ich vertrau der dkv ein unternehmen der versicherungsgruppe. european health forum gastein 2003...
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Ich vertrau der DKVEin Unternehmen der Versicherungsgruppe.
European Health Forum Gastein 2003workshop „patient-oriented quality management in healthcare“
Programs for chronically ill patients: experiences of a private insurer
DKV Deutsche Krankenversicherung AG, CologneTorsten L Hecke MD, MPH
2 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
3 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
definition and procedures of the programs
satisfaction surveys
results
future challenges
„health programs for chronically ill patients“outline
4 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
5 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
DKV
“Think Healthcare”
“THINK HEALTHCARE”
INSURANCE SPECIAL SERVICES HEALTHCARE
– Substitutive and supplemental forms of private health insurance
– Innovative insurance products, such as BESTCARE and OPTIMED
– DKV Health Phone
– DKV Healthcare Programs
– Healthcare platform on the Internet
– Health-related publications, such as up2date, Mediothek
– Customer magazinepluspunkt
– goMedus-Healthcare Center
– goDentis-Centers for Dental Prophylaxis
– Long-term Care & Residences
– DKV offers convincing solutions wherever people's health is concerned.
6 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
7 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
standardized and population-based programs for treatment of
patients with chronical diseases
evidence-/ guideline-based program in cooperation with all
participants and institutions of the German health system
voluntary participation of insured persons
free of fees for the participants
Disease Management Programs at DKVdefinition
8 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
strengthen patient empowerment
increase of compliance and satisfaction
increase of quality of life
decrease of hospital stays and their length
long-term cost reduction
Disease Management Programs at DKV:aims
9 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
regular training and support of the patients:
specially edited informations
assistance of trained call centre agents by phone and internet
regular report of health status for patients and their physicians
continuous monitoring of patients to recognize adequate
intervention point
assistance of physicians according to ebm guidelines
controlling and evaluation of all processes and results
Disease Management Programs at DKV:instruments
10 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
three diagnoses
diabetes mellitus type II
chronic heart failure (with telemetric applications)
hypertension
programs are run by DKV (initiation and evaluation) and ArztPartner
almeda AG in Munich (participants´assistance and contacts)
two studies
Diabetoguide (start 1998, finish in 2003)
DIAMART (start 2002, in cooperation with Hestia Healthcare)
Disease Management Programs at DKV:overview
11 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
process analyses
satisfaction surveys:
overall satisfaction surveys (patients and physicians)
special satisfaction surveys (instruments, tools; quality of
life)
medical outcomes and regular report of health status for
patients and their physicians
cost-benefit-analysis
defined schedules
Disease Management Programs at DKV:schemes of quality management
12 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
three diagnoses
diabetes mellitus
chronic heart failure (with telemetric applications)
hypertension
future diagnoses:
to be defined
two studies:
Diabetoguide (start 1998, finish in 2003)
DIAMART (start 2002, in cooperation with Hestia Healthcare)
Disease Management Programs at DKV:program overview
13 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:Diamart
one year study with 180 participants
program for patients with diabetes type II
typical instruments and tools as described before
3 additional risk reports („health reports“)
medical data are analyzed and transformed into risk reports in two
variations: non-medical language for participants and medical
language for physicians; participants are asked to discuss those
documents with their physicians and to fix a goal, eg a certain level
of blood glucose at the end of a year
14 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:Diamart continued
quality management approaches:
survey for acceptance of risk reports
overall program satisfaction survey
medical outcomes
quality of life (SF 36)
process analyses
15 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
16 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:Diamart, program satisfaction survey: contents
overall satisfaction
call centre assistance
amelioration of health status
changes of participants´ behaviour
satisfaction with written information
acceptance of telemetric applications if used
patient´s view of physician´s opinion
participants´ expectations
recommendations
individual parameters (age, gender, etc.)
17 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:Diamart, survey of risk reports: contents
reading and understanding of reports
opinion in general
understandability
content of reports
frequence of reports
consequences for the participants
changes of behaviour
discussion with the physician
physician´s recommendations
18 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:Diamart, medical outcomes: contents
HbA1c
serum cholesterol
systolic blood pressure
19 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
20 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:satisfaction survey: results
42,9 % answered questionnaires
overall satisfaction with program: very high scores
21 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:program satisfaction survey: results
0% 20% 40% 60% 80% 100%
very satisfied
satisfied
dissatisfied
very dissatisfied
don´ t know
Satisfaction scores
22 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:satisfaction survey: results
43%
54%
0%
3%
betterno changesworsedon´t know
Change of health status
23 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
HbA1cHbA1c
syst.blood pressure
syst.blood pressure
185 205 225 245 265
Beginn
Nach 3Monaten
total cholesterol
total cholesterol
-0,6% (-7,1%)p<0,04
-0,6% (-7,1%)p<0,04
-11mmHg (-7,1%)p<0,02
-11mmHg (-7,1%)p<0,02
-25mg/dl (-9,6%)p<0,01
-25mg/dl (-9,6%)p<0,01
N=
25 (31%)
N=
25 (31%)
N=
19 (24%)
6.5 7.5 8.5 9.5
start
after 3months
130 140 150 160
start
after 3months
Disease Management Programs at DKV:medical outcomes: results
medical outcomes after 3 months
start
after 3months
24 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:medical outcomes: results
Medical outcomes after one year: HbA1c:
25 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:medical outcomes: results
Medical outcomes after one year: systolic blood pressure:
26 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:medical outcomes: results
Medical outcomes after one year: total serum cholesterol:
27 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Changes of behaviour
Disease Management Programs at DKV:satisfaction survey: results
75%
22%
3%
yesno changedon´t know
28 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
expectations:
amelioration of life quality
optimization of drug use
risk decrease
refund of expenses for medical equipment and additional drugs
expectations became reality: 67 % „yes“
Disease Management Programs at DKV:satisfaction survey: results
67 % of those expectations were realized
29 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
would you recommend the program to your friends suffering from the same disease?
93 % „yes“ 3 % „no“ 3 % „don´t know“
Disease Management Programs at DKV:satisfaction survey: results
30 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:survey of risk reports: results
88 % of those returned the questionnaires read the report
overall satisfaction with report
comprehensiveness: 96 % „very good“ or „good“
reports are useful instruments of program: 80 % „yes“
32 % of responders planned change of behaviour
31 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Interaction with physicians
Disease Management Programs at DKV:survey of risk reports: results
Total of answers
no. of reports taken to physician visit
19%
no. of discus-sion with physician
9% 9%
no. of individualized recommendations
32 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
33 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
risk assessment (need of a sufficient software)
individual system of aims between patient and physician
telematic application (in complicated cases or bad compliance)
adequate mix of case- and disease management
bidirectional approach: DMP und BMP
call centre support with reminder systems
importance of individualized information, education and motivation
incentives for participants and all partners
electronic patient documents, data management
Disease Management Programs at DKV:key success factors
34 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
35 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
–DKV expands its range of innovative insurance products to
include highly attractive new services and efficient healthcare
components.
“Think Healthcare”
36 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
medical
care
German healthcare delivery system: providers
Providers of health care
pharma-
ceutical
care
longterm
care
health
promotion
patient
information
• physicians in
ambulatory sector (gen., spec.)• medical services in hospitals• medical rehabili- tation
• public pharmacies• hospital pharmacies• distribution systems
• home care• nurses in hospitals• rehabilitation• telecare
• no defined
professions• no defined sectors
• sickness funds• private insurances• public institutions• private institutions• patients´ unions• physicians• media
37 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
strict separation between healthcare sectors
emphasis on free access of patients to the providers
high number of providers in the market
no negotiations between private health insurances and physicians
no general gatekeeping system
disproportionate share between familiy practitioners and specialists
(relation under 40 / 60)
hospitals charged by per diem rates / from up 2004: DRG-system
waiting-lists are nearly unknown
German healthcare delivery system: frameworks
38 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
120 year-old history
statutory health insurance as major component (88%)
private health insurances as minor component (9%)
sickness fund membership compulsory for employees with gross income below a level of about EUR 40,000
employees pay 50% of the total monthly contribution
contribution rate rises with an increased income to a certain level
Social Code Book V: definition of all claims, rights, duties, bodies, possible negociations ...
German health insurance systembasic informations
39 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
German healthcare delivery system IV/VIIIGerman healthcare expenditures, 1998 (m€)
54,577
45,055
30,109
14,85
10,987
8,871
7,7516,6974,073 3,191
24,866
medical care
nursing care
drugs
medical devices
hospital care (excl. med. & nursingcare)
administration
prevention / health promotion
others
compensation for inability to work
science / education
transportation
40 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
German healthcare delivery system VIII/VIIIOverview: benefits and paymentsbenefit defined by theSocial Code Book V
payment bysocial health insurance
payment bythe patient
prevention of disease ~ negociations ~ negociationsscreening for disease fully nonediagnostic procedures fully nonenecessary ambulatorymedical care
by global budget to theregional associations ofsickness-fund-affiliatedphysicians
none
necessary hospital care per diem rates;DRG starting latest in 2007
co-payment of ~ 10 EURper day
dental care by global budget to theregional associations ofsickness-fund-affiliateddentists
in specified cases co-payments
drugs directly to provider defined co-payments-system
non-physician care directly to provider co-paymentsmedical devices directly to provider co-paymentsnursing home care directly to provider co-payments if amount
exceed a defined limitRehabilitation (non-amb.) directly to the clinic co-payment per day
41 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
German health delivery systemdevelopment of the hospital sector 1991 to 2000
(year 2000)source: Globus, in: Deutsches Ärzteblatt , 99(10): C460
hospitals -7% (2,242)
hospital beds -18% (560,000)
patients (16.5 m) +19%
duration of stay (days) -4,5 days (10.1)
medical employees (112,900) +13%
non-medical employees -2% (879,400)
42 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
German healthcare delivery system V/VIIIfinancing by sources, 1998 (m€)
18,734public households
118,468statutory health insurance
3,418statutory pension
3,538statutory employment insurance
16,186private health insurance
8,622employers
23,273private households
5,095private organisations
14,700statutory long-term care insurance
source: Statistisches Bundesamt 2002, internet data
43 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
18.6 %
35.2 %
8.1 %9.4 %
24.1 %
–POPULATION 82.3 MILLION
persons who are obligated to be covered within the statutory health insurance system 29.0 m
voluntarily insured within the statutory health insurance system 6.63 m
persons with private comprehensive health insurance cover 7.7 m
family members of those covered within the statutory health insurance system (“co-insureds”)19.85 m
pensioners with statutory insurance15.33 m
Source: Statistisches Taschenbuch Gesundheit 2002, Private Health Insurance Association
GKV (statutory health insurance): 355 fundsPKV (private health insurance): 50 companies
Persons with supplementary insurance 14.1 million
The German health insurance market 2001
44 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
comparison between statutory health insurance scheme & private health insurance system
stat.health
ins.
health-care
providerpatient
payments
care
contributions
Negociations
payments
privatehealth
ins.
health-care
providerpatient
care
premiums
payments
payments
statutory health insurance scheme private health insurance system
45 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
„healthcare management at DKV“who does what in the German health care system?
statutory sickness funds
actvities since about ten years
nearly every fund is running healthcare management plans
examples:
- case management in hospitals- employees´ health promotion- disease management (start beginning 2003)- cooperation with ambulatory medical networks- integrated care models- pharmaceutical care
healthcare
management
plans
in Germany
private imsurance system
activities since about five years
only few of the 52 private health insurance companies run plans
examples:
- case management of high-cost inter-sectoral cases - healthcare programs for chronical ill patients- demand management- pharmaceutical care- health promotion programs- gate-keeping systems in trial
46 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management
core competence of a client-orientated health insurance
improvement of quality of care for the insured persons
amelioration of the client´s health status
choice, planning, realization, evaluation and controlling of
programs and services for the insured persons
„healthcare management at DKV“definitions
47 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
managed care
„When one thinks about managed care, one should distinguish
between
the techniques of managed care and the organizations that
performs the various functions.
Managed care can embody a wide variety of techniques ... .
These include various forms of financial incentives for providers,
promotion of wellness, early identification of disease, patient
education, self-care, and all aspects of utilization management.“
(Fox 1996)
„healthcare management programs at DKV“definitions
48 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKV:telemetric tools
Initial positionof patient
seriously ill patientwith highprobability of acutedecrease of illness
Example:patient withcardiacinsufficiency whois in danger ofdecompensation
Medical andfinancial benefit
• due identification (e.g.decompensation)
• avoidance ofcostly hospitalstay
Selfmessure-ment ofrelevant databy thepatientat home
automa-tical datatranfer toArztPartner
allocation ofvalues toelectronicalhealth file(elek-tronischeGesund-Heitsakte(ProCare© )
control ofdataProCare©orArztPartner
In case ofcall foraction:informationof thepatient orphysicianon-site
functionality of telemetric medicine
49 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
claims management
all activities of an health insurance to treat the clients´ claims
claims´ investigations
claims´ inspection
description of claim management rules for the insurer
„healthcare management programs at DKV“definitions
50 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management: a stepwise approach
first approach
cost containment strategies
second approch
improvement of quality of healthcare
expectation: better quality leads to lower expenses
third approach
DKV as healthcare provider
„healthcare management at DKV“definitions
51 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management: a stepwise approach
first approach
cost containment strategies
data management and controlling
risk and claims research on own data base
to establish cooperations with financial benefits for the
company and quality benefits for the insured persons
to offer valued information to insured persons
„healthcare management at DKV“definitions
52 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management: a stepwise approachsecond approach
improvement of quality of careDKV as „first class insurer“ has to provide data on
healthcare providers with high quality on demand to
insured personsto increase insured persons´ and patients´satisfaction
and compliance
„healthcare management at DKV“definitions
53 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management: a stepwise approachthird approach
DKV as healthcare providerprovision of high-level care (Best Care)dental health centres (goDentis)primary care centers (goMedus)growing share in hospital marketfranchise system for prevention-orientated primary
care (Medwell)pathways for sales of supplementary insurances
„healthcare management at DKV“definitions
54 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
healthcare management at DKVintegration of insurance and care
new insurance products
new healthcare bussinesses
active role of insurer in improving quality of care
insurance
core competence
care
newcompetence
55 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
Disease Management Programs at DKVfirst results: telemetric tool conveys confidence
80
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87
88
89
90
56 octobre 3, 2003 – EHFG, Torsten L Hecke: health programs for chronically ill patients
A member of the Group
80
81
82
83
84
85
86
87
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89
90
Son of the patient does a test;
ArztPartner phonecall
Disease Management Programs at DKVfirst results: telemetric tool conveys confidence
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