The Pharmaceutical Journal
Vol 266 No 7132 p122
Germany recently introduced health care reoforms with a view to broadening the current health care system. One of the main areas of change was the development of integated care. Sonia Sanghani reports on progress
On January 1, 2000, the German health minister, Andrea Fischer, introduced health reforms. These emphasise patient- focused care, innovation and modernisation of health care, and increasing quality assurance and transparency. The main concerns are threefold:
- Broadening of the current health care system
- Developing demographics of the population
Historically, Germany?s cost-containment policies have tended to be primarily price-containment policies. Previous reforms over the past 20 years have introduced some element of market economics, but in the main, state regulation is the norm. In order to broaden the current health care system the main areas of change include:
- Introduction of a co-ordinating GP
- Referring patients to relevant services
- Reducing ?doctor shopping? and double investigations
- Integrated care networks
The changing demographics of the German population and high unemployment rates, especially since the reunification, are the main reasons for the reforms. Around 22 per cent of the German population is presently over 65 years old. In the next 40 years, this level is expected to rise to 35 per cent of the population, with the average age increasing, leading to more demands on the health care system. Germany still has a relatively low birth rate and the proportion of the population in work is decreasing. The unemployed are not in a position to pay insurance contributions but still require health treatment.
Through integrated care, the German government aims to offer users of the state health insurance schemes better quality of care and increasing competition between the different health schemes, thereby leading to better efficiency.
Integrated care role
The aim is to co-ordinate ambulatory (generalist) and hospital (specialist) care and eventually to take up responsibility for budgets, costs and performance analysis, as well as undertaking risk calculations. The emphasis is on local level, decentralised decision making.
All professional groups, besides pharmacists, can participate in such groups. Patients can choose whether they want to be treated by the new groups and are informed in detail of group members and services provided.
Why are pharmacists not involved?
The Hartmannbund (German Medical Association) feels that pharmacists are not involved probably because pharmaceutical prices are not subject to negotiation.
In the first pilot schemes, pharmacists were not included even though drug costs played a role in some models. The pharmaceutical industry has agreed to health economic evaluations of its products but the pharmacy profession as a whole wishes to retain the status quo regarding the medicines laws and the pharmacy laws and has been called inflexible and resistant to change by the insurance agencies.
Current activity spread
There are no such groups working to date, only pilot schemes set up since the mid-1990s by the health insurance schemes. These include a diabetes group, general practice (physician) networks, Hippokrates (a group looking at treating patients in community rather than hospital), a medical quality group (MQR), as well as groups for homoeopathy, acupuncture, natural remedies, and rehabilitation of chronically ill patients using complementary therapies, among others.
These first generation models of innovative care are based on the United States managed care and decentralised health care structures.
There are currently around 300 to 400 informal physician practice networks in Germany but only 20 to 30 have managed to come to a contractual agreement with the insurance companies, partly because of poor, untrained advisers. In view of this, the German pharmacists and physicians will, together with doctors? associations, found a new ?network academy?, where students will be taught law, ethics, economics, and consultancy. A curriculum is currently under development.
Communication issues and decision making
A scientific investigation conducted by the Institute for Social and Communication Research in Munich has stated that ?increased income potential is marginal, workload reduction is minimal, and the economic effects have yet be proved?. The lack of a common fundamental goal within the network results in failure. Arguments centre around organisational problems, eg, technology links, and then progress to quality of patient care. The networks hardly profit from the attained savings.
One such practice network in Nuremberg-North is currently, during a five-year pilot scheme, attempting to integrate 140 community-based specialists with the local hospital. Important stepping stones for co-operation within the network and hospital are seen as:
- A co-ordinating doctor
- A patient passport/documentation card, in the possession of the patient, where the health status is documented
- Guidelines/recommendations for treatment of certain chronic conditions
- Standardised communication lines and documentation between the hospitals and doctors before, during and after a hospital admission
- Quality circles
In this pilot scheme, doctors were unable to assume budget responsibilities because of a lack of important information and data.
One insurance company?s experience with practice networks in Hessen has shown that the amount of work in the start-up phase is often underestimated. It is a long road from the idea of a practice network to realisation of integrated care, and a big paradigm shift is required along the way.
For and against integrated care
An example of a successful medical practice network, known as MQR, is to be found in Schleswig-Holstein. It has been concentrating on asthma treatment and patient education. Around 250 doctors participate but this number is expected to rise to over 300. The aim of the group is to ensure that doctors have a solid position in a competent health system and higher remuneration is more a long-term rather than immediate goal. The main reason doctors join is job satisfaction and intensified training options.
The health insurance companies have signalled quite clearly that they want more influence in doctors? working practices. Some doctors feel that networks will be the end of professional freedom and a step further towards rationed care and are distrustful of this new way of working. From experience, even the doctors within networks could be roughly split into one-third activists, one-third proactive supporters and the rest as resigned hangers-on.
A study conducted in Munich using the Delphi technique showed that doctors? motives were varied and the clearer the goals of each player, the stronger the conflict between the different interested parties. Many thought that they could change something without having to change themselves. The myth was to join a few practices together, delegate unwanted tasks to the network and carry on working as before.
Networks with more than 100 doctors have more power but in practice they are difficult to lead. Those with 20 to 30 doctors are easier to lead but are too small to have any power to achieve much change.
The first networks before the January, 2000, reforms received funding from the sickness funds for infrastructure, office establishment, etc. Subsequent groups received no assistance. The experiences of such networks were reported at the 10th International Congress of Group Medicine, organised by Hartmannbund and NAV Virchow-Bund in 1997 in Cologne. Attending doctors were of the opinion that none of these activities was anything special and that they belonged to ordinary, good health care. There is no real evidence yet that these networks produce better medical or economic results.
Following the reforms, the new groups can negotiate budgets, together with the assistance of the doctors? negotiating committee (Kassen?rztliche Vereinigung), to cover other sectors, eg, hospital care or pharmaceutical products, based upon existing figures. There is no economic advantage for the participating doctors. The only advantage is through direct negotiations, thereby gaining influence, especially in the hospital sector.
Some are calling for a change in the remuneration system towards a more performance/results oriented payment. This outcomes-oriented, group application approach should ensure that the networks will be rewarded more, the closer they work together, and it is thought that certain disease states lend themselves quite nicely to this methodology. A certain profit orientation is necessary and politicians are being urged to alter physicians? remuneration to ensure that integrated care is sustainable.
Barriers to progress
The Hartmannbund thinks it is difficult to break doctors? solidarity. The health insurers can ?buy? medical groups and negotiate contracts outside the regional contracts which can, and probably will, divide doctors as well as patients. It says: ?We think communication, co-ordination of care, and co-operation are essentials of good medical care and should not be burdened with extra administrative tasks. Electronic networks under construction will help more than the budget holding of doctors or pharmacists.?
The Hartmannbund feels that ?budgets are not really adequate for medical care?. They are ?too small and they lead to rationing. In Germany, the first signs of rationing are occurring as drug costs weigh heavily on a doctor?s budget.?
One insurance company is now experimenting with the second generation of care models and recognises that although it is necessary to include other health care providers, it will be a great challenge in practice to integrate these into the primary care physician models. All service providers should remember that the patient must be central focus for all their activities.
The pharmacist?s role in this new form of health care provision?
At the pharmacy conference in Cologne in September, 2000, Hans Guenter Friese, president of the ABDA (German Pharmaceutical Association) made it quite clear to the health minister that the original paradigms of the doctor having responsibility for diagnosis and therapeutic safety, the pharmaceutical industry for product safety and the pharmacist for safety of usage by the general public should remain unchanged. Pharmacists agreed with improving co- operation between health service providers, with drug therapy being recognised as a necessary part of integrated care. However, this should only take place within the current legal framework and most importantly the freedom of the patient to use the pharmacy of their choice should not be restricted. Health insurance companies and hospitals are experimenting with the drug regulations and he warned against this, as it would lead to an Americanisation (capitalism) of the system, ie, it would be profit/competition oriented, and there would be price cutting, hospital closures, unemployed doctors and restricted distribution of pharmacies. Cost-containment should not dominate quality control, and co-operation and co-ordination should not necessarily be labelled a ?network? as this could be open to misinterpretation and fraudulent use. Having two parallel systems, ie, integrated care for some and normal care for others, was inefficient. Better co-ordination for all should be the goal, with drug therapy optimisation, and close co-operation with patient and doctor through pharmaceutical care, rather than budgets to control performance. He presented the minister with her ready-to-use patient data card which could be used for electronic prescriptions and as a medication profile passport for over-the-counter and prescribed medicines and requested her assistance in arranging the legal framework for its use in telemedicine. Ending his presentation, he stated: ?We want our pharmaceutical knowledge to be of use to others. That is the integration that we need.?
In support, Dr Frank Diener, of the ABDA?s social/economics department, stated that by the end of 2001 there should be available a ?health professional card? to ensure confidential communication streams between doctors, pharmacists and health insurance companies via the internet. Also, data from prescription pricing bureaux should be available much quicker in order to assist in prescription analysis. He also suggested setting up locally based drug committees where pharmacists and doctors could assess therapeutic quality and economic options, supported by therapy manuals provided by the ABDA. A framework contract between doctors, complementary therapists and pharmacists should state each profession?s role within this collaborative work with clearly defined borders. More co-ordinated out-of-hours services was another aspect of collaboration on offer.
Instead of individually selling their services to the health insurance companies, Dr Sebastian Schmidt, of the ABDA?s legal department, urged pharmacists to offer services collectively without singly taking part in the current models of integrated care. What was important was to prevent an insurance company finalising a contract with a single pharmacy and thereby cutting other pharmacies out of the picture. Free pharmacy choice for the consumer should remain the highest priority.
I thank Mrs Regine Kleinert, (AOK Bundesverband), Mrs Merte Bosch (Hartmannbund, German Medical Association) and Mrs Christina Claussen (economics and social politics department, ABDA, and Federation of German Pharmacists) for their assistance with this article.
Sonia Sanghanu is a pharmacist in Britain and an apothekerin in Germany, where she lives