CURRENT ISSUES

--------------------------------------------------------------------------UK & Gennany: European leaders in disease management implementation?

-Robert Short-

'J"lte UK and Germany appear to be in a better position than other European countries to begin ~ implementing disease management strategies, according to Merilyn Penn, a research

consultant with Promar International. Ms Penn provided evidence in support of this view at an I1R Ltd meeting on disease management in Europe [London, UK; December 1995].

A country's suitability to the implementation of disease management strategies is a reflection of the degree of interest and the influence of the key health­care players in the country. Such players include phanna­ceutical companies, payers, healthcare providers and regulatory authorities.

'For example, if the national government is not in favour, or if doctors' support cannot be counted on, then attempts to introduce disease management are unlikely to succeed' , said Ms Penn. Conversely, the countries that are likely to lead the introduction of disease manage­ment systems into Europe are those in which the key players are already proactive in establishing healthcare structures that can facilitate this new approach. Ms Penn reviewed the current healthcare systems of 5 European countries, with a view to establishing their suitability to disease management strategies.

Many advantages in the UK In the UK, a large number of general practitioners

(GPs) are responsible for their own budgets (fund­holding GPs) and many hospitals are autonomous (trust hospitals). Thus, there is considerable financial incentive to invest in long-term healthcare manage­ment and to provide value for money.

Communication between primary and secondary care structures is set to improve with the development of Health Commissions this year. These commissions have been devised to help to reduce the layers of administration that exist within the health service.

Furthermore, computerisation of activities in GP surgeries has been achieved to a greater extent in the UK than anywhere else in Europe, said Ms Penn. Computer­isation facilitates better information management. In the UK, some fundholding GPs have a budget allocated towards the improvement of information management systems.

Audit a positive feature Another positive feature of UK healthcare is the

emphasis on audit and the GPs' role in disease prevention. GPs' pay is often related to how much is provided to patients in the way of screening, 'wellness clinics' or vaccination programmes for children. Thus, incentives for disease prevention are already in place, and certain aspects of the disease management process. e.g. consumer education and screening, can be performed with relative ease. The presence of private players within the healthcare sector provides an extra force to encourage disease management implementation.

However, an obstacle to the implementation of disease management exists in the form of the EL (94)94 directive. This is a letter sent out by the National Health Service (NHS) executive to organisations within the NHS. such as Health Commissions, trust hospitals. etc.

1173-5503/96IIlO48-01.ocF Aclle Im.m.tJonel UmltM 11M. All rlghte ~

It stipulates that discussion of managed-care issues can take place with suppliers, but that no decisions are to be taken at this stage. 'This is basically telling local providers not to negotiale specific contracts with pharmaceutical companies' , said Ms Penn.

Clearly, the government is trying to avoid situations in which pharmaceutical companies expect loyalty to their products from NHS organisations. as a result of joint schemes involving information collection on disease management The government wants to consider the optimal national strategy on purchasing and managed care before local agreements are set up that could undermine such a structure, she added.

The NHS executive is expected to state their position in the next couple of months. Meanwhile, EL (94)94 is valid until June this year - its successor is expected to be less cautious.

Looking good in Gennany The Krankenkassen, which is the government­

sponsored health insurer in Germany, is a very important player in this country's healthcare system. The opinions of this body will undoubtedly influence the acceptance of disease management strategies.

This year. competition against the Krankenkassen is being introduced. This is likely to spur the Krankenkassen into a phase of more careful monitoring of costs and treatments, said Ms Penn.

As in the UK, GPs already have some financial responsibilities. There is also an increasing emphasis on the regional provision of healthcare, which will provide population networks of a manageable size across the

What is. disease management? There 818 fNI'IY daf.illolls d disease nmagement,

tlow8ver.1ha kayCXXIC8P illIe majorly Is hit d ... iaglaIBd, .1')'8t8rnIIIi: approadl" the deMry d heaIIh:are., 0fDnIse ttaI paIiart cdlomeS nile moat CIIIHIIfec:IMt manner.' Diaaase ~CIII bevilWad .... appoCt based on 1ha CO«IiIllialI d aI pIayIn nile ~ chait wIIh the ~Ilaim d ~"CJJ8IlydC818 whIe car Ibolilg COllIs. 2

The kay steps n ~ .... 1I818gIII'n8It i1clIde:3

• in1JrtMng COImU1icaIion and co-qJ8nIIion' between health­an...,.., 8IJl8datI belween priMly and 8XIIdary C8/8

• Incorporating InCenINes irio the aysIam to encourage such co-operation

• eliminating duplication of aIfort and activity • _eloping an overall view of heaIItIcara provision for

individual patients

• standardising therapeutic practices across 1oc:aiIies, regions and countries

• measuring outcomes to guide future irnprowImentI in Iherapeutic intI8rvenIions.

PHARMACOECONOMICS & OUTCOMES NEWS 10 Feb 11M

3

4 CURRENT ISSUES

Disease management - continued

country. Also, patients in Germany put a strong emphasis on the importance of quality of care.

However, there are also a few disadvantages to consider in Germany, such as: • the low level of communication between primary and

secondary care structures • limited computerisation beyond the payer sector

(providers have little access to any computerised information)

• several legislative barriers, which present problems in terms of confidentiality of data and restrictions on negotiations between the Krankenkassen, GPs and other providers.

France: ready to change for the better? At present in France, there are many factors working

against the implementation of disease management strategies, but some important changes are under consideration, said Ms Penn. Negative aspects include: • a lack of integration between primary and secondary

healthcare structures • the absence of incentives to prescribe rationally because

of the fee-for-service system • the large number of independent primary care physicians,

and the opportunity for patients to see any physician and even to approach secondary care givers directly

• a lack of computerisation. The high level of fragmentation within the healthcare

system hinders communication and makes it particularly difficult to monitor the treatments that a patient has received and which physicians they have attended.

10 Feb 11196 PHAAMACOECONOMICS & OUTCOMES NEWS

The monopoly that pharmacies hold could also prove to be a problem if they do not wish to co-operate with the disease management implementation strategy, said Ms Penn. However, important changes are being discussed. New treatment guidelines issued by the medicine's agency include the requirement to prescribe 'economically'. In theory, the government could enforce this.

The introduction of patient dossiers was also discussed in the recent reform plans. If implemented, patients would have to go to one GP and would have to contact that GP to be referred to a hospital. This would greatly improve the management of a patient's journey through the healthcare system. GP financial respon­sibilities are also on the agenda for future discussion.

Italy and Spain lag behind At present, Italy and Spain are unsuitable for the

implementation of disease management approaches, Ms Penn commented. She explained that this was because both countries have healthcare structures that are highly fragmented and hierarchical.

In Italy, there is a lack of incentive for physicians to co-operate with any healthcare schemes, and communication between providers is poor.

In Spain, it may be possible to develop schemes on a local basis, but a national strategy would be difficult to implement. This is due to the wide regional variations in medical practice. Added to this, information technology systems are underdeveloped in hospitals and GP surgeries in this country. 1. Is disease management a viable option for Europe? PharmacoResources 30: 3-4. \0 Jun 1995 2. The 'nuts and bolts' of disease management. PharmacoResources 31 : 3-4. 24 Jun 1995 3. Disease management - what role for the industry in Europe? Scrip Magazine 36: 2 9-32. Jun 1995 1OIll"""

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