>> In the reports from 2007 and 2009, the Advisory Council for the Assessment of Developments in the Health Care System (SVR) dealt in detail with the content of the so-called “special forms of care”. These forms of care include the structural contracts according to §73a, the model projects according to §§63-65, the family doctor-centered care according to §73b, the special outpatient care according to §73c, the integrated care according to §140a-d and the structured treatment programs according to §137f-g (all SGB V 1). In their transsectoral or controlling component, they are supplemented by the medical care centers according to §95, the practice clinics according to §115 and by pay for performance programs according to §136 Para. 4 SGB V and are characterized to a varying extent by features such as those found in Managed care programs, for example in the United States (for an overview see SVR special report 2009, No. 380) - in particular interdisciplinary and cross-sector orientation, special financial incentives and capitation. The model projects and the structured treatment programs also allow selective contracting: In the case of family doctor-centered care, special outpatient care and integrated care, selective contracting is also combined with a restriction of the insurance mandate of the Association of Statutory Health Insurance Physicians.
Since the GKV-WSG came into force, this increasing importance of the trans-sectoral perspective and competition between service providers has been linked to the mandate given to the Federal Joint Committee to supplement service provider-related quality assurance with a trans-sectoral approach (§137). In cooperation with the independent institution according to §137a, which has now been taken over by the AQUA Institute, “indicators that are coordinated across sectors as far as possible” are to be developed in order to be able to measure and present the “quality of care in all areas of care”. The corresponding G-BA guidelines are currently being voted on.
However, against the background of these important initiatives and developments, the authors would like to point out an urgent need for action that has emerged in recent months with regard to the increasing importance of selective contracts and population-based care. The new special forms of care, especially family doctor-centered care and special outpatient care, are not included in the quality assurance by the statutory health insurance associations according to §135a in conjunction with §137 SGB V. There is an obligation to comply with the personnel and material quality requirements regulated by the joint federal committee and in the federal framework contracts (§73c para. 1 sentence 3 and indirectly §140b para. 4 sentence 1) or to exceed them (§73b para. 2 ), but there is a complete lack of concrete guidelines on how to ensure the implementation of this requirement. In addition, contracts with reference to the population or insured persons, which are concluded either according to §73b, §73c or §140a, cannot be meaningfully described by service provider-related quality indicators with regard to their impact on the quality of care, since These sectoral indicators refer to the individual institutions and not to the overall care of an insured population (see SVR Report 2007, No. 501). Trans-sectoral indicators, which relate to the disease-related selective cross-sectoral collaboration of cooperating institutions, are also not a solution to the question of how the quality of care develops when insured populations are cared for by groups of service providers on the basis of a contact-independent flat rate (capitation) (see systematic review on managed care and quality of the SVR, special report 2009, No. 988 ff.), as is the case in relation to the sector in general practitioner contracts or in relation to the population in the integration contracts of the Kinzigtal type.
Of course, it should be noted that the primary approach aims to improve quality, be it through improving coordination in the sense of gatekeeping (family doctor contracts) or through shared financial responsibility for the most efficient cross-sector care possible (population-based integrated care). However, for contracts with a capitation approach, in which a prospective flat rate is paid for enrolled patients, no quality assurance is carried out that not only takes into account the perspective of the quality of the individual service providers but also the perspective of the quality of care for the insured or enrolled population , this is like flying blind with an uncertain outcome. It also seems difficult to understand if the collective agreement requires proof of quality assurance measures with a high level of regulation for the same service providers, but no further provisions beyond the basic obligation are made in the selective forms of contract.
The Advisory Council has carried out an extensive systematic review on this subject, which, on the basis of almost 11,000 references, has identified 107 controlled studies that describe the effects of population-based care with capitation (managed care) on the quality of care (SVR Sondergutachten 2009, No. 991 ff). Six studies were randomized studies, five studies had a quasi-experimental design, and the majority of the studies were comparative cohort studies. The studies were conducted in the USA between 1979 and 2007, with a peak in frequency in the second half of the 1990s, at a time when managed care in the USA was facing strong criticism. The results on quality were balanced: 18 studies showed a positive impact on quality, 17 studies showed negative results. The bottom line is that the risk of a negative impact of population-based capitation contracts on the quality of care cannot be dismissed, even if there are just as many studies that show positive effects. It should also be noted that the constellations as examined in the USA cannot simply be transferred to the conditions in Germany, but rather only provide information about the potential and dangers of certain care models. The heterogeneity of the results also suggests that the specific design of the care model is very important. Since this in turn depends on the institutional and legal framework conditions, with a view to the future viability and security of supply in Germany, it is necessary that the legislature exercise particular care here.
Against this background, it is essential to demand that adequate instruments be developed quickly that evaluate the development of population-based contracts with regard to their impact on the quality of care, especially since a scientific evaluation is only required for the model projects and the structured treatment programs. As a result, the question must also be discussed as to who - in coordination with the responsibility of the G-BA - should be responsible for quality assurance at the state level, be responsible for the “quality assurance of quality assurance” and possibly apply sensible remuneration incentives. What should be taken into account here are, in particular, selective contracts that revoke the security mandate of the statutory health insurance associations, small-scale contracts with their own legal status and contracts with a cross-state catchment area.
In this context, the timeline appears to be of crucial importance if spontaneous development is to be prevented from leading to noticeable losses in quality, which cast population-based contracts and sensible approaches that go hand in hand with an urgently needed improvement in cross-sector care in a bad light. We should be spared a discussion about the withholding of services, undercare and discrimination against chronic and multiple sufferers like in the USA in the 1990s. <<