ich vertrau der dkv ein unternehmen der versicherungsgruppe. european health forum gastein 2003...

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



definition and procedures of the programs

satisfaction surveys

results

future challenges

„health programs for chronically ill patients“outline



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.



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



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



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



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



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



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



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



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



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.)



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



Disease Management Programs at DKV:Diamart, medical outcomes: contents

HbA1c

serum cholesterol

systolic blood pressure



Disease Management Programs at DKV:satisfaction survey: results

42,9 % answered questionnaires

overall satisfaction with program: very high scores



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




43%

54%

0%

3%

betterno changesworsedon´t know

Change of health status



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




Medical outcomes after one year: HbA1c:




Medical outcomes after one year: systolic blood pressure:




Medical outcomes after one year: total serum cholesterol:



Changes of behaviour


75%

22%

3%

yesno changedon´t know



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“


67 % of those expectations were realized



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: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



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



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



–DKV expands its range of innovative insurance products to

include highly attractive new services and efficient healthcare

components.

“Think Healthcare”



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 rehabilitation

• 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



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



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



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



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



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)



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



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



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



„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



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



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



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



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



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: 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: 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: 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 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



Disease Management Programs at DKVfirst results: telemetric tool conveys confidence

80

81

82

83

84

85

86

87

88

89

90



80

81

82

83

84

85

86

87

88

89

90

Son of the patient does a test;

ArztPartner phonecall

Disease Management Programs at DKVfirst results: telemetric tool conveys confidence

ich vertrau der dkv ein unternehmen der versicherungsgruppe. european health forum gastein 2003...

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