Key Aspects of a Sustainable Health Insurance System in Germany.

BACKGROUND: The main goals of health-care systems are to improve the health of the population they serve, respond to people's legitimate expectations, and offer fair financing. As a result, the health system in Germany is subject to continuous adaption as well as public and political discussions about its design. OBJECTIVE: This paper analyzes the key challenges for the German health-care system and the underlying factors driving these challenges. We aim to identify possible solutions to put the German health-care system in a better position to face these challenges. METHODS: We utilize a broad array of methods to answer these questions, including a review of the published and grey literature on health-care planning in Germany, semi-structured interviews with stakeholders in the system, and an online questionnaire. RESULTS: We find that the most urgent (and manageable) aspects that merit attention are holistic hospital planning, initiatives to increase (administrative) innovation in the health-care system, incentives to increase prevention, and approaches to increase analytical quality assurance. CONCLUSION: We found that hospital planning, innovation, quality control, and prevention, are considered to be the topics most in need of attention in the German health system.

Work-related musculoskeletal diseases and the workers' compensation.

The Industrial Accident Compensation Insurance Act (IACIA) regulates the workers' compensation insurance system and the standards for the recognition of occupational diseases (ODs). Since its establishment in 1994, the IACIA has been amended several times. Before 2008, the approval of compensation for work-related musculoskeletal diseases (WMSDs) was decided based on the recommendation of consultants of the Korea Workers' Compensation and Welfare Service (COMWEL). The IACIA was amended in 2008, and since then, the approval of compensation for occupational injuries has been decided based on the recommendation of COMWEL consultants, whereas the approval of compensation for ODs was decided based on the judgment of Committee on Occupational Diseases Judgment (CODJ) which was established in 2008. According to the 2013 amendment to the IACIA, degenerative musculoskeletal diseases among workers engaged in musculoskeletal-burdening work should be considered compensable ODs. Despite some commendable changes to the workers' compensation insurance system, other significant issues persist. To resolve these issues, related organizations including the associations of orthopedic surgery, neurosurgery, and occupational and environmental medicine; Ministry of Employment and Labor; and COMWEL need to work cooperatively.

The incremental value of medical nutrition therapy in weight management.

OBJECTIVE: To evaluate the incremental cost of and health benefits attributable to medical nutrition therapy (MNT) for managed care members participating in an obesity-related health management program. DESIGN: Retrospective case-control. METHODOLOGY: Overweight or obese adult managed care members who utilized the MNT benefit (n = 291) were matched, using propensity score matching, with similar individuals (n = 1,104) who did not utilize the MNT benefit. Health outcomes data on weight, body mass index (BMI), waist circumference, and physical exercise were collected via surveys administered at baseline and approximately 2 years later. PRINCIPAL FINDINGS: Both groups experienced statistically significant reductions in weight, BMI, and waist circumference and increases in exercise frequency. Compared with matched controls, individuals who received MNT were about twice as likely to achieve a clinically significant reduction in weight, with an adjusted odds ratio of 2.2 (95% confidence interval, -1.7-2.9; P < .001). They also experienced greater average reductions in weight (3.1 vs. 1.4 kg; beta = -1.75; t[1314] = -2.21; P = .028) and were more likely to exercise more frequently after participating in the program (F[1,1358] = 4.07, P = .044). There was no difference between the groups in waist circumference. The MNT benefit was used by 5% of eligible members and cost $0.03 per member per month. CONCLUSION: MNT is a valuable adjunct to health management programs that can be implemented for a relatively low cost. MNT warrants serious consideration as a standard inclusion in health benefit plans.

[On the selected problems of the involvement of spa-and-resort facilities in the implementation of territorial programs of compulsory medical insurance].

The inclusion of spa-and-resort facilities in the sphere of compulsory medical insurance is in accordance with the law "On the compulsory medical insurance in the Russian Federation". However, this work implies serious preparatory activity aimed at estimating the requirements of different groups of the country's population in the follow-up treatment and rehabilitation based at the spa-and-resort facilities as well as the available resources for this purpose, modes of payment, rate structure, etc. The spa and resort-based treatment within the framework of the compulsory medical insurance system must be made one of the components of the regional programs of medical rehabilitation.

[Competition between hospitals--from a legal perspective]. / Wettbewerb zwischen Krankenhäusern--aus uristischer Sicht.

Competition between hospitals exists in many different fields. In legal terms this competition is shaped by disputes over the status of "hospitals forming part of the Hospital Plan" (Plankrankenhaus). The German Federal Constitutional Court's ruling of January 14, 2004 granted hospital authorities the right of action for unfair competition. According to the Federal Administrative Court's ruling of September 25, 2008, however, third-party protection is limited to cases where the hospital filing the suit has itself unsuccessfully applied for inclusion in the state-level hospitals plan for the market segment served by the accepted hospital. In contrast, action that merely challenges an unfair preference of a competitor will remain inadmissible. Third-party protection between hospitals is also under way in the field of "Integrated Healthcare" (Integrierte Versorgung) (Sect. 140a et seqq. Book V of the German Social Security Code-SGB V): in the case of ECJ C-300/07 on December 16, 2008 (Oymanns/AOK Rheinland & Hamburg) the Advocate General in his final submissions not only expressed the opinion that the statutory health insurance funds are contract-placing authorities, but also argued that integration contracts are public orders. If the European Court of Justice (ECJ) takes the Advocate General's view, future integration contracts will become subject to the regulations governing public orders and thus also subject to the relevant verification procedure.

[Comprehensive Care Centre and section 116b SGB V. Experiences from the point of view of the health insurance company]. / Comprehensive Care Center und section sign 116b SGB V. Erfahrungen aus der Sicht des Kostenträgers.

Through the GMG (modified law of health system) the section sign 116b "out-patients department" was newly introduced into the SGB V (5(th) social welfare legislation) in 2004. Thus, the health insurance companies had the possibility to come to an agreement with hospitals concerning rare illnesses such as haemophilia. On this basis a care agreement was agreed upon in 2005 between the University Hospital Eppendorf (Hamburg) and three big health insurance companies. The result leads to positive changes for all concerned: The patients were offered an optimal care through the link to the CCC and this with an adequate compensation for the coagulation section for out-patients. As the therapy programme became more clarified, the communication between the parties involved became more constructive. With the law to strengthen competition (WSG) for the insurance companies, a change of section sign 116b of the SGB V (5(th) social welfare legislation) came into force in 2007. Thus the legal basis for the a. m. agreement was withdrawn. It is now the task of the a. m. parties to find a way to secure the advantages obtained through this agreement, to the benefit of the patients, the coagulation sections for out-patients and the cost bearers.

[Medical centers--from a Statutory Health Insurance Company's perspective]. / Medizinische Zentren--Anforderungen aus Sicht der GKV.

In the course of recent activities involving the bundling of healthcare institutions into so-called "Centers", many kinds of Healthcare Centers, Breast Centers, Comprehensive Cancer Centers etc. have been established. The term "Center" suggests expertise and superiority, and, without doubt, centers take medical care closer to higher quality and cost efficiency at the same time. However, there are preconditions which need to be fulfilled, such as the compliance with certain structural and process-oriented criteria in patient care. From the perspective of the compulsory health insurance funds, this raises questions regarding the type of centers that should be supported, the requirements that must be met, and the role that centers are assigned within the complex of our healthcare system. For health insurance purposes, Medical Centers provide innovative structural conditions for group-balanced concepts. Since the Statutory Health Insurance System Modernization Act (GKV-Modernisierungsgesetz and 140 a ff. SGB V) has provided individual contract options and inpatient oriented institutions have opened up to offer highly specialized ambulatory treatment (and 116b SGB V), centers have become attractive contractual partners for health insurance companies. The present article describes expectations and requirements in relation to the formation of Medical Centers from the perspective of a compulsory health insurance company, focusing on oncological centers.

[Setting up an interdisciplinary cancer center between the poles of internal and external interests]. / Etablierung eines interdisziplinären Krebszentrums im Spannungsfeld interner und externer Interessen.

Excellence in oncology requires specialized centers covering a broad spectrum of oncological competence and technology. Such Comprehensive Cancer Centers, which in most cases are affiliated with a university, are well established in many countries, particularly North America. But despite their advantages, only few of these interdisciplinary cancer centers have so far been set up in Germany. The establishment of a Comprehensive Cancer Center covering patient care, cancer research as well as education and training in Germany will be discussed using the example of the Dresden University Cancer Center. Consideration will be given to the interests of the different groups involved and to critical success factors such as its mission, interdisciplinary leadership structures, interfaces, responsibilities and quality management.

Made in the USA: the import of American Consumer Assessment of Health Plan Surveys (CAHPS) into the Dutch social insurance system.

BACKGROUND: In the Netherlands, managed competition between health plans has been introduced. For Dutch health plans this implies that they need to collect data about their own performance and that of the care providers they contract. To that end, Consumer Assessment of Health Plan Surveys (CAHPS) instruments have recently been adopted by a large Dutch health plan. OBJECTIVES: This paper presents the results of a validation study of the Dutch version of the CAHPS Adult Commercial questionnaire. The questions addressed are as follows: Can this questionnaire be adapted for use in the context of the Dutch insurance system? and Can it generate valid information about the quality of health care and the performance of Dutch health plans? METHODS: The translated questionnaire has been mailed to a sample of 977 enrollees. The psychometric properties of the translated instrument have been studied, and the results have been compared with those of other Dutch and American studies. RESULTS: The net response rate was 51% (n = 500). In general, the questionnaires were filled out completely and consistently. Principal component analyses revealed a factor that can be labelled as patient-centredness in the primary process. It contains the domains that in the CAHPS literature are described as 'courteous/helpful staff' and 'doctors communicating well'. CONCLUSIONS: The translated version of the CAHPS Adult Commercial questionnaire is a promising tool for Dutch health plans. More research is needed on the external and the content validity of these questionnaires in the Dutch context.

Shifting the focus from cost to value: a private payer perspective.

OBJECTIVE: To present the issues, concerns, and advances possible as private (commercial) payers attempt to incorporate value into their health care plans, using a commercial provider of disease and medication management as a model. SUMMARY: Most approaches to health care have dealt with persistent or chronic diseases, but, increasingly, payers are expanding their interests to include wellness, high-risk case management, and care management. Technology is crucial in health care today, enabling clinicians to reach out to patients, capture data, and integrate medical and pharmaceutical data. Data integration will help build efficiencies and effective ways to deal with the growing population of patients who have chronic disease. The disease-centric model is being replaced with a patient-centric model. Health care providers must help patients identify their unique motivators and de-motivators and encourage them to be self-sufficient partners in their own health care. CONCLUSION: Adding value to traditional health care is a task that seems daunting at first. It is not insurmountable, however, and ultimately, adding value decreases cost in unprecedented ways.