Disease management and health care reforms in Germany - does more competition lead to less solidarity?

Up to the 1990s German health care legislation was dominated by measures regulating the supply side. Measures, such as budgets, aimed at volume control and sought to confine the increase of health care spending to the growth of the national income. To curb costs more effectively, competitive elements were introduced in the 1990s with free choice of sickness funds (open enrollment). To balance competition and solidarity, a risk compensation scheme (RCS) was implemented two years prior to open enrollment. Since then, balancing competition and solidarity has been a key feature of all consecutive health care reforms. The implementation of disease management programs in the statutory health insurance (SHI) served the dual purpose to promote quality of care and to foster competition. Preliminary experiences suggest, that the aligning of disease management programs with a RCS can greatly aid its implementation and benefit solidarity and competition.

Does prevention save costs? Considering deferral of the expensive last year of life.

Published cost-effectiveness analyses may overstate the cost-effectiveness ratio of preventive care if they do not explicitly model the costs of the last year of life, which is postponed by prevention. To determine the degree of overestimation, the authors built a statistical model using Medicare expenditure data on survivors and decedents. The model shows that the cost-effectiveness ratio of prevention may decrease by up to US$ 11,000 per quality-adjusted life year saved when expenditure data on the last year life are used. The model is able to explain more than half of the median cost increase of published cost-effectiveness analyses on clinical preventive services.

How much does it cost to change the behavior of health professionals? A mathematical model and an application to academic detailing.

Several strategies have shown to be effective at enhancing the implementation of research findings in daily practice. These implementation strategies improve the delivery of preventive or therapeutic care by successfully educating health professionals. On the other hand, little is known about the costs of these implementation strategies. The goal of this article is to present a mathematical model that predicts implementation costs by using published data. As an important feature, the model portrays the relationship between the degree of treatment underuse and implementation costs. Two application examples of outreach programs for the prevention of stroke and coronary disease analyze the relevance of implementation costs with respect to the cost-effectiveness ratio and total costs. They demonstrate that implementation costs may have little impact on the cost-effectiveness ratio but may nevertheless be relevant to a 3rd-party payer who needs to stay within the budget and ensure that care is provided to a large underserved population. The model and its consideration of implementation costs may contribute to a more efficient use of health care resources.

[When is it worth reducing overuse of health care services? The example of prescribing expensive antihypertensives]. / Wann lohnt es, eine medizinische Uberversorgung abzubauen? Das Beispiel der Verschreibung teurer Antihypertonika.

BACKGROUND AND PURPOSE: Reducing overuse of health care services saves costs only if implementation costs are lower than savings from avoided health care services. Predicting the expected net benefit helps policymakers to make a choice among the various overuse problems and components of implementation programs in health care. The goal of this paper is to demonstrate how to calculate the net benefit of reducing overuse. In an application example feedback or outreach visits to primary care physicians in Germany reduce the prescription of expensive antihypertensives with questionable benefit. METHODS: In a mathematical model secondary data were used to portray the relationship between the net benefit from reducing overuse and the degree of overuse. RESULTS: Assuming that currently 30% of treated hypertensive patients could switch to thiazides and combinations with other drugs, an overuse reduction through feedback or outreach visits to primary care physicians is efficient. CONCLUSION: If the degree of overuse is large, an overuse reduction can be efficient. The explicit consideration of the size of an overuse problem may contribute to a more efficient use of health care resources.

An evidence-based disease-management program for patients with diabetic nephropathy.

BACKGROUND: In Germany, a surge in the number of dialysis patients is expected over the next 10 years. This article aims to: (1) address this trend by developing an evidence-based disease-management program for patients with diabetic nephropathy and; (2) to identify areas for future research on disease management tools. METHODS: We conducted a systematic search of studies published between January 1966 and December 2001 investigating the relationship between disease management tools and clinical and economic outcomes of patients with diabetic nephropathy. Studies were categorized according to level of scientific evidence. As a disease management tool when scientific evidence was lacking, expert judgement was used. RESULTS: We identified 10 studies that formed the scientific basis of this program's recommendations. For patients with incipient or clinical nephropathy the program recommends the implementation of clinical guidelines, patient feedback to physicians and treatment documentation. For predialysis patients it suggests that specialists or a team of specialists coordinate patient care. Further, the program recommends educational sessions, use of case managers and regular quality circles for dialysis patients. Trial evidence suggests that the prospect of cost-saving is greatest for the management of pre-dialysis patients. CONCLUSIONS: High-quality studies on the use of many disease management tools are lacking, for example, on the role of case managers and primary care physicians in non-dialysis patients. To keep costs manageable the disease-management program can begin with enrolling predialysis patients.

When is it worth introducing a quality improvement program? A mathematical model.

Quality improvement programs must compete with other health care interventions for limited health care resources. The goal of the research presented here was to develop a model that portrays the mathematical relationship between the size of a quality deficit caused by the noncompliance of health professionals and the cost-effectiveness of a quality improvement program. The model allows the determination of the minimum size of a quality deficit for which it is worth introducing a quality improvement program. If a quality improvement program has already been implemented, the model can be used to define the quality threshold beyond which a reduction in quality becomes economically unattractive. An example considering the reduction of underuse in depression treatment demonstrates that an intervention with a favorable cost-effectiveness ratio may become economically unattractive once the costs for the implementation effort are considered.

Appropriateness of invasive cardiovascular interventions in German hospitals (2000-2001): an evaluation using the RAND appropriateness criteria.

OBJECTIVE: Germany has the highest per capita rate of percutaneous transluminal coronary angioplasties (PTCAs) in Europe and the third highest per capita rate of heart surgeries requiring a heart-lung machine. The goal of this study was to evaluate the appropriateness of PTCA, coronary artery bypass graft (CABG), and carotid endarterectomy (CEA) in German hospitals using RAND appropriateness criteria. METHODS: A retrospective study in 121 randomly selected German hospitals (52% of all hospitals contacted) was performed from December 2000 to August 2001. A total of 361 patients were enrolled providing information on the appropriateness of 128 PTCAs, 92 CABGs, and 141 CEAs. RESULTS: Inappropriateness rates were 2% (95% CI 0-5%), 4% (95% CI 1-9%), and 3% (95% CI 1-7%) for PTCA, CABG, and CEA, respectively. The overall rate of uncertain procedures was 42% (95% CI 36-47%). Only 38% (95% CI 32-45%) of patients who received a coronary intervention had had a pre-interventional stress test. CONCLUSIONS: The study yielded little overt overuse in the performance of PTCAs, CABGs, and CEAs, but potentially large underuse of stress tests. Despite a high per capita rate of invasive cardiovascular interventions in Germany, the rate of inappropriate procedures was not larger than in other countries.

Inductive reasoning in medicine: lessons from Carl Gustav Hempel's 'inductive-statistical' model.

The purpose of this paper is to discuss both the fundamental requirements of sound scientific explanations and predictions and common fallacies that occur in explaining and predicting medical problems. To this end, the paper presents Carl Gustav Hempel's 'covering-law' model (1948 and 1962) and reviews some of the criticism of the model. The strength of Hempel's model is that it shows that inductive arguments, when applied with the requirement of maximal specificity, can serve as explanations as well as predictions. The major weakness of the 'covering-law' model, its inability to portray causal relatedness, has been addressed by philosophers such as Wesley Salmon. While few philosophers today agree with the 'covering-law' model in its original formulation, there is widespread consensus that the law has made a central contribution to describing the fundamental requirements of sound scientific explanations. Applying this model and its revisions in the medical context may help uncover potentially undetected fallacies in reasoning when explaining and predicting medical problems.

An evidence-based evaluation of quality and efficiency indicators.

The goal of this study was to identify and appraise quality and efficiency indicators relevant to hospitals or physicians' practices by performing a systematic literature search. Process indicators were limited to 11 diagnoses and treatments. To appraise the indicators identified, a framework for grading health care recommendations was expanded to categorize evidence on cost-effectiveness. Seven indicators of structural quality and 34 indicators of process quality were identified and appraised. The set of performance indicators could serve as a state-of-the-art system of measurement for governments and organizations evaluating the quality and efficiency of health care.

[Cost-effectiveness of quality improvement measures in health care]. / Zur Wirtschaftlichkeit von Qualitätsverbesserungsmassnahmen im Gesundheitswesen.

GOAL: To discuss the costs and cost-effectiveness of quality improvement programs in health care. COST SAVINGS THROUGH QUALITY IMPROVEMENT: A quality improvement program saves costs if its investment costs are lower than savings from avoiding medical services. Cost savings are most likely realized if a) an overuse or misuse problem is targeted, b) many patients are affected, and c) striving for optimal quality is avoided. The overall prospect of cost savings is small, however. COST-EFFECTIVENESS OF QUALITY IMPROVEMENT PROGRAMS: From a societal perspective a quality improvement is economically attractive if an improvement in health status justifies its expenses including induced costs--even if total costs increase. In the USA a cost-effectiveness ratio of $50,000 per quality-adjusted life year is often applied as a maximum acceptable threshold value. From an institutional perspective the impact of a quality program on revenues is also important. An improvement of the image may increase the number of cases and thus revenues. For services reimbursed on a per-diem basis revenues behave according to changes in the length of stay. From an institutional perspective it is therefore reasonable to consider economic criteria when targeting problem areas.

The influence of the labor market on German health care reforms.

On the surface, the health care systems of Germany and the United States seem to be quite different from each other. However, in both systems, health care financing has close ties to the labor market. Recent changes in Germany's labor market have challenged the traditional employment-based funding of its social health insurance (SHI), to the extent that all political parties advocate decoupling health care financing from labor costs, to various degrees. This paper explores the impact of changes in the labor market on the proposed reforms in health care financing in Germany and suggests some implications for the United States.

Technology assessment in dentistry: a comparison of the longevity and cost-effectiveness of inlays.

OBJECTIVES: An example of technology assessment in dental care by evaluating the (cost-)effectiveness of types of three-surface inlays (gold, laboratory-fabricated ceramic, and chairside CAD/CAM ceramic) is provided. METHODS: MEDLINE, EMBASE, and the Cochrane Library were searched for studies published between 1966 and June 2003 that reported annual survival probabilities and annual observations. The longevity of different types of inlays was measured by the number of failure-free years. Annual survival rates from different studies were pooled by weighing the rates of each study by the inverse of the variance of the effect estimate. A cost-effectiveness analysis from the perspective of German private health insurers was performed using billing charges. RESULTS: Three, five, and two case series on laboratory-fabricated ceramic, chairside CAD/CAM ceramic, and gold inlays, respectively, were included. Over a 9-year observation period, the number of undiscounted failure-free years was 8.62 (95 percent confidence interval, 8.40-8.85), 8.65 (8.58-8.73), and 8.76 (8.72-8.80) for laboratory-fabricated ceramic, chairside CAD/CAM ceramic, and gold inlays, respectively. Laboratory-fabricated ceramic inlays were the most expensive. CONCLUSIONS: While laboratory-fabricated ceramic, chairside CAD/CAM ceramic, and gold inlays had a strikingly similar failure-free survival rate, laboratory-fabricated ceramic inlays had the highest costs and, thus, were less cost-effective than chairside CAD/CAM ceramic and gold inlays.

Utilitarian theories reconsidered: common misconceptions, more recent developments, and health policy implications.

Despite the prevalence of the terms utilitarianism and utilitarian in the health care and health policy literature, anecdotal evidence suggests that authors are often not fully aware of the diversity of utilitarian theories, their principles, and implications. Further, it seems that authors often categorically reject utilitarianism under the assumption that it violates individual rights. The tendency of act utilitarianism to neglect individual rights is attenuated, however, by the diminishing marginal utility of wealth and the disutility of a protest by those who are disadvantaged. In practice, act utilitarians tend to introduce moral rules and preserve traditional rules. At the same time, the tenability of rule utilitarianism is limited because it ultimately collapses into act utilitarianism or a deontological theory. Negative utilitarianism is a viable utilitarian variant only if we accept complete aversion to suffering, ie, if we disregard any forgone opportunities to increase pleasure. Finally, the adoption of preference utilitarianism requires us to accept the subjectivity of individual claims which may be perceived as unfair.

[At what time is a reduction of medical under- or overtreatment sensible? Treatment of acute depression as an example]. / Wann lohnt sich der Abbau medizinischer Unter- und Uberversorgung? Das Beispiel der Behandlung akuter Depressionen.

OBJECTIVE: 1) To portray the mathematical relationship between the size of an underuse or overuse problem caused by non-compliance of health professionals and the cost-effectiveness of a quality improvement program; 2) to demonstrate the applicability of the models to a real-world problem (underuse and overuse in the treatment of major depression) and to stress the importance of the costs of a quality improvement program using this example. METHODS: Mathematical formulation of the relationship between the costs of a quality improvement program and the degree of underuse and overuse. RESULTS: The example of reducing underuse in the treatment of major depression shows that an intervention with a favorable cost-effectiveness ratio may be economically unattractive if a quality improvement program incurs high costs secondary to a small quality deficit. The application example also shows that reducing treatment overuse is inefficient if overuse is small and hence the costs of a quality improvement program are higher than the costs of overuse. CONCLUSIONS: The explicit consideration of the size of an underuse or overuse problem in the cost-effectiveness ratio of a quality improvement program may contribute to a more efficient use of health care resources.

A cost-effectiveness model of screening strategies for amblyopia and risk factors and its application in a german setting.

PURPOSE: To develop a general setting-independent decision-analytical model that determines the costs, effectiveness, and cost-effectiveness of four screening strategies to detect amblyopia or amblyogenic factors in pre-school children and to apply the model in a German setting. METHODS: The general setting-independent decision-analytical model was developed from the perspective of society and the statutory health insurance was developed. Outcomes were the total number of newly detected true positive cases of amblyopia and the costs per newly detected true positive case of amblyopia. Strategies were screening of high-risk children up to the age of 1 year (ophthalmologists), screening of all children up to the age of 1 year (ophthalmologists), screening of all children aged 3 to 4 years (pediatricians or general practitioners), and screening of children aged 3 to 4 years visiting kindergarten (orthoptists). For the application example in a German setting, data from the published medical literature were used. RESULTS: In the base-case analysis of the application example, screening high-risk children by ophthalmologists had the lowest average cost per case detected but became dominated (less effective and more costly than an alternative) if a low (5.3%) probability of familial clustering of strabismus was assumed. Considering the various assumptions tested in the sensitivity analysis, screening of all children up to the age of 1 year by ophthalmologists was the only strategy not dominated by others. Detection rates, including cases detected before screening, were between 72% and 78% for the strategies that screen for all children. CONCLUSIONS: The model suggests that in Germany, both from a cost-effectiveness and a pure effectiveness point of view, screening all children up to the age of 1 year by ophthalmologists is the preferred strategy to detect amblyopia or amblyogenic factors. All strategies left a significant portion of children undetected.