Innovative Strategies for Chronic Diseases: German Health Care Experience

1. Rijksinstituutvoorziekte- en invaliditeitsverzekering (RIZIV) Belgian strategic Plan for Implementing Health Care Innovations for Chronic Diseases – German experience Brussel, April 2nd 2014Evert Jan van Lente, Federal Association of AOK, Germany

2. The AOK-Group AOK is the leading statutory health insurance group with 11 regional health insurances Federal Association, Berlin AOK Bremen AOK Nordost AOK Niedersachsen AOK Sachsen- Anhalt AOK Nordwest AOK Rheinland/ Hamburg AOK PLUS AOK Hessen AOK Rheinland- Pfalz Saarland AOK Bayern 24 millioninsured = 34 % market share (public health insurance) AOK Baden- Württemberg

3. Strategic Plan Chronic Diseases and German experience • 20 years experience with projects and adjustments in regular care … and still searching for the right way! • The goals are the same as in Belgium: • Reduce demand for health services • Reduce costs of hospital care • Improve Quality of Life through less emergencies, less complications, longer staying at home • Possibly relevant experience in Germany on: • Patient empowerment • Case-Management • Discharge-Management

4. Patient information and empowerment I

5. Patient information and empowerment II

6. Lessons Learned - patient interventions • Mostly no evidence for (cost) effectiveness; some education programs have a weak evidence • Some interventions are part of a complex-intervention (e.g. DMP) and the effect of single interventions can't be determined. • Cetral role of the physician practice is becoming became more important. • So far Germany didn’t start explicitly involving the carer

7. Case management in Germany • First problem to solve: which patients will be targeted? Predictive modelling, Heart Failure • Nurses, or qualified staff in doctors practice making home visits (“Agnes”) for one or more practices – mostly in remote areas. Paid by health insurance. • Independent nurse – foreseen in the law since 2012, but not put into practice. Discussion on delegation and substitution of services rendered by physician • Case-Manager in larger practices for patients with chronic diseases (PraCMan) – developed by the University Heidelberg – evaluation • Private company specialized on case management • Sickness Funds

8. Case Management in PraCMan Case Finding Assessment Define Goals Planing Monitoring Intervention Freund et al. BMC Health Services Research 2010

9. Case Management in Germany

10. Lessons Learned - Case management • If done well, it can be cost effective • If health providers are paid well for CM, they tend to provide too many patients with CM • CM which is independent from physician’s practice is leading to a higher need for additional management and communication • Nurses are scarce – qualified physician-assistants can be the CM • Private companies tend to improve their results by risk selection • Integrating CM in the sickness fund is a big challenge

11. Discharge Management in Germany • Deficiencies identified: • Prescription of expensive drugs • The patient’s home is not suitable, because of (new) disabilities: e.g. adjustment of kitchen, bathroom • Information from and to outpatient care to hospital • Law obliges the hospital to provide coordination for the time after discharge. No regulation on how it is paid for. • Sickness funds can provide coordination and do this for special cases

12. Thanks for your attention E.J.van Lente Rosenthaler Straße 31 10178 Berlin Germany evertjan.vanlente@bv.aok.de