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The outline

European Health Forum Gastein 2003 workshop „patient-oriented quality management in healthcare“ Programs for chronically ill patients: experiences of a private insurer DKV Deutsche Krankenversicherung AG, Cologne Torsten L Hecke MD, MPH. The outline.

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The outline

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  1. European Health Forum Gastein 2003workshop „patient-oriented quality management in healthcare“Programs for chronically ill patients: experiences of a private insurerDKV Deutsche Krankenversicherung AG, CologneTorsten L Hecke MD, MPH

  2. The outline

  3. „health programs for chronically ill patients“ outline • definition and procedures of the programs • satisfaction surveys • results • future challenges

  4. The company

  5. “Think Healthcare” • DKV offers convincing solutions wherever people's health is concerned. DKV “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 magazine pluspunkt – goMedus- Healthcare Center – goDentis-Centers for Dental Prophylaxis – Long-term Care & Residences

  6. The programs

  7. Disease Management Programs at DKV definition • 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

  8. Disease Management Programs at DKV: aims • strengthen patient empowerment • increase of compliance and satisfaction • increase of quality of life • decrease of hospital stays and their length • long-term cost reduction

  9. Disease Management Programs at DKV: instruments • 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

  10. Disease Management Programs at DKV: overview • 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)

  11. Disease Management Programs at DKV: schemes of quality management • 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

  12. Disease Management Programs at DKV: program overview • 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)

  13. 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. 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. The questionnaires

  16. 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. 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. Disease Management Programs at DKV: Diamart, medical outcomes: contents • HbA1c • serum cholesterol • systolic blood pressure

  19. The results

  20. Disease Management Programs at DKV: satisfaction survey: results • 42,9 % answered questionnaires • overall satisfaction with program: very high scores

  21. Disease Management Programs at DKV: program satisfaction survey: results • Satisfaction scores

  22. Disease Management Programs at DKV: satisfaction survey: results • Change of health status

  23. Disease Management Programs at DKV: medical outcomes: results • medical outcomes after 3 months 6.5 7.5 8.5 9.5 HbA1c -0,6% (-7,1%)p<0,04 start N=25 (31%) after 3 months 130 140 150 160 syst.blood pressure -11mmHg (-7,1%)p<0,02 start N=25 (31%) after 3 months total cholesterol start -25mg/dl (-9,6%)p<0,01 N=19 (24%) after 3 months

  24. Disease Management Programs at DKV: medical outcomes: results • Medical outcomes after one year: HbA1c:

  25. Disease Management Programs at DKV: medical outcomes: results • Medical outcomes after one year: systolic blood pressure:

  26. Disease Management Programs at DKV: medical outcomes: results • Medical outcomes after one year: total serum cholesterol:

  27. Disease Management Programs at DKV: satisfaction survey: results • Changes of behaviour

  28. Disease Management Programs at DKV: satisfaction survey: results • 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

  29. Disease Management Programs at DKV: satisfaction survey: results • would you recommend the program to your friends suffering from the same disease? • 93 % „yes“ • 3 % „no“ • 3 % „don´t know“

  30. 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. Disease Management Programs at DKV: survey of risk reports: results • Interaction with physicians 19% 9% 9% no. of individualized recommendations Total of answers no. of reports taken to physician visit no. of discus-sion with physician

  32. Future challenges

  33. Disease Management Programs at DKV: key success factors • 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

  34. Back-up

  35. “Think Healthcare” • DKV expands its range of innovative insurance products to include highly attractive new services and efficient healthcare components.

  36. German healthcare delivery system: providers Providersof health care medical 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. German healthcare delivery system: frameworks • 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

  38. German health insurance systembasic informations • 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 ...

  39. German healthcare delivery system IV/VIIIGerman healthcare expenditures, 1998 (m€)

  40. German healthcare delivery system VIII/VIIIOverview: benefits and payments

  41. 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% -2% (879,400) non-medical employees German health delivery system development of the hospital sector 1991 to 2000 (year 2000) source: Globus, in: Deutsches Ärzteblatt , 99(10): C460

  42. public households 18,734 statutory health insurance 118,468 statutory pension 3,418 statutory employment insurance 3,538 private health insurance 16,186 employers 8,622 private households 23,273 private organisations 5,095 statutory long-term care insurance 14,700 German healthcare delivery system V/VIIIfinancing by sources, 1998 (m€) source: Statistisches Bundesamt 2002, internet data

  43. The German health insurance market 2001 • POPULATION 82.3 MILLION GKV (statutory health insurance):355 funds PKV (private health insurance):50 companies persons who are obligated to be covered within the statutory health insurance system 29.0 m pensioners with statutory insurance 15.33 m family members of those covered within the statutory health insurance system (“co-insureds”) 19.85 m persons with private comprehensive health insurance cover 7.7 m Persons with supplementary insurance 14.1 million voluntarily insured within the statutory health insurance system 6.63 m Source: Statistisches Taschenbuch Gesundheit 2002, Private Health Insurance Association

  44. private health ins. stat. health ins. premiums Negociations payments payments contributions payments patient health- care provider care patient health- care provider care payments comparison between statutory health insurance scheme & private health insurance system statutory health insurance scheme private health insurance system

  45. 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 at DKV“ who does what in the German health care system? 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. „healthcare management at DKV“ definitions 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

  47. „healthcare management programs 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)

  48. Disease Management Programs at DKV: telemetric tools

  49. „healthcare management programs at DKV“ definitions 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

  50. „healthcare management 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

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