Disease Management & Health Outcomes

, Volume 14, Issue 1, pp 5–12 | Cite as

Population-Based Disease Management in the German Statutory Health Insurance

Implementation and Preliminary Results
  • Stephanie A. K. Stock
  • Marcus Redaelli
  • Karl W. Lauterbach
Leading Article

Abstract

Social healthcare systems in Europe must cope with aging populations and rising costs. For the German social healthcare system, which dates back to the 19th century, this problem is especially apparent, as soaring structural unemployment and the demographic transition of the population threaten the financial basis of the Statutory Health Insurance (SHI) [Gesetzliche Krankenversicherung]. In order to preserve free access to high-quality care and mandatory insurance for most of the population with affordable contributions, the traditional methods of healthcare delivery are challenged. As a result of its historic development, the system is tailored to acute care. Infectious diseases and accidents, however, have lost their relevance as main sources of mortality and morbidity of the population.

Chronic diseases that can be influenced in their course by patient self-management and preventive measures dominate as causes of morbidity, mortality, and rising costs of healthcare. Since cost-containment measures can no longer stabilize cost development, structural reforms are strongly advocated. The implementation of a legal framework for disease management programs is the first of several structural reform measures implemented in the SHI.

Diseases for which a legal framework has been approved include type 1 and type 2 diabetes mellitus, coronary artery disease, breast cancer, and asthma/chronic obstructive pulmonary disease. Quality requirements for the programs are high and include a central-accreditation process, evaluation in 3-year intervals by independent investigators, and specific quality management measures outlined for each disease. Major features of the programs include a population-based, patient-centric, and physician-based design. Since 2002, >1.6 million patients were enrolled in diabetes programs nationwide.

Preliminary results point to positive effects of the programs on outcomes and process parameters, such as blood glucose and blood pressure readings or performed yearly eye examinations for patients with diabetes. Differences in the German and the US approach to disease management not only include a top-down versus a bottom-up approach; the German approach aims at secondary prevention regardless of risk state, co-morbidities, and possible cost savings, whereas in the US high-risk approaches are common. For the US, the German physician-based approach to disease management could be of interest in the evolving Medicare programs whereas German programs could become more effective drawing on US pay-for-quality experiences.

Disease management, whether vendor or physician based, may not be the ultimate solution to all problems in the care of chronically ill patients, but it may facilitate change from a system traditionally focused on acute care to one focused on chronic care.

Keywords

Disease Management Disease Management Program Sickness Fund Statutory Health Insurance Quality Improvement Strategy 

Notes

Acknowledgments

No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.

References

  1. 1.
    Bodenheimer T. Disease management in the American market. BMJ 2000; 320(7234): 563–6PubMedCrossRefGoogle Scholar
  2. 2.
    Hunter DJ, Fairfield G. Managed care: disease management. BMJ 1997; 315(7099): 50–3PubMedCrossRefGoogle Scholar
  3. 3.
    Crippen DL. Congressional Budget Office testimony before the United States Senate Special Committee on Aging, Disease Management in Medicare: data analysis and benefit design issues [online]. Available from URL: http://www.cbo.gov/showdoc.cfm?.index=3776&sequence=0 [Accessed 2004 Oct 28]
  4. 4.
    Whitelaw NA, Warden GL. Reexamining the delivery system as part of Medicare reform. Health Aff (Millwood) 1999; 18(1): 132–43CrossRefGoogle Scholar
  5. 5.
    Etheredge L, Moore J. A new Medicaid program. Health Aff (Millwood) 2003; Suppl Web Exclusives: W3-426-39Google Scholar
  6. 6.
    Gillespie JL, Rossiter LF. Medicaid Disease Management Programs: findings from three leadings US state programs. Dis Manage Health Outcomes 2003; 11(6): 345–61CrossRefGoogle Scholar
  7. 7.
    Bodenheimer T. Disease management: promises and pitfalls. N Engl J Med 1999; 340(15): 1202–5PubMedCrossRefGoogle Scholar
  8. 8.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288(14): 1775–9PubMedCrossRefGoogle Scholar
  9. 9.
    McAlister FA, Lawson FM, Teo KK, et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med 2001; 110(5): 378–84PubMedCrossRefGoogle Scholar
  10. 10.
    McAlister FA, Lawson FM, Teo KK, et al. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323(7319): 957–62PubMedCrossRefGoogle Scholar
  11. 11.
    Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness: which ones work? Meta-analysis of published reports. BMJ 2002; 325(7370): 925–33PubMedCrossRefGoogle Scholar
  12. 12.
    Knight K, Badamgarav E, Henning JM, et al. A systematic review of diabetes disease management programs. Am J Manag Care 2005; 11(4): 242–50PubMedGoogle Scholar
  13. 13.
    Schaich-Walch G. Disease management programs: importance, hopes, results [in German]. Z Arztl Fortbild Qualitatssich 2003; 97(3): 180–2PubMedGoogle Scholar
  14. 14.
    Eichenlaub A, Steiner M, Riedel D, Maetzel J, Kaatz I, Reiche R. Final report: evaluation of a model program diabetes Saxony-Anhalt [in German]. Köln: Prognos, 2004Google Scholar
  15. 15.
    Fireman B, Bartlett J, Selby J. Can disease management reduce health care costs by improving quality? Health Aff 2004; 23(6): 63–75CrossRefGoogle Scholar
  16. 16.
    Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case management for people with diabetes: a systematic review. Am J Prev Med 2002; 22(4 Suppl.): 15–38PubMedCrossRefGoogle Scholar
  17. 17.
    Advisory Council for the Concerted Action in Health Care. Appropriateness and efficiency: Volume III. Overuse, underuse and misuse [in German] [online]. Nomos: Baden Baden, 2000/01: 80–1Google Scholar
  18. 18.
    Lauterbach KW, Stock S, Redaèlli M, Kühn M, Lungen M. Disease Management in Germany: a framework for development, implementation and evaluation in the Statutory Health Insurance [in German] [online]. Cologne: Institute of Health Economics and Clinical Epidemiology of the University of Cologne, 2001: 1–333. Available from URL: http://www.medizin.uni-koeln.de/kai/igmg/guta/GutachtenDMP.pdf [Accessed 2004 Nov 15]Google Scholar
  19. 19.
    Busse R. Disease management programs in Germany’s Statutory Health Insurance system. Health Aff (Millwood) 2004; 23(3): 56–67CrossRefGoogle Scholar
  20. 20.
    Federal Ministry of Health and Social Security (BMGS) [in German] [online]. Available from URL: http://www.bmgs.bund.de/downloads/Kennzahlen_und_Faustformeln_2005_1Q.pdf; http://www.bmgs.bund.de/downloads/Beitragssaetze.pdf [Accessed 2005 Sep 2]
  21. 21.
    Cotis JP. EFPIA Annual Meeting 2003: healthcare demand in Europe: economic growth and sustainability of the European model. 2003 May 26–28 [online]. Available from URL: http://www.oecd.Org/dataoecd/3/7/12024754.pdf [Accessed 2004 Nov 15]
  22. 22.
    Organisation for Economic Cooperation and Development. OECD health data 2004: a comparative analysis of 30 countries [available on CD Rom, Version 3.0]. Paris: OCED, 2004Google Scholar
  23. 23.
    Federal Ministry of Health and Social Security. Social Healthcare Modernization Law -(GKV -Modernisierungsgesetz) [in German] [online]. Available from URL: http://www.die-gesundheitsreform.de/reform/gesetzgebung/pdf/gkv-modernisierungsgesetz-gmg.pdf [Accessed 2004 Nov 11]
  24. 24.
    Federal Ministry of Health and Social Security. Overview of laws relating to social security [in German] [online]. Available from URL: http://www.bmgs.bund.de/download/gesetze_web/gesetze.htm [Accessed 2004 Nov 11]
  25. 25.
    Gemeinsamer Bundesausschuss [online]. Available from URL: http://www.gba.de [Accessed 2004 Nov 11]
  26. 26.
    Stock S, Redaelli M, Lauterbach KW. Disease Management Programme in Deutschland: Anspruch, Wirklichkeit und Perspektiven [in German]. In: Stock S, Redaelli M, Lauterbach KW, editors. Disease Management als Grundlage integrierter Versorgungsstrukturen, W. Stuttgart: Kohlhammer GmbH, 2005: 64–5Google Scholar
  27. 27.
    Federal Ministry of Health and Social Security [online]. Available from URL: http://www.bmgs.bund.de/deu/gra/aktuelles/pm/bmgs04/6040_6141.cfm [Accessed 2004 Nov 11]
  28. 28.
    Altenhofen L, Brenner G, Haβ W, et al. Report on quality assurance: disease-management programs in north-Rhine [in German] [online]. Düsseldorf: KV Nordrhein, 2004: 1–40. Available from URL: http://www.kvno.de/importiert/qualbe_dmp04.pdf [Accessed 2005 Sep 2]Google Scholar
  29. 29.
    AOK Bundesverband. Qualitative evaluation of the implementation of DMP Curaplan Diabetes [in German] [online]. Available from URL: http://www.aokbv.de/imperia/md/content/aokbundesverband/dokumente/pdf/gesundheitsversorgung/dmp_wl_evaluation.pdf [Accessed 2005 Sep 2]
  30. 30.
    von Stackelberg JM. Disease Management Programme Patienten profitieren von einer besseren Qualität der Versorgung [online]. Available from URL: http://www.aok-bv.de/imperia/md/content/aokbundesverband/dokumente/pdf/dieaok/aid_310505_stackelberg_f.pdf [Accessed 2005 Nov 17]
  31. 31.
    Berger ML, Nebenfuhr P, Murray RK. The value of disease management. Dis Manage Health Outcomes 2000; 8(4): 181–4CrossRefGoogle Scholar
  32. 32.
    Foote SM. Population-based disease management under fee-for-service Medicare. Health Aff (Millwood) 2003; Suppl Web Exclusives: W3-342-56Google Scholar
  33. 33.
    Fuller MG. Disease state management programmes. Dis Manage Health Outcomes 1999; 6(1): 29–36CrossRefGoogle Scholar
  34. 34.
    Schrappe M. The hospital perspective: disease management and integrated health care [in German]. Z Arztl Fortbild Qualitatssich 2003; 97(3): 195–200PubMedGoogle Scholar
  35. 35.
    Forman S. Medicare risk plans and disease management vendors. Dis Manage Health Outcomes 2000; 7(1): 1–4CrossRefGoogle Scholar
  36. 36.
    Lewis A. ‘Build versus buy’ in disease management. Dis Manage Health Outcomes 1999; 6(6): 315–8CrossRefGoogle Scholar
  37. 37.
    Leider HL. Selecting a vendor for disease management programmes. Dis Manage Health Outcomes 1999; 6(3): 131–9CrossRefGoogle Scholar
  38. 38.
    Goldman DP, Smith JP. Can patient self-management help explain the SES health gradient? Proc Natl Acad Sci U S A 2002; 99(16): 10929–34PubMedCrossRefGoogle Scholar
  39. 39.
    Scheibler F, von Pritzbuer E, Pfaff H. Shared decision making as a chance of implementing disease management programs [in German]. Z Arztl Fortbild Qualitatssich 2004; 98(2): 109–14PubMedGoogle Scholar
  40. 40.
    Szecsenyi J, Schneider A. Between individuality and “evidence-based medicine”: the role of the general practitioner within the scope of disease management programs [in German]. Z Arztl Fortbild Qualitatssich 2003; 97(3): 183–7PubMedGoogle Scholar
  41. 41.
    Rosenthal MB, Fernandopulle R, Song HR, et al. Paying for quality: providers’ incentives for quality improvement. Health Aff (Millwood) 2004; 23(2): 127–41CrossRefGoogle Scholar
  42. 42.
    Leider HL. Gaining physician buy-in for disease management initiatives. Dis Manage Health Outcomes 1999; 6(6): 327–33CrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  • Stephanie A. K. Stock
    • 1
  • Marcus Redaelli
    • 1
  • Karl W. Lauterbach
    • 1
  1. 1.Institute for Health Economics and Clinical Epidemiology of the University of CologneCologneGermany

Personalised recommendations