Primary Care Revolution in Gemany_Mehl

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    - Eberhard Mehl -1

    Health is our profession

    Eberhard Mehl

    - CEO -

    Organizing the revolution

    in primary care in GermanyFirst US-German summit on primary care

    Thursday, April 8, 2010

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    Underlying situation

    - Mid 90ies:

    Beginning of shortage in family physicians- However:

    Joint self-administration took the wrong decision:

    Revenues in favor of medical specialists instead offavoring family physicians!

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    Thats our family physician catch your own one!

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    Underlying situation

    The legislator intends to help:

    - First measure: Another 600 Mio. Euro of subvention- Second measure: Legally insured additional revenue

    share for family physicians

    - Third measure: Individual reimbursementcontracts should be negotiateda) Failed due to lacking

    support of health funds

    b) Accordingly, obligation wasdetermined

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    Legislator interferes by:

    - Enforcing the role of family physicians,

    - Aiming at creating a real improvement of the out-patients

    in making the doctor the first contact person for all healthrelated problems,

    - Imposing an obligation on the insured members to

    voluntarily consult their family doctor in the first placebefore consulting a medical specialist.

    Underlying situation

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    Underlying situation

    The traditional reimbursement regulation forambulatory services (literally standard ratingmeasure) contains many disastrous problems:

    - limitation of services (budgets)

    - All services are rated according to a complex andintransparent system of points- Value of these points is variable (floating points)

    Lacking acceptance from the point of view of patientsand doctors

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    Underlying situation

    Logical consequence:

    Creation of an own profession-related reimbursementsystem!

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    Reimbursementflat-fee System

    The Payment Model

    Base payment of 65 p.a. (approx. $90) for every insured

    person, independent of service/contact

    If one or more visits occur, payment of 40

    per 3 months period (approx. $55) covers all

    further visits and services

    Additional payment for chronic patientsof 30 approx. $42 per 3-month period

    for all visits/services

    Additional payments for special services:i.e. ultrasound, minor surgery,

    psychosomatics up to 8 p.y. per patient

    Result oriented gratifications:

    i.e. for effectively and efficient

    medication prescription up to 4 p.a. per

    patient

    Base paymentfor every

    insured person

    whether healthy

    or sick

    Additional payment

    covers all services

    for 3-month period

    Further payment forchronic patients incl. any

    visits or services

    Payments for being able

    to provide special

    services and outcome-

    related incentive

    payments

    Average House

    Doctors Income,

    $1,000 patients:

    $90,000

    On average:

    2,5 contacts p.a.

    $ 120.000

    On average: 30%

    $ 50.000

    up to $ 40.000,00

    Total gross income: $260.000 - $300.000

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    health funds

    negotiating contractsAccording to the obligation to conclude familydoctors contracts, health funds start negotiatingwith Hausrzteverband:

    About 50.000 family physicians in Germany(nearly 35.000 are members of Hausrzteverband)

    Hausrzteverband develops from traditional

    professional association to a player in health care In 2004 Hausrzteverband establishes its own

    management company HVG

    The contract volume, managed by HVG, is about1 billion , tendency rising!

    Currently, about 10.000 - 40.000 family physicians areparticipating in family doctors contracts (depending oncontract structure), tendency rising!

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    Contents of contract

    basic structure

    Uniform structure of reimbursement system:

    Contract covering complete treatment, Contact-independent flat-fee,

    Service/contact-dependent flat-fee,

    Few single treatments, No limitation of treatment.

    Individual creation of reimbursement elements

    (i.e. home-visits, prevention, single treatments etc.) Uniform administrative procedure

    (immatriculation, basic data, billing, data structure)

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    Contents of contract

    quality

    Particular presuppositions of participation:

    - Provision of basic technical equipment,- Participation in disease-management-programs,- Economical prescription of medication.

    Quality-oriented reimbursement structure/particular (economical) aims

    Outstanding focus on chronically ill patients

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    Contents of contract

    contract participation duties

    Participation in structured quality circles of medication

    therapy, Treatment according to evidence-based guidelines,

    Fulfilment of obligatory further training,

    Compulsory particular quality management for familyphysicians.

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    Contents of contractefficiency

    Contact-independent flat-fee combined with quality-

    related incentives, Contact-dependent flat-fee for actual

    treatment/service,

    Special reimbursement for the chronically ill treatment, Supplementary reimbursement when fulfilling quality &

    particular criteria,

    Particular, compulsory software for contracts.

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    Contents of contractcontinuity

    Long terms of contracts,

    Adequate mechanism of solution to conflicts,

    Creation of a new and adequate reimbursementstructure,

    Economic efficiency and quality in a permanentprocess of organizing,

    Evaluation of effects aiming at proof of ameliorationof treatment along with simultaneous economicefficiency.

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    Contents of contract

    advantagesFor out-patients:

    More time for service by means of less

    bureaucratic procedures and reducedadministrative efforts,

    Reimbursement structure furthers treatment ofchronically ill,

    Need in coordination in case of multimorbidityand therapy will be enforced, avoids poly-pharmacy and improves quality of therapy,

    Combined contracts with medical specialistsimproves cooperation at a new level.

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    Contents of contract

    advantagesFor family physicians:

    Concentration to original primary care, Reimbursement of core services of

    family physicians,

    Calculability of reimbursement, No limitation of services,

    The attractiveness of the profession

    increases and guarantees the primarycare in times of rising chronical diseases.

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    Contents of contractadvantages

    For health funds:

    Calculability and transparency of reimbursementstructure,

    Possibility of actual cost-efficiency management,

    Possibility of provision of efficiency-resources,i.e. economic medication therapy.

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    Contracts of primary care

    realization in Germany

    6810

    1112

    1110

    11

    11

    1111

    11

    1111

    11

    11

    60 102

    The south:Establishment almostcompleted

    Central-Germany:Establishment probably

    completed until end of April

    Lower Saxony:Add-on contracts andcontracts coveringcomplete treatments arecompetitive

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    Steps to realize

    future contractsFuture prospects:

    Current arbitral procedures (probably fully completed untilend of April),

    Recent hesitations on the side of health fundsare vanishing,

    From the middle of the year onwards: Starting contractsranging all over Germany.

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    Realization

    future contractsSample contracts in Germany:

    For the family physicians practical number ofdifferent contracts,

    Participating family physicians remain panel-doctors,

    Free choice of family physicians guaranteed:Patients immatriculate voluntarily into contract,

    Start of real competitiveness in health care,

    Creation of a new health-care service systemincluding high quality combining medical specialists.

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    Key targets

    Aims of the contract structure:

    Doctors need their whole concentration tosolve patients problems,

    Doctors need more time for compulsory medical

    further training instead of administration, Doctors have to be paid adequately,

    Young doctors must be guaranteed a professional

    perspective!

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    Thank you foryour attention!


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