collective agreement through an add-on solution in this project. It is not about replacing the collective agreement, but rather simply supplementing the free access to medical care provided for in the collective agreement. The selective approach is recommended here, as the aim is for long-term, loyal and close cooperation between those involved in the treatment paths.
Conclusion
Selective or direct contracts, together with optional tariffs and discount contracts, are among the most interesting competitive opportunities for a health insurance company. However, the health insurance companies are still far from exploiting the potential. This is especially true for the
§ 73c-SGB V contracts. They offer opportunities to differentiate yourself from competitors by optimizing the quality, transparency and cost-effectiveness of care. The key to success is the creation of win-win structures for everyone involved. The concept of the KBV contract workshop for “quality-assured outpatient care for patients with heart failure” described as an example in this article is an important step in this direction.
The cost dynamics in healthcare will not decrease in the coming years. Against the background of limited income from the health fund/mRSA, sustainable solutions in the sense of specialist medical care must be implemented as a supplement to collective agreements. Last but not least, selective contracts can also make an important contribution to better, close-to-home care for chronically ill insured people in underserved regions, for example through targeted telemedical support. <<
from:
Dirk Steffan
