Financial alignment Part 1Next step forward to disease management in the

Netherlands: functional pricing for chronic conditions

Evelien van der Vinne , Wageningen, The Netherlands

Introduction

olicy makers across the world increasingly recognise that chronic conditions and

diseases are one of the most important challenges that health systems face. The

World Health Organisation (WHO) has identified chronic conditions to be the

leading cause of morbidity and mortality by 2020 and, if not successfully managed, they will

become the most expensive problem for health care systems1.

PAccording to the WHO definition, chronic conditions are health problems that require

continuous comprehensive and complex management over a period of years or

decades2.Moreover, these conditions require coordinated input from a wide range of

1Mathers CD, Loncar D. Updated Projections of Global Mortality and Burden of Disease, 2002–2030: Data Sources, Methods and Results. Geneva: World Health Organization (Evidence and Information for PolicyWorking Paper), 2005. Available at http://www.who.int/healthinfo/statistics/bodprojections2030/en/index.html

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multidisciplinary health professionals, regardless which country they live. New models of

providing integrated health care were being introduced in Europe and the USA in response to

the fragmented health care3. The models are as diverse as the healthcare systems are, but they

share the focus on patients needs and cost reduction. Most countries developed new models

inpsired by the concept ‘Disease Management’. According to the Disease Management

Association of America (DMAA)4, disease management is “a system of coordinated

healthcare interventions and communications for populations with conditions in which patient

self-care efforts are significant.” It focuses on the management of chronically ill patients, with

the goal of slowing progression of disease and avoiding costly hospitalizations and delaying

complications. The key components of Disease Management are eg. prevention of

exacerbations and complications/comorbidity utilizing evidence-based practice guidelines and

patient empowerment strategies, evaluation of outcomes and collaborative practice models to

include physicians and support-service providers.

The mission for the 21 century is to align care to vertical integrated chains by substitution of

expensive inpatient care for outpatient care and rearrangement of tasks over multi-

providerdisciplins. This vertical integration requires a more dominant role for professionals in

primary care. Last decennia, primary care reform is a worldwide imperative5. National health

care systems with strong primary care infrastructures have healthier populations, fewer

health-related disparities and lower overall costs for health care6. The WHO7 encouraged all

countries to orient their health care systems toward strengthened primary care. Such reforms

are only succesful if they‘re enforced by financial incentives8. To ensure integration and

substitution, financial flows must be first aligned and incorporated. Financial alignment is the

catalyst of disease management.9

In The Netherlands, minister Klink of Department Public Health, Welness and Sports(PHWS)

has proposed a new finance mechanism for outpatient, primary chronical care ie. functional

5 Starfield B Toward international primary care reform. CMAJ • MAY 26, 2009 • 180(11), http://www.cmaj.ca/cgi/reprint/180/11/10916 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.7 World Health Organization. The world health report 2008: primary health care:now more than ever. Geneva (Switzerland): The Organization; 2008. Available:www.who.int/whr/2008/whr08_en.pdf (accessed 2009 Apr. 17).8 Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-18.9 Gleave, R. ACROSS THE POND – LESSONS FROM THE US ON INTEGRATED HEALTHCARE. The Nuffield Trust 59 New Cavendish Street, London. Website: www.nuffieldtrust.org.uk 2009

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pricing; an outpatient DRG for a chronic disease. This is a next step forward to disease

management in the Netherlands.

Other countries used other strategies because of other health care systems.There’s no one-

size-fits-all solution, but general lessons can be learned. Comparison with other

(vertical)systems, (finance)mechanisms and (disease management)programs provide insight

into a countries own system and reform plans but provide also interesting options for future

directions for other countries.

Chapter 1 describes The Dutch health care system with the arise of disease management,

vertical integration, role for general practitioners and functional pricing.

Chapter 2 describes the lessons from the east and west; the USA and Japan by the same

sections: disease management, vertical integration, role for general practitioners and

functional pricing. Chapter 3 gives the lessons from Europe: United Kingdom, France and

Germany. The last chapter (4) summarizes the articel and gives insights for future directions.

The Dutch health Insurance system

ince 2006, The Dutch health care system(primary and hospitalcare) is a national

insurance-based system with free choice for insurerd and managed competition

between private insurers10111213. Managed competition is an artificial free marketplace

run under strict government control and regulation.1415 The government sets a standard

‘basic’package for the basicinsurance and mandates individuals to purchase a basic

healthinsurance. Individuals have a free choice of health insurers and health providers.

Insurers compete on price, cost sharing, and additional services.

SEssential features of the managed competition market are risk adjustment, open enrollment

and community rating. A system of risk equalisation16 compensates the financial risks (c.q.

high costs of patients) more evenly over the health insurers which enables insurers to meet

their acceptance obligation and prevents (in)direct risk selection by insurers.17 Risk

equalisation devides 50% of the health care costs to insurers by adjustment for age, gender,

morbidity etc. Open enrollment reflects to the obligation for insurers to accept applicants and

free choice of insurer. Community rating reflects to the obligation for insurers to offer the

basic benefits package for each enrollee for the same nominal premium (non risk related).

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Competing health insurers obtained various tools to attract consumers. With respect to the

mandatory basic benefit package they compete on price, and are allowed to offer premium

discounts for group contracts. Health insurers can also compete with different (voluntary)

supplementary insurance packages(dentistry, physiotherapy), service levels and different

types of preferred provider networks. Especially this latter tool (selective contracting) should

encourage health insurers to bargain favourable contracts with health care providers to offer

preferred provider arrangements.There are trends in healthcare to vertical integration like

PPO’s or HMO’s. These models stimulate patient-centric, coordinated, seamless connected

health care if health insurers succeed in steering their enrollees only to those efficient

providers with high quality. In return, enrollees don’t have to pay the compulsory axcess of

165 euro. This mechanism can only work if information about quality of care is available and

enrollees are willing to be steerd. At the moment, in 2009, there is still competition on price

only, premiums are hardly profitable. Nevertheless, on the background, health insurers are

building up disease managementstrategies, negotiate with patientfoundations and offer special

insurancepackages with high quality care (eg. “Topcare”). So The Netherlands is in the

starting blocks to compete on quality of care by creating disease management arrangements

with selected preferred providers.

Disease management in The Netherlands

n the Netherlands disease management was started as “transmural care” as an attempt to

overcome persistent barriers between ambulatory and acute services18. Transmural care

aims to link primary, outpatient and secondary inpatient care; it has been defined as care

geared towards the needs of the patient, provided on the basis of cooperation and coordination

between general and specialized caregivers, with shared responsibilities and specification of

delegated responsibilities1920. Transmural care has been likened to shared care concepts in the

United Kingdom and integrated care in the United States 212223. Transmural care concepts in

the Netherlands vary widely, with early approaches focusing on structural elements. Later,

there was a growing awareness for redesigning health care, with a shift in the focus from

acute care to chronical care.24

I

More recently, rehabilitation wards were created for patients who required temporary care

after hospitalization. Also, advances in technology, telemonitoring, made it possible to

transfer certain services that were previously restricted to the hospital setting into the patient’s

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home. Over time, transmural care approaches became increasingly complex, as exemplified

by the development of disease management programmes, involving cooperation between a

greater range of health care facilities and health professionals25.

This “bottom-up” approach used in the creation and implementation of these programmes has

unfortunately contributed to fragmentation. There was considerable resistance on the part of

General Practitionars and medical specialists to the idea of a new professional group

‘transmural nurses’, taking on their responsibilities and tasks. New nursingroles were also

seen as a threat as they risk increasing future shortages of nurses. There was no government

strategy on issues such as integrated care and chronic disease management. The benefits of

the “bottom-up” approach were the local tailormade programmes, the intense motivation and

close cooperation. Despite the lack of government intervention, both providers and payers

saw the ‘Atlantic Disease Management wave’ comming up to Europe as an inevitable trend in

their own health care landscape. They were charmed by the key-element of DM; its patients

centric character, focusing on patients medical needs. After all, all chronic patients (all over

the world) have the same symptoms and needs.

During the 1990’s there was an increasing rumor in DM-land. Ceo’s from large insurance

companies saw costoppotunities and made hot studytours to the USA to learn about the

concepts “Managed Care” and “Disease Management”. Congresses26 (STG) were organized

about how to deal with disease management and the role of the general practicioner within it

and how to align general care to hosipatal care. Hot discussiontopics between providers and

payers were the fragmented nature (bulkheads/fences in the care) and finance structure of the

Dutch health system. Many health providers submitted DM-proposals to the insurer but were

rejected because of lack of legal options to align financial flows. This resulted in a lot of

frustrations at both sides. However, many projects, which were funded, were being financed

for the most part by health insurers.

In 1996/1997 first articles and thesis about Disease Management were published by Dutch

authors272829 Since the 2006 health insurers are writing policy documents whitin their vision on

disease management and quality agreements with preferred providers. The big three, Achmea,

CZ and Uvit, have written such policies.30

In 2008 Zon MW (Healthcare Research Netherlands)31 started a large scale, Disease

Management Program commissioned and mainly funded by the Ministry of PHWS for twelf

miljon euro. There are 22 providergroup experiments with the disease management approach

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in practice.The experiments are implemented across the Netherlands and vary in size, chronic

disease, focus (selfmanagement or guidelines) and composition of providers and insurers. The

Erasmus University conducts the research for economic evaluation. This initiative is a

fundamental step in the development of DM in the Netherlands.

The road to vertical integration in the Netherlands

ecent reforms in Dutch healthcare sector have introduced the possibility of

selective contracting of providers by insurers. Selective contracting is intended to

stimulate competition between healthcare providers. New forms of vertical

relations between health insurers and healthcare providers will arise(e.g., exclusive contracts

between insurers and hospitals, or between insurers and general practitioners) and may

potentially increase the extent of vertical relations, ranging from selective contracting to

(partial or full) vertical integration.32

RVertical relations have several positive effects. First, vertical integration and vertical contracts

can be used to coordinate pricing and investment decisions of vertically related firms, by

aligning their pricing and investment incentives. Because the products offered by vertically

related firms are complementary in nature, vertical integration can increase welfare. Second,

vertical integration and vertical contracts can also reduce horizontal spillovers between

horizontally related firms competing at some level of the vertical chain (for example among

healthcare providers, or among health insurers). Last, but not least, they solve problems that

result from informational asymmetry or contractual incompleteness. This last advantage is

probably the most important in this case, given the pervasive information asymmetries

between insurers and providers. 3334

So far, there has been little experience in the Netherlands with selective contracting or

vertical integration. However, it is widely expected that vertical relations will proliferate in

the near future. The biggest insurer, Achmea, opens insurance stores in hospitals and primary

care centres.

The only known insurance where selective contracting was used actively, in the sense that the

insurer has contracted only a small number of hospitals to offer an insurance policy fully

covering only these hospitals, is the ‘Zekur polis’ of the Dutch health insurer Univé. This

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insurance policy offers full reimbursement for only 13 hospitals in the Netherlands; if the

policyholder visits other hospitals, a co-payment of 20% is required.

Also, there are few examples of stronger forms of vertical relations: one case of partial

vertical integration between a hospital and an insurer (the take-over of a minority share in a

small orthopaedic clinic by the CZ insurance group), some examples of financing of general

practitioner (GP) medical centres by insurer Menzis.

Finally, a small regional insurer DSW has financial interests in a number pharmacies and

health centers, and DSW has announced its wish to participate in a regional cooperative

partnership with a general practitioners group, nursing homes and medical staff and hospital

staff that wants to take over the hospital Vlietland. As a respons, opposition parties submitted

a motion with a request to ban this hospital takeover by DSW. The motion was accepted but

so was the takeover. The motion requested a ban on a complete acquisition but DSW wanted

te be part-owner of the Vlietland Hospital. Minister Klink examined whether there were any

legal obstacles for a complete acquisition. His research comitte concluded that a legal ban on

vertical integration between insurers and health providers is not necessary and proportional to

ensure the public interests of quality, affordability and accessibility of care.

Moreover, a ban would be in conflict with European law and easy to circumvent. So this

payer-provider case rumoured politics and a final decision on mergers has not yet been taken.

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Lessons from East and West

Introduction

lthough all healthcare systems are different, they can be grouped into four

"archetypes".35 Socialised medicine (as in Britain or Sweden) covers everybody,

has a single payer, and usually has those who provide care salaried or capitated

(paid so much for every person for whom they provide care). Socialised insurance (as in

Australia, Canada, or France) also covers everybody and has a single payer but pays those

who provide care a fee for each service. Mandatory insurance (as in Germany, Netherlands,

Japan) again covers everybody but has multiple sickness funds or insurance carriers and

provides care through a mixture of salaried public providers and private providers paid a fee

for each service. Voluntary insurance (as in the United States or South Africa) does not offer

coverage to everybody and has many payers and providers and different systems of payment

and delivery.

A

In the USA, managed care has been a central strategy in the reform programme. Disease

management is one of the key tools that managed care organizations (MCOs) have used in

attempting to control costs and assure quality. Its apparent success has been promoted as a

basis for further reform in Europe36.

Lessons from the West: USA

35 AtKearny, Healthcare Out of Balance: How Global Forces Will Reshape the Health of Nations. Jonathan Anscombe, September 2009. http://www.atkearney.com/images/global/pdf/healthcareoutofbalance.pdf.

36 McKee Martin; Suhrcke Marc; Nolte Ellen; Lessof Suszy; Figueras Josep; Duran Antonio; Menabde Nata Health systems, health, and wealth: a European perspective. Lancet 2009;373(9660):349-51. European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, London, UK.

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he first lesson to be learned is that development of disease management is long term

proces. Processes with different waves, learning curves and dominant topics.

Therefore disease management needs a long term strategic vision. The management

of disease(mesolevel) requires also a long-term view, since the effects of a treatment may

only be realized after many years. Pressure for short-term results or benefits can lead to the

rejection of better alternatives that do not yield quick returns.37

TDisease management

isease management established in the USA bottom up, by private

entrepreneurship under the umbrella Managed Care. Managed care has developed

primarily as a response to the potentially perverse effects of incentives in the

health insurance market and fragmentation in the delivery system.

DPharmaceutical benefit programs arised in the very first beginning of DM with drug

compliance programmes for stronger selfmanagement and to ensure sales.38.

Traditionally, physicians in the USA were paid fee-for-service which stimulated

overtreatment. As a response, Managed Care models or health insurance plans were created to

reduce unnecessary health care costs.39 However, Porter and Teisburg saw the origin in a more

dominant rol for primary care physicians close to the patient, to monitor that delivered care

was neither too much nor too little, involved with appropriate specialists and reflected

individual patients’ needs and values.40 Both visions are not contradictory but complementary,

it is to create health insurance plans that combine vertical integration with a dominant role for

primary care to stimulate substitution to low cost care.

Health insurance plans contains DMP’s focusing on high risk, expensive, chronical conditions

like diabetes mellitus, cardiac diseases, chronic heart failure, CVA, cancer etc where high cost

38 Pilnick A; Dingwall R; Starkey K Disease management: definitions, difficulties and future directions. Bulletin of the World Health Organization 2001;79(8):755-63. Genetics and Society Unit, School of Sociology and Social Policy, University of Nottingham, England. Alison.Pilnick@nottingham.ac.uk 39 National Library of Medicine (2008) www.ncbi.nlm. nih.gov/sites/entrez. 40 Porter, M and Teisburg, E (2006) Redefining Health Care: Creating value-based competition on results. Cambridge, Mass: Harvard Business School Press.

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reductions could be achieved. The aim was to prevent or delay comorbidities and

complications, so the emphasis was on secondary and tertiary prevention rather than primary

prevention. Disease management programs identify and deliver the most effective and

efficiënt combination of available resources; support the physician-patient relationship;

emphasize prevention of exacerbations and complications of chronic conditions; and

continuously evaluate clinical, functional, and economic outcomes of treatment. Although

disease management programs vary in nature and scope, the following key components are

common41:

_ Population identification process and patient registry

_ Evidence-based practice guidelines

_ Case management and support services

_ Screening, risk stratification, and matching interventions with need

_ Patient monitoring, self-management education, and satisfaction surveys

_ Treatment intervention, outcome measurement, and reporting

_ Appropriate use of information technology such as specialized software,

computerized data warehouse, automated decision support tools, and callback systems In

fact, first-generation disease management companies are giving way to second-generation

companies that have embraced electronic disease management programs. Technologies used

by electronic disease management companies include telephonic interactive voice response

systems, patient monitoring devices, videoconferencing, and, of course, the Internet.

An additional driver of disease management, especially during the last 15 years, has been

aggressive marketing by a growing commercial disease management industry seeking profits

in a new market.

There are two basic types of disease management programs—those based on primary care and

integrated within a managed care organization (eg, Group Health Cooperative and Kaiser

Permanente), and commercial vendors to which employers and health plans may outsource

their disease management functions. The former has been well accepted within the medical

community as an important advance in the care of chronic disease. Group Health Cooperative

and Kaiser Permanente have pioneered new approaches to chronic disease management based

upon a new paradigm, the Chronic Care Model42. For example, primary care teams are

provided support in the form of electronic diabetes registries, evidence-based guidelines,

patient self-management support, and decentralized on-site consultation with a diabetes expert

team (a physician and a nurse specialist). Early commercial disease management programs

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were designed to identify high-risk patients with a single disease and then to sell a program of

patient education and self-management to employers and managed care organizations.

A large commercial disease management industry has emerged that utilizes claims data to

identify patients with selected chronic diseases. Commercial disease management vendors

increasingly sell their programs for multiple diseases, more population based. Although

participation in a disease management program has remained voluntary for patients, the trend

is to include all patients with selected chronic diseases unless they opt out of the program.

Another next trend was the expansion into the “wellness” arena via the acquisition of wellness

companies. This evolution from separate disease management programs and separate wellness

programs into “total population health management” was a natural evolution that satisfied

market demand, economies of scale, etc. Shortly after this consolidation phase of the market,

many DM/Health Management Companies also began to explore international opportunities,

to export ‘US-style’ disease-management programs.

Vertical integration

anaged care covers diseasae management programmes in a broad range of care

models. The two leading models are health maintenance organizations (HMOs)

and preferred provider organizations (PPOs43). HMOs are based on ‘vertical

integration,’ while PPOs favor ‘virtual integration.’ Vertical integration is associated with

‘closed systems,’ where hospitals, physician groups, and insurance companies are fully

interrelated and only members of the health plan can access the delivery system. HMO is an

insurance product that uses pre-paid capitated payment to a physician or group of physicians

(usually combined with a requirement that referral to a specialist is made by a PCP) so they

are often linked with group practice or independent practioners associations (IPA)s. HMOs

are often integrated systems of physician groups, hospitals and insurance companies, but can

also maintain collaborative arrangements with hospitals that are ‘outside’ the system. A PPO

is a ‘virtually integrated system’ with a ‘provider network’ whereby an insurance company

has established a cooperative agreement with hospitals and physician groups regarding

payment levels and reimbursable health care services for subscribers. Physicians and hospitals

may treat patients from a number of health insurance plans with a variety of agreements.

Preferred provider organisations (PPOs)

M

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are another insurance product that is more likely to use negotiated fee-for-service payments

with a specified network of physicians and hospitals and so have a much weaker association

with providers seeking to deliver integrated care.

Managed Care Organisations(MCO) limited the financial commitment of payers by paying

clinicians a periodic fee per life covered and making them share the risk of costs for excessive

or expensive treatment. MCO payers may be employers, insurers, the state, or, more rarely,

individual clients. the MCOs’ economic incentives are usually reinforced by a range of direct

interventions. These typically include controls on clinical autonomy, controls on patient

choice and a degree of vertical integration. Vertical integration may take a number of forms,

varying from mergers between primary and secondary care providers to contractual

arrangements where specialist or secondary care providers offer MCOs preferred partner

arrangements, including discounted fees. As a result of such restriction and standardization,

whereby patients relinquish some freedom of choice.

An important issue is whether disease management should be provided by traditional health

insurers or by carve-out disease management companies. Those based on primary care and

integrated within a managed care organization (eg, Group Health Cooperative and Kaiser

Permanente) has been well accepted within the medical community as an important advance

in the care of chronic disease4445.

Commercial vendors could act as contractual intermediaries between consumers and

providers, and implement payment for quality outside of the scope of a traditional insurance

policy. In a market with multiple insurance plans, having a single carve-out company would

eliminate adverse selection, and care could be portable across insurers. Such a solution has

disadvantages, however, including the potential decrease in care coordination resulting from

the separation of ordinary care, and the possible duplication of infrastructure investment46.

44 Geyman John P Disease management: panacea, another false hope, or something in between? Annals of family medicine 2007;5(3):257-60. Department of Family Medicine, University of Washington, Seattle, Wash, USA. jgeyman@u.washington.edu, http://www.annfammed.org/cgi/content/full/5/3/257.45 Nancy Dean Beaulieu Harvard Business School David M. Cutler and Katherine E. Ho Harvard University Dennis Horrigan Independent Health Association George Isham HealthPartners THE BUSINESS CASE FOR DIABETES DISEASE MANAGEMENT AT TWO MANAGED CARE ORGANIZATIONS: A CASE STUDY OF HEALTHPARTNERS AND INDEPENDENT HEALTH ASSOCIATION FIELD REPORT April 2003 The Commonwealth Fund.

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In Bodenheimers vision, disease management should be performed within healthcare

institutions and be integrated with primary care rather than being outsourced to specialised

commercial entities4748

Dixon et al. believe in competitive pressure between managed care organisations as an

incentive for innovation in management of chronic diseases. Doctors in these organisations

have a strong management role. Goals are agreed between clinicians and managers, and

financial incentives exist to improve care.49.

Again, it is to combine incentives: to align existing providers to an efficient partnership with

sound managerial leadership and accountability, strong awareness of innovations and

possibilities for substitution by adjusted capitation.

Lessons from the East: Japan

apan is facing one of the most rapidly aging populations in the world. In 2000, 17.2 %

of Japan’s population was age 65 or older. By the year 2020, 26.9 % of the population

will be over age 65. The number of individuals needing long-term care is expected to

double between 1997 and 2025.50

JDisease management

n Japan, disease management established in a different way than in the USA. In the

Japanese national regulated system, a national governemental program tends to fit better

than a local private program introduced by MCO’s in the USA. Futhermore , in a

universal insurance system there’s a significant role for health insurers, so it’s more likely that

insurers develop programs, programs to controll healthy behavior with financial incentives.

The rapidly aging population forced the government to focus on primary prevention rather

than secundary or tertiary prevention. There’s also no general practitioner in the system to

I50 Jeong, Hyoung-Sun and Jeremy Hurst. “An Assessment of the Performance of the Japanese Health Care System,” OECD Labour Market and Social Policy Occasional Papers, No. 56, OECD Publishing.

13

enforce. So Disease management performed as the National Chronic Disease Prevention

Program51.

In 2000, The Japanese Ministry of Health, Labour and Welfare (MHLW) launched a policy

known as National Health Promotion in the 21st Century. The National Chronic Disease

Prevention program52 is one of the main features. The sense of crisis and the intent to reduce

the future chronic disease burden combined to drive the development of this large-scale

project. The National Chronic Disease Prevention Program focuses on lifestyle-related disease

and metabolic syndrome with primairy prevention.

The campaign was named “Kenko-Nippon-21” 53 (Healthy Japan 21); this was aimed at

promoting health at a national level. Concrete numerical targets that are required to be met by

2010 were set across 9 fields, namely, (1) nutrition and diet, (2) physical activity, (3) mental

health, (4) tobacco, (5) alcohol, (6) dental health, (7) diabetes mellitus, (8) cardiovascular

diseases, and (9) cancer54.

According to the reform law passed by the congress in June 2006, health insurers were

required to provide annual health checkups to all beneficiaries aged 40–74 years starting in

April 2008 and give ‘health guidance’ to those who are found to be at risk of ‘metabolic

syndrome’ to change their unhealthy life-style or maintain good control of their diseases. The

ambitious goal is to reduce the number of metabolic syndrome patients by at least 25%

between 2008 and 2015 with a hope that health care cost may be controlled consequently.

Japan’s NHI Act 55explicitly states that insurers ‘‘shall refuse reimbursement if disease or

injury are intentionally caused by the insured (article 116)’’, or ‘‘caused by grave misconduct

or negligence (article 117)’’ and ‘‘may withhold reimbursement if the insured refuses to

follow doctor’s directions (article 119)’’. Doctors are required to report to the insurers when

they find such patients (Practicing Rules, article 10). These fine-printed disclaimers are

necessary to prevent moral hazards and protect the common interest of the insured population.

Insurers nationwide are rolling out new programs. The Komatsu Health Insurance Society has

been operating lifestyle-related disease prevention programs for the insureds and their

dependents since 1999 already. Komatsu Health Insurance is implementing the National

Mandatory Chronic Disease Prevention Program using these programs. Komatsu Health

Insurance has various lifestyle-related disease prevention programs. Among the dependents of

the insureds, Komatsu Health Insurance attaches particular importance to the wife, based on

the concept that she is in charge of family health. Under its health check system for wives

(Computer Doc), Komatsu sends health questionnaires to member wives, seventy percent of

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whom respond. Other features of Komatsu Health Insurance include activities promoting

health, health programs offered through collaboration with employers and labor union, and

the use of external entities as required, in order to provide diverse programs. Komatsu

received the first society award of the Japan Society of Health Support Science for it’s series

of lifestyle-related disease prevention programs.

Vertical integration2 World Health Organization. Innovative Care for Chronic Conditions: building blocks for action. Geneva: World Health Organization, 2003. www.who.int/diabetesaction online/about/icccreport/en/index.html (accessed 8December 2008).3 Congressional Budget Office (CBO) Testimony CONGRESSIONAL BUDGET OFFICE SECOND AND D STREETS, S.W. WASHINGTON, D.C. 20515 Statement of Peter R. Orszag Director The Overuse, Underuse, and Misuse of Health Care before the Committee on Finance United States Senate July 17, 2008. 4 DMAA: The Care Continuum Alliance. DMAA definition of disease management. Retrieved 2008-12-0410 Health care reform in the Netherlands by Rudy Douven, Esther Mot, Marc Pomp, CPB Netherlands Bureau for Economic Policy AnalysisDouven, R. C. M. H. and F. T. Schut (2006a), Health Plan Pricing Behaviour and Managed Competition", CPB discussion paper no 61, Den Haag.11 Health Insurance Act (Zorgverzekeringswet), Act of 16th June 2005 (Netherlands Bulletin of Acts, Orders and Decrees 2005, 358.12 Ministry of Health Welfare and Sport (2006),The New Care System in the Netherlands: Durability, Solidarity, Choice, Quality,Efficiency, Ministry of Health Welfare and Sport: http://www.minvws.nl/images/boekje-zorgstelsel--engels_tcm20-107938.pdf.13 The Ministry of Health, Welfare and Sport, Health Insurance in the Netherlands The new health insurance system from 2006, The Hague, 1st September 2005, downloaded from the ministry’s website at www.minvws.nl by keying in the search instruction “Health insurance in the Netherlands”.14 Alain Enthoven, “The History and Principles of Managed Competition,” Health Affairs 12, suppl. 1 (1993): 24–48.)15 Schut, E. (2006), Competition in health one year later, ESB-Dossier: Market in action, December 2006, pages 20-24 (in Dutch).16 The risk equilisation system adjusts for age, gender and client health characterstics and minimises the costs differences for health insurers resulting from the health profiles of the insured persons.17Michael Tanner, The Grass Is Not Always Greener. A Look at National Health Care Systems Around the World, Policy analysis, No. 613 March 18, 200818 Vrijhoef H J; Spreeuwenberg C; Eijkelberg I M; Wolffenbuttel B H; van Merode G G Adoption of disease management model for diabetes in region of Maastricht. BMJ (Clinical research ed.) 2001;323(7319):983-5.Department of Health Care Studies, Faculty of Health Sciences, University of Maastricht, The Netherlands. b.vrijhoef@zw.unimaas.nl19Maarse H; Mur-Veeman I; Spreeuwenberg C The reform of hospital care in the Netherlands. Medical care 1997;35(10 Suppl):OS26-39.Faculty of Health Sciences, Universiteit Maastricht, Netherlands.

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n Japan has an undifferentiated delivery system for inpatient hospital care and long-term

care. Therefore most institutional care is provided in hospitals rather than in nursing

homes. The payment mechanism reflected and reinforced the undifferentiated delivery

system. Elderly long-term patients were for a long time in the hospital, keeping expensive

beds occupied for acute patients.

I20 Steuten L M G; Vrijhoef H J M; Spreeuwenberg C; Van Merode G G Participation of general practitioners in disease management: experiences from The Netherlands. International journal of integrated care 2002;2():e24. Department of Health Care Studies, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands. L.Steuten@ZW.unimaas.nl21 Vrijhoef H J M; Diederiks J P M; Spreeuwenberg C; Wolffenbuttel B H R; van Wilderen L J G P The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes. International journal of nursing studies 2002;39(4):441-51. Department of Health Care Studies, University of Maastricht, P.O. Box 616, 6200 MD, Netherlands. b.vrijhoef@zw.unimaas.nl22 Steuten L M G; Vrijhoef H J M; van Merode G G; Severens J L; Spreeuwenberg C The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management. Journal of clinical epidemiology 2004;57(9):881-8. Department of Health Care Studies, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. L.Steuten@zw.unimaas.nl23 Steuten Lotte; Vrijhoef Bert; Severens Hans; van Merode Frits; Spreeuwenberg Cor Are we measuring what matters in health technology assessment of disease management? Systematic literature review. International journal of technology assessment in health care 2006;22(1):47-57. Department of Health Care Studies, Maastricht University, The Netherlands. L.Steuten@zw.unimaas.nl24 Wagner EH. Deconstructing heart failure disease management. Ann Intern Med. 2004;141:644-646.Grumbach K, Bodenheimer T. Can primary care teams improve primary care practice? JAMA. 2004;291:1246-1251.Bodenheimer T, Wagner EH, Grumbach K. Improving care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288:1909-1914.Weingarten S, Henning J, Badamgarav E, et al. Interventions used in disease management programmes for patients with chronic illness—which ones work: metaanalysis of published reports. BMJ. 2002;325:925-942.An analysis of the literature on disease management programs. Congressional Budget Office. Washington, DC: Congressional BudgetOffice; October 13, 2004. Available at: http://www.cbo.gov/ftpdocs/59xx/doc5909 /10-13-DiseaseMngmnt.pdf. Accessibility verified December 30, 2004. (Disease Management and the Organization of Physician Practice).25 Eijkelberg I M; Spreeuwenberg C; Mur-Veeman I M; Wolffenbuttel B H From shared care to disease management: key-influencing factors. International journal of integrated care 2001;1():e17. Faculty of Health Sciences, Department of Health Organisation, Policy and Economics, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands. I.Eijkelberg@beoz.unimaas.nl.

16

For this reason, Long-term Care Insurance (LTCI) was introduced in April 2000 with the goal

to introduce insurance for home care and new coverage for nursing home facilities and to

curtail social hospitalization. Several attempts to reform the elderly insurance were also

made56. These included (1) increase of co-payment, (2) increase of government contribution,

and (3) increase of age criterion for coverage of elderly insurance from 70 to 75 years.

So Japan is differentiating her system rather than integrating.

26Het congres “De toegevoegde waarde van Managed Care in de gezondheidszorg” op 26 juni 199527 Post, D., Disease management uitdaging voor verzekeraars, Doelmatigheid onder bewaking.(prof. Rijksuniversiteit Groningen en adviseur Onderzoek van ziektekostenverzekeraar Groene Land Verzekeringen.), Zorgverzekeraars magazine, juni 1996.Post, D., Disease management, Een nieuw beheersinstrument in de gezondheidszorg. Medisch Contact, nr 23, jaargang 51/ 7 juni 1996.Post, D., Disease management: een totaal visie op behandeling. Health Management Forum, nr 1, maart 1996.Post, D. Disease-management: een nieuwe taak voor de huisarts? Patient Care 1996, januari, p.8-9.28Schut, F.T., Managed Care: een terreinverkenning. Health Management Forum, nr 1, maart, 1996.Schut, F.T., Health Maintenance Organizations. Een geïntegreerde wijze van verstrekken en verzekeren van gezondheidszorg. Lochem, De Tijdstroom, 1986.29 Vinne, van der E, Een verkennende studie naar de mogelijkheden van disease management voor zorgverzekeraars Erasmus Universiteit Rotterdam, Instituut Beleid en Management Gezondheidszorg, augustus 1997.30 Univé-VGZ-IZA-Trias Naadloze zorg voor chronische aandoeningen. Policyreports 2008. Achmea Divisie Zorg, Achmea kwaliteitsbeleid 2009 medisch specialistische zorg Zorginkoopbeleid 2009.CZ, Inkoopbeleid CZ op het gebied van ketenzorg/diseasemanagement. Policyreports 200831 The Netherlands Organisation for Health Research and Development is a national organisation that promotes quality and innovation in the field of health research and health care, initiating and fostering new developments. The majority of ZonMw’s commissions come from the Ministry of Health, Welfare and Sport (VWS) and the Netherlands Organisation for Scientific Research (NWO). The Ministry’s main concern is to contribute to public health, including prevention and health care services. NWO is a non-governmental organisation concerned with fundamental and strategic research32Michiel Bijlsma, Arno Meijer and Victoria Shestalova , CPB Vertical relationships between health insurers and healthcare providers. CPB Document No 167, Den Haag, Centraal planBureau, 2008.33 Bijlsma, M., V. Kocsis, V. Shestalova and G. Zwart, 2008, Vertical foreclosure: a policy framework, CPB Document 157.34 Bishop, S., A. Lofaro and F. Rosati, 2005, The Efficiency-Enhancing Effects of Non-Horizontal Mergers, a report for the Enterprise and Industry Directorate-General, European Commission, 2005.37 Pilnick A; Dingwall R; Starkey K Disease management: definitions, difficulties and future directions. Bulletin of the World Health Organization 2001;79(8):755-63. Genetics and

17

In April 2008, the Government implemented a new insurance scheme for the elderly aged 75

and older, named 'Health Insurance for the Old-Old'. In terms of healthcare delivery, the act

stipulates the reform of providing comprehensive assessment, home care, palliative care, and

integrated care as critical areas57. The new insurance scheme mainly aims at handling the

growth of health expenditure for the elderly in order to maintain affordable universal coverage

of health insurance5859. An other reason was to increase transparency of who pays for the

healthcare cost of the elderly by establishing the new insurance, separated from other

insurances, and making explicit rules for who contributes how much to the health care for the

aged60.

Society Unit, School of Sociology and Social Policy, University of Nottingham, England. Alison.Pilnick@nottingham.ac.uk41 Arthur Lazarus, M.D., M.B.A., The Promise of Disease Management. PSYCHIATRIC SERVICES _ February 2001 Vol. 52 No. 2.42 Wagner chronical care model43 Enthoven, A and Tollen, L eds (2004) Towards a 21st Century Health System: The contribution and promise of prepaid group practice. San Francisco: Jossey Bass; Preface. 46 Beaulieu Nancy Dean An economic analysis of health plan conversions: are they in the public interest? Frontiers in health policy research / National Bureau of Economic Research 2004;7():129-77. Harvard Business School, USA.47 Bodenheimer Thomas The future of primary care: transforming practice. The New England journal of medicine 2008;359(20):2086, 2089. Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, USA.48 Thomas Bodenheimer Disease management in the American market BMJ 2000;320;563-566 doi:10.1136/bmj.320.7234.563. http://bmj.com/cgi/content/full/320/7234/56349 Jennifer Dixon, Richard Lewis, Rebecca Rosen, Belinda Finlayson and Diane Gray Can the NHS learn from US managed care organisations? BMJ 2004;328;223-225, doi:10.1136/bmj.328.7433.223. http://bmj.com/cgi/content/full/328/7433/22351 Takahide KOHRO,1 MD, Yuji FURUI,2 PhD, Naohiro MITSUTAKE,2 PhD, Ryo FUJII,2, Hiroyuki MORITA,1 MD, Shinya OKU,2 MD, Kazuhiko OHE,3 MD, and Ryozo NAGAI,4 MD The Japanese National Health Screening and Intervention Program Aimed at Preventing Worsening of the Metabolic Syndrome Int Heart J March 2008 Vol 49 No 252 Takahide KOHRO,1 MD, Yuji FURUI,2 PhD, Naohiro MITSUTAKE,2 PhD, Ryo FUJII,2, Hiroyuki MORITA,1 MD, Shinya OKU,2 MD, Kazuhiko OHE,3 MD, and Ryozo NAGAI,4 MD The Japanese National Health Screening and Intervention Program Aimed at Preventing Worsening of the Metabolic Syndrome Int Heart J March 2008 Vol 49 No 253 Kenko-Nippon-21 Official Website. 2007; Available at: http://www.kenkounippon21.gr.jp. And Kenko-Nippon-21 Interim Results Report. 2007; Available at: http://www.kenkounippon21.gr.jp/kenkounippon21/ugoki/kaigi/pdf/0704hyouka_tyukan.pdf.54Atsushi Kobayashi Launch of a National Mandatory Chronic Disease Prevention Program in Japan. Sompo Japan Research Institute, Nishi-Shinjuku, Shinjuku, Tokyo. Disease Management & Health Outcomes, Volume 16, Number 4, 2008 , pp. 217-225(9).

55

18

Most countries wrestle with the fragmentation in healthcare system and tend integrate, but

Japan split Short-term care versus Long-term care insurance. From a technical insurance

perspective it ’s a logical step, because short-term care insurance cover high severities with

low risk, long-term care insurance covers severities with high risk. So both types of care need

a different insurance. In the USA this split is visible in Medicaid and Medicare, in The

Netherland in Basic Insurance and AWBZ (Long term care insurance defined as a set of

uninsurable risks with big losses, not to bear by an insurance company). So governmental

regulation is necessary here, like in most other european countries; UK, France and Germany.

Lessons from Europe

Introduction

he overall trend in European health care systems is to move away from centralized

government control to managed competition with market-oriented features to come

finally to patient centric care. Each country has its own learning curve and waves to

wrestle.

TLessons from the United Kingdom

Disease management programmes

19

isease management in the United Kingdom established in a setting where

fundholding general practitioners have demonstrated an ability to manage

resources, have enhanced their role as gatekeepers to secondary care, and have

encouraged negotiations between the two sectors to promote efficient and effective

treatments. The purchaser/provider split has increased flexibility within the system for the

movement of resources.

DOn the other hand, the development of primary care trusts may be seen as creating

organizations of the MCOtype for disease management. However, a wholly integrated disease

management programme would require the full development of a single budget for primary

and secondary care and a compatible series of information technology systems to follow

patients through their treatment. Both these requirements have only recently been introduced

into the NHS.

The strong focus on primary care in the United Kingdom means that the general practitioner is

the patient’s ultimate disease manager. If a patient has a single disease the general practitioner

may be willing to hand over responsibility for its management. Overall, it seems that the

disease management programmes most likely to succeed in the United Kingdom will be

evidence-based, will minimize the extent to which patients fall into gaps between providers,

and will be led by the NHS rather than commercial interests. Clinicians need to be reassured

that such programmes are concerned with adopting the best rather than the cheapest practice

and therefore with increasing professionalism61.

A recent trend in the NHS is to give patients a more dominant role. Patients gets more

responsibilities namely responsibilities towards oneself, responsibilities towards others, and

responsibilities towards the health system. These 'types' of responsibility are described in the

NHS Constitution, launched in January 2009 and apply to all members of the public. This can

be seen as a push to selfmanagement.

An other key element of disease management is prevention. In the UK, the Change4life

programme is introduced in 2008. The Government has announced a range of initiatives that,

in conjunction with the private and charitable sectors, it hopes will encourage people to lead

healthier lives. These initiatives, similar to personal financial incentives to effect behaviour

change, are aimed at 'structuring' people's decisions so that they choose healthier options. The

government selected nine towns to receive funding to advance what is known as its

'Change4Life' initiative. Many of these towns are relatively disadvantaged, so one may

20

presume that this initiative is also tied into the Government's policy to reduce health

inequalities62.

Further back in time, in January 2005, the government launched a bespoke NHS and Social

Care Model designed to help local health and social care organisations improve care for

people with long-term conditions. This model outlines how people with long-term conditions

will be identified and receive care according to their needs; how the Expert Patients

Programme will be expanded throughout England to promote self-management; how

specialist nurses (community matrons) will support people with complex conditions; and how

teams of staff will be encouraged to work together with people with long-term conditions and

their families.

Other similar frameworks are being implemented throughout the world, like: The (Expanded)

Wagner’s Chronic Care Model, PACE model, Guided Care Kaiser Permanente’s triangle ,

EverCare, and Pfizer service delivery approaches (see sector USA). It is too early to say

which model in the UK is more effective and efficient.

Vertical and virtual integration

Since 1991 the NHS has tried to separate purchasers and providers and, to some degree, push

purchasing into primary care. While primary and secondary care have worked together, there

was no push to merge them into one "vertically integrated" organisation until the 1997

Primary Care Act. The act allowed NHS trusts (acute or community) to employ the primary

team directly, including the general practitioners, and allowed the merger of budgets for

general medical services and hospital and community health services. In the United Kingdom,

local vertical partnerships between hospitals and community services and primary care have

developed at the interface between primary and secondary care. Examples include hospital at

home schemes, outreach, shared care, general practitioners working in accident and

emergency departments, and community staff attached to general practices as part of the

primary care team. These have developed mostly to improve the quality and seamlessness of

services provided, and in response to new technologies that allow more treatment at home and

21

easier communication with hospital. The potential of such partnerships to contain costs by

reducing unnecessary hospital use has become important.

Possibilitis for primary care organisations arises to link up more closely with hospitals

through innovative local arrangements. Possible developments include vertically integrated

disease management packages, as well as schemes to pool resources and share financial

incentives to keep patients out of hospital where appropriate.

In many ways virtual integration already exists in the NHS. Through fundholding and its

variants, purchasers with capitated budgets, who are also primary care providers, have entered

into long term contractual relationships with other providers. This has already encouraged

greater efforts to provide seamless care and curb costs. For example, many of the new total

purchasing pilots have made a priority of attempting to reduce both length of stay and medical

admissions where appropriate in order to be able to use the resources elsewhere. Some have

employed "tracker" nurses to work in provider units to encourage prompter discharge for

patients, and others have persuaded NHS trusts to employ specialist nurses to help manage

patients with chronic disease in the community. It remains to be seen whether these schemes

will be effective, or whether the new primary care groups will develop them further. This

partly depends on whether hospitals will have strong incentives to increase inpatient activity

or whether they will develop wider roles for themselves.

Lessons from France

he World Health Organisation rates France’s health system performance as number

one out of 191 countries. It has been suggested that France’s attention to chronic

care is one of the reasons that this country spends less than half the amount of the

United States per capita on annual healthcare.63 The model used in France focuses on regional

systems, population-based prevention, continuity of care, physician involvement in decision-

making, and combining specialised medical care, assistive technology, and home support. The

regional systems aim to make services more geographically accessible.

TDisease Management - Vertical integration - Financial alignment

22

rance introduced a soft gatekeeping model in 2005 giving general practitioners new

responsibilities in terms of better care coordination and prevention. Except for a

small per capita payment for chronically ill patients, there are no financial changes

in the way doctors are paid. But in the national collective convention setting the fees for

doctor services, the generalists have promised to improve their treatment patterns in particular

with better respect to clinical recommendations, more attention to prevention and

coordination of care. After three years, and despite a high rate of participation in gatekeeping

program, the reform did not achieve what was expected.

FSince the beginning of 2009, the National Health Insurance Fund offers "contracts to improve

individual practice" (CAPI, Contrats d'amélioration des pratiques individuelles) to individual

general practitioners working as "soft" gatekeepers (médecin traitant) in order to improve

their medical practice by providing financial incentives. The contracts set common objectives

to health care professionals with respect to treatment and prescription patterns to be achieved

over three years. These objectives are based on the recommendations of the High Health

Authority (HAS), the National Institution for Health Products (AFSAPS) and the results of

international comparisons. 

The objectives set in the contracts are inspired by global public health objectives fixed by the

parliament and currently cover three domains: prevention, prescription practices, quality of

care for patients with chronic diseases(diabetes, high blood pressure).

Doctors who sign the contract accept to improve the prevention rates among their patients,

respect some treatment guidelines and increase generic prescription. On the side of the health

insurance fund, it promises to provide the data required to monitor changes in their practice.

Remuneration given to doctors will depend on their results in terms of prescription and

treatment. Those who do not fully achieve the objectives set will be paid according to the

progress made. The remuneration scheme is rather complex, but it is announced that the

maximum amount earned could be near 6000 Euros a year, which makes an extra month of

salary for the average GP.

The health insurance fund is planning to extent the contracts in the future to cover other

public health priorities such as improving the rate of treatment in line with guidelines

concerning moderate/severe depression and detection of osteoporosis.

23

The payment does not replace any other payment made (fee-for-service and a small capitation

payment already given to treat chronically ill patients) but adds on to it. And there is no cost

for the GPs who do not achieve the objectives64..

Lessons from Germany

n Germany in 2004, integrated care obtained further support from the removal of certain

legal and financial obstacles by means of the Social Health Insurance Modernization

Act. This effectively established integrated care as a distinct sector, enabling health

insurance funds to designate financial resources for selective contracting with single providers

or network of providers, many of which targeting the interface between acute hospital and

rehabilitative care6566. So the case Germany shows too, legal and financial incentives are

necessary to stimulate DMP.

I

Disease Management Programmes

our main characteristics of the German health care system facilitated the introduction

of DMPs: (1) free choice among not-for-profit sickness funds, which must balance

income and spending; (2) risk-structure compensation between sickness funds

aiming at narrowing contribution differences that are attributable to differences in members’

incomes and risk levels; (3) “sectorization” of health care, especially strict separation between

ambulatory care and inpatient care delivered by hospitals; and (4) quality and efficiency

problems, especially for the chronically ill.

FThe crucial piece of legislation was the Act to Reform the Risk Adjustment Scheme (2002) to

address the redistribution of money among sickness funds more directly67. The new law aimed

to improve compensation for differences in the morbidity structure, to avoid “cream

skimming” among sickness funds and to give them an incentive to care for chronically ill

24

insured people. Insured people who join DMPs were labeled “chronically ill” for the purpose

of the RSC scheme, and spending is calculated separately for them. Therefore, sickness funds

with a high share of DMP participants receive higher compensation from the scheme. It was

hoped that this would provide a stimulus for the sickness funds to try to attract chronically ill

people (instead of looking at them as “bad risks”). Relatively early on, critics pointed to the

fact that the actwould provide mainly an incentive for the sickness funds to enroll as many

chronically ill people as possible but not necessarily to improve their care.

In January 2009, the existing risk structure compensation scheme between sickness funds has

been expanded to include morbidity-oriented factors. The measure aims at preventing risk

selection, improving care for patients with chronic diseases and equalizing starting points for

competition between sickness funds. The introduction of morbidityoriented (80 defined

diseases) risk structure compensation ("morbi-RSA") entails a major reorganization of

financial flows which is highly controversial.

Nevertheless, disease-management programmes in Germany seem to improve the

management and coordination care of patients with chronic conditions. The results of a study

by Szecsenyi et al (2008) show that changes in daily practice which have been established by

disease-management programmes are acknowledged by patients ‘as care that is more

structured and that reflects the core elements of the chronic care model and evidence-based

counselling to a larger extent than usual care’.Another study found that patients enrolled in

disease-management programmes encounter fewer complications than patients in usual care.

These improvements are obviously due to changes in the organisation of health care on the

micro-level – the introduction of more practices specialising in diabetes care, improved

referral mechanisms, and more prescriptions based on evidencebased guidelines68.

The German disease management programmes have attracted considerable international

attention. They are highly structured and regulated and embedded in the social health

insurance system. Existing programmes cover diabetes type 1 and 2, asthma/chronic

obstructive pulmonary disease, heart disease and breast cancer.69

In contrast to the U.S., the core content of a DMP in Germany (e.g., evidence-based clinical

guidelines, basic dataset, quality indicators, transfer between different levels of care,

provision of feedback, recall for patients, etc.) is defined by a national expert group, and its

recommendations are compulsory for contracts between insurers and providers, although there

are smaller differences in detail (e.g., type of feedback report, remuneration, etc.) among

25

programs of different contracting partners70. Family practitioners (general practitioners,

family physicians, and internists) in small- to medium-size practices have a central role in

coordinating the care of enrolled patients. Currently, it is unclear how good family

practitioners in private practices can fulfill this role and if they can make a difference for

patients enrolled in a DMP. It also would be interesting to know if they provide similar

quality of care to that of practitioners in a managed-care environment or in centrally

coordinated programs like those existing in many countries. At the time of their development

and introduction, the national DMPs were heavily opposed by the medical profession under

arguments such as their being “cookbook medicine” providing “suboptimal care” or that

recommendations that were given are not new but are already fully implemented into routine

daily practice.

Vertical and horizontal integration

ealth care delivery in Germany is highly fragmented, resulting in poor vertical and

horizontal integration and a system that is focused on curing acute illness or

single diseases instead of managing patients with more complex or chronic

conditions, or managing the health of determined populations71.

HMedical care centres are another innovation introduced in 2004. While integrated care

contracts allow for contracts between providers of inpatient and outpatient care, medical care

centres are legally required to only provide ambulatory care. Medical care centres, also

referred to as polyclinics, build upon a state-run primary care delivery model that was well

established in former East Germany. By law, they are defined as interprofessional institutions,

headed by physicians, with other registered physicians working as employees.

Under the name of AGNES the Institute of Community Medicine at the University of

Greifswald started several pilots in 2005 to test if nurse practitioners, so-called ‘Community

Medicine Nurses’, can support primary care physicians in sparsely populated areas in

prevention, nursing and assistance during routine home visits. They are expected to ensure

regular access to basic health care services for elderly patients. ‘Community Medicine

Nurses’ act only by order of a family physician. They visit patients at home, run basic

diagnostic tests, apply new bandages or take blood samples and they serve as contact persons

26

for mostly elderly patients, supervise their medication, consider preventive action, and offer

advice and support72.

56 Ikegami, Naoki and John Creighton Campbell. “Health Care Reform in Japan: The Virtues of Muddling Through,” Health Affairs, vol. 18, no. 3, 1999, 58-61.57Ministry of Health, Labour and Welfare, Annual Report on Health and Welfare, 2008, wwwhakusyo.mhlw.go.jp/wpdocs/hpaz199801/b0079.html (Accessed 28 Sept 2008)58 Ministry of Health, Labour and Welfare, Choujyu Iryo Seido: The new health insurance for the elderly, 2008 www.mhlw.go.jp/bunya/shakaihosho/iryouseido01/info02d.html (Accessed 28 Sept 2008).59 Tomizuka, Taro and Ryozo Matsuda. "New Health Insurance for the Elderly". Health Policy Monitor, October 2008. A vailable at http://www.hpm.org/survey/jp/a12/4. Kinugasa Research Institute, Ritsumeikan University, Kyoto, (12) 2008.60 Ministry of Health, Labour and Welfare, Choujyu Iryo Seido: The new health insurance for the elderly, 2008 www.mhlw.go.jp/bunya/shakaihosho/iryouseido01/info02d.html (Accessed 28 Sept 2008).61 Pilnick A; Dingwall R; Starkey K Disease management: definitions, difficulties and future directions. Bulletin of the World Health Organization 2001;79(8):755-63. Genetics and Society Unit, School of Sociology and Social Policy, University of Nottingham, England. Alison.Pilnick@nottingham.ac.uk62 Oliver, Adam, Developments in libertarian paternalism Health Policy Issues: Public Health, Prevention Country: United Kingdom Partner Institute: London School of Economics and Political Science Survey no: (13) 200963 NHS Institute for Innovation and Improvement IMPROVING CARE FOR PEOPLE WITH LONG-TERM CONDITIONS A REVIEW OF UK AND INTERNATIONAL FRAMEWORKS Univerisity of Birmingham, HSMC 2006. http://www.improvingchroniccare.org/downloads/review_of_international_frameworks__chris_hamm.pdf.64 (A small step towards P4P in France Country:  France Partner Institute:  Institut de Recherche et Documentation en Economie de la Santé (IRDES), Paris Survey no:  (13) 2009 Author(s):  Or, Zeynep Health Policy Issues:  Quality Improvement, Prevention, Remuneration / Payment )65 Busse R. Disease management programmes in Germany's statutory health insurance system. Health Affairs 2004;23:56-67.66 Busse R, Riesberg A (2004): Health care systems in transition: Germany. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies.67 Greß S, Focke A, Hessel F and Wasem J. Financial incentives for disease management programmes and integrated care in German social health insurance. Health Policy 2006;78:295–305.68 S Greß, C Baan, M 86 Calnan et al, Co-ordination and management of chronic conditions in Europe: the role of primary care – position paper of the European Forum for Primary Care.

27

Conclusion and future directions

ll countries saw added value in disease management to improve care for chronic

conditions and to contain costs. Common components are:A- Population identification process and patient registry

_ Evidence-based practice guidelines

_ Case management and support services

_ Screening, risk stratification, and matching interventions with need

_ Patient monitoring, self-management education, and satisfaction surveys

_ Treatment intervention, outcome measurement, and reporting

_ Appropriate use of information technology such as specialized software.

The used models differ over the countries because in each country health care is different

organized.

An obvious point is that in Japan primary prevention is the centrally component of DM and in

the other countries secundary or tertiary prevention, probably caused by the absence of

general practitioner. Obvious is that all the countries are busy to (re)form primary care and

see a central place for the gatekeeping general practitioner in DM. More and more multi-

disciplinary provider groups are formed to rearrange tasks to make chronic care efficient and

complete.

Quality in Primary Care 2009;17:75–86 # 2009 European Forum for Primary Care69 Szecsenyi J, Rosemann T, Joos S, Peters-Klimm F and Miksch A. German diabetes disease management programs are appropriate for restructuring care according to the Chronic Care Model: an evaluation with the Patient Assessment of Chronic Illness Care instrument. Diabetes Care 2008;31:1150–4.70 Greß S, Focke A, Hessel F and Wasem J. Financial incentives for disease management programmes and integrated care in German social health insurance. Health Policy 2006;78:295–305.71 Macinko J, Starfield B and Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Services Research 2003;38:831–65.72 Mark Harris, Geoff Meads, Petra Riemer-Hommel, Special series: Integrated primary health care Integrated primary care in Germany: the road ahead International Journal of Integrated Care – Vol. 9, 20 April 2009 – ISSN 1568-4156 – http://www.ijic.org/.

28

n the USA, NL DM established bottom up, while in Japan, Germany, UK DM

established top down by government intervention. In the USA DM is the most

developed, with a wide range of different models, specialised outcomes research and

Electronic patient record.

IIn Japan, UK, Germany and the Netherlands, guidelines are developed, tasks are rearranged in

different models but all on experimental basis. There’s no sufficient outcome research to

support the best way. France is the last on the DM-road, they’re busy to formulate guidelines.

n the USA different strategies are used to embed DM, like HMO and PPO. PPO’s tend

to survive on road to vertical integration. In the NL several preferred providers are

marked but not selectively contracted. In the UK, local vertical partnership established

by the fundholding system and Primary Care Act, were the merger of budgets was allowed.

ISo financial incentives are necessary to push DM. The case of Germany with the Risk

Adjustment Scheme supports this. In the Netherlands risk adjustment is a feature of the

managed competition market. The next step is to start with functionale pricing of primary

chronical care defined in CDTC and to link CDTC’s to the DRG’s by disease and to link this

to the risk adjustment system to spread the risks over the whole chain.

The last step is to examen how to adjust for the multitasking package of provider groups and

to implement them in the budget. Then a financial flow is born to stimulate DM. 73

73

29

Notes

30