Volker Amelung

The value of health care – a matter of discussion in Germany

BackgroundInterest in assessing the value of health-care services in Germany has considerably increased since the foundation of the Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG (Institute for Quality and Efficiency in Health Care). The practical application of value assessment illustrates how problematic the process can be. In all decisions made for the provision of health care, data concerning the measurable dimensions (quantity and quality of efficacy and effectiveness, validity of the results and costs) flow into a complex and not yet standardized decision-making process concerning public financing. Some of these decisions are based on data of uncertain validity, unknown reproducibility and unclear appropriateness.DiscussionIn this paper we describe the theoretical aspects of value from psychological and economic viewpoints and discuss national and international approaches. Methodic details and difficulties in assessing the value of health-care services are analysed. A definition of the intangible value of health-care services will be proposed which contains only three factors: the absolute risk reduction (usually a measure of efficacy), the validity of the scientific papers examined and the type of the expected effectiveness (prevention of death and disability, restitution of well-being). The intangible value describes the additional benefit when comparing two possible actions, like treatment or observation only.ConclusionThe description of intangible value from the viewpoint of different stakeholders is a useful measure for subsequent steps (not discussed here) – the evaluation of costs and of patient benefit. A standardised, transparent, fair and democratic evaluation is essential for the definition of a basic benefit package.

Improving palliative care in Germany: summative evaluation from experts’ reports in Lower Saxony and Brandenburg

The German Health Care System is in substantial change. New structuring of services and processes of care are necessary, particularly to meet the complex requirements of the ever-increasing chronic illness and multimorbidity. The main deficits and strategies of improvement can be pointed out clearly by illustrating the situation of palliative care, which is more and more in the focus of experts and public. However, current statements are only slightly based on scientific data. Therefore, policymakers and self-governing bodies in the federal states of Lower Saxony and Brandenburg have commissioned reports from a multidisciplinary study group of health system research. This article describes the cumulative evaluation of both reports, referring to literature findings, specific empirical surveys and expert discussions. The main findings include a high level of emotion among the involved caregivers and social groups, resulting in difficulties in rational discussions; furthermore, a large multiplicity of viewpoints on the assessment of the current situation and on the appropriate needs for improvement was shown. The current deficits are significantly caused by inadequate structuring of care processes. Therefore, better integration of the large and diverse number of involved services and professions is necessary, including new specialised services. Health policy has created legal conditions, but up to now, fulfilment is low. Other improvement strategies should focus on working conditions of personnel in the basic services, such as family doctors and nurses, because the current conditions seem not to meet the patient or caregiver needs. Furthermore, a debate on principles regarding responsibilities of the health care system is needed: What should be covered by social health insurances, and what should be part of other areas of public welfare?

Health Care and the Labor Market: Learning from the German Experience

Many observers have begun to question the U.S. reliance on an employment-based private health insurance system. In thinking about the future of this system, it is instructive to examine the German experience. The German health insurance system is almost entirely organized and financed around the labor market. In recent years, the German labor market has changed in several ways. Among other changes, more German women now work, the proportion of retirees in the population has increased, the share of manufacturing in employment has declined, and the economy has become more open. These labor market changes have made it more difficult to organize health insurance around employment in Germany. Recent changes in the German health insurance system have, to some extent, decoupled health insurance from employment. This decoupling is likely to continue as the labor market changes further. We explore the implications of this experience for the United States.

Discrepancies in the Viewpoints of Different German Health Care Providers on Palliative Care

In many countries with highly developed health care systems, significant improvements in end-of-life care are strongly recommended. Up to the present, the assessment of perceived deficits predominantly reflects the point of view of experts in the palliative and hospice movement, with very little being known about the perspective of other professionals. The aim of this study was to assess the points of view of a wide range of different health care providers who treated or interacted with palliative care patients. The authors subsequently performed 597 semistructured telephone interviews with a wide range of German health care professionals. Overall, the assessment of the current situation was better than expected, although statistically significant differences existed among the groups surveyed. However, there is an unquestionable need for improvement, although opinions regarding the extent of these deficits depend significantly on the individual respondents’ roles and professional orientation.

Integrierte Versorgung – Vom Hoffnungsträger zum Ladenhüter der deutschen Gesundheitspolitik?

Dr. Sascha Wolf, Geschäftsführer, Bundesverband Managed Care e. V. Das deutsche Gesundheitswesen befindet sich in keiner Krise: Die medizinische Versorgung gehört immer noch zu den besten der Welt. Nicht Revolution, sondern Evolution lautet daher das Gebot der Stunde. Der entscheidende Treiber für notwendige Strukturveränderungen ist weder die Politik noch sind es die Akteure des Gesundheitswesens, sondern es sind die Versorgungsherausforderungen selbst, die einen kontinuierlichen Prozess hin zu integrierten und kooperativen Modellen erzwingen. Aufgabe der Politik ist es, den Akteuren ausreichende Handlungsmöglichkeiten zu geben, Anreize für Investitionen zu setzen sowie die Rahmenbedingungen schrittweise nachzubessern.

Integrated Health Care Delivery Based on Transaction Cost Economics: Experiences from California and Cross-National Implications

Integrated health care delivery (IHCD), as a major issue of managed care, was considered the panacea to rising health care costs. In theory it would simultaneously provide high-quality and continuous care. However, owing to the backlash of managed care at the turn of the century many health care providers today refrain from using further integrative activities. Based on transaction cost economics, this chapter investigates why IHCD is deemed appropriate in certain circumstances and why it failed in the past. It explores the new understanding of IHCD, which focuses on actual integration through virtual integration instead of aggregation of health care entities. Current success factors of virtually integrated hybrid structures, which have been evaluated in a long-term case study conducted in the San Francisco Bay Area from July 2001 to September 2002, will elucidate the further development of IHCD and the implications for other industrialized countries, such as Germany.

Would German physicians opt for pay-for-performance programs? A willingness-to-accept experiment in a large general practitioners’ sample

BACKGROUND Implementing pay-for-performance (P4P) programs is a non-trivial task. As evaluation studies showed, P4P programs often failed to improve performance quality. A crucial element for the successful implementation of P4P is to gain acceptance with health care providers. OBJECTIVES The aim of our study was to determine, if (and at what bonus rate) German general practitioners (GPs) would participate in a P4P program. We further examined differences between respondents who would participate in a P4P program (participants) versus respondents who would not participate (non-participants). METHODS A mail survey was conducted among 2493 general practitioners (GPs) in Lower Saxony (with a response rate of 36.2%). The questionnaire addressed attitudes toward P4P and included a willingness to accept experiment concerning P4P implementation. RESULTS The participation rate increased from 28% (at a bonus of 2.5%) to 50% (at a bonus of 20%). Participants showed better performance in target achievement and expected higher gains from P4P than non-participants. Major attitude differences were found in assessing feasibility of P4P, incentivizing performance and unintended consequences. The crucial factor for (not) accepting P4P might be the sense of (un)fairness of P4P. CONCLUSION To convince GPs to participate in P4P, better evidence for the effectiveness of P4P is required. To address the concerns of GPs, future endeavors should be directed to tailoring P4P programs. Finally, program implementation must be well communicated and thoroughly discussed with health care providers.

Totgesagte leben länger

The traditional separation of health care into sectors in Germany causes communication problems that hinder continuous, patient-oriented care. This is most evident in the transition from inpatient to outpatient care. That said, there are also breaks in the flow of information, a lack of supply, or even incorrect information flowing within same-sector care. The transition from a division of functions into sectors to a patient-oriented process represents a change in the paradigm of health care that can only be successfully completed with considerable effort. Germanys statutory health insurance (SHI) funds play a key role here, as they are the contracting parties as well as the financiers of integrated care, and are strategically located at the center of the development process.The objective of this article is to explore how Germanys SHI funds view integrated care, what they regard as being the drivers of and barriers to transitioning to such a system, and what recommendations they can provide with regard to the further development of integrated care. For this purpose semi-structured interviews with board members and those responsible for implementing integrated care into the operations of ten SHI funds representing more than half of Germanys SHI-insured population were conducted. According to the interviewees, a better framework for integrated care urgently needs to be developed and rendered more receptive to innovation.Only in this way will the widespread stagnation of the past several years be overcome. The deregulation of § 140a-d SGB V and the establishment of a uniform basis for new forms of care in terms of a new innovation clause are among the central recommendations of this article. The German federal governments innovation fund was met with great hope, but also implied risks. Nonetheless, the new law designed to strengthen health care overall generated high expectations.

Comparable outcome of liver transplantation with Histidine-Tryptophan-Ketoglutarate vs. University of Wisconsin preservation solution: a retrospective observational double-center trial

BackgroundThe question of whether the choice of preservation solution affects outcome after liver transplantation is still not satisfactorily answered. The purpose of this study is to examine the preservation solutions’ impact on outcome after liver transplantation.MethodsA double-center retrospective study of short- and long-term results of 3134 consecutive liver transplantations with follow-up periods up to 23 years was performed applying multivariate, risk-adjusted analyses with a subset for living-donor transplants, pediatric transplants and cases with prolonged cold ischemic times. An additional focus was put on biliary complications. The primary study endpoints were short- and long-term patient survival and death-censored graft survival. Secondary study endpoints were the occurrence of post-transplant complications, the necessity of operative revisions, the length of hospital stay, and the length of intensive care unit stay.ResultsAlthough long-term graft survival appears to be increased by Histidine-Tryptophan-Ketoglutarate-use (p = 0.018), this effect could not be confirmed in risk-adjusted analysis (p = 0.641). Multivariate regression analysis revealed that 3-month mortality (p = 0.120), 3-month graft survival (p = 0.103) and long-term patient survival (p = 0.235) were not influenced by the choice of preservation solution. There was no difference in the occurrence of common complications or necessity of operative revisions after liver transplantation. This was confirmed in subgroup analyses for living donor and pediatric transplantation and cases with prolonged cold ischemic time. Analysis of the preservation solutions’ impact on length of hospital (p = 0.113) and intensive care unit stay (p = 0.481) revealed no significant difference.ConclusionsUniversity of Wisconsin and Histidine-Tryptophan-Ketoglutarate solutions are clinically equivalent. Histidine-Tryptophan-Ketoglutarate solution could have an economically superior profile. The notion that the choice of preservation solution can have an impact on the onset of biliary complications after liver transplantation remains a matter of controversy.

Starting the Debate on the Role of Health Economics to Support Child Friendly Health Care in Europe.

From the Institute for Quality and Efficiency in Health Care (IQWiG), K€ oln, Germany; Child Health Department, Bath, United Kingdom; European Paediatric Association (EPA-UNEPSA); Bundesverband Managed Care e.V., Berlin; Institute of T he Council of Europe produced “Child-Friendly Health Care,” which was endorsed by 47 Ministers of Health during the Declaration held in Lisbon 2011. This health care approach stipulates that sustainable development should fulfill the needs of the present generation without endangering the health of future generations. The aim was to create a virtuous cycle to improve children’s health applying the “5 rights” of protection, prevention, provision, promotion, and participation. However, they did not provide an economic model to support the implementation of the recommendations. Our aim is to outline the contribution of health economics to the realization of child-friendly health care. The application of classic economic adult health care cost models to child health care is technically difficult because child health care is often more complex and less standardized than adult care (eg, pediatricians are not only treating diseases but the whole child and the family). Up to 8000 rare diseases are the main causes for children with long-term conditions, thus making the use of diagnosis-related group (DRG) systems very difficult to implement. Measures such as quality-adjusted life years (QALYs) developed for adults may be insensitive to the needs of children for a number of reasons, including the lack of appropriate measures and long-term studies. In summary, there appears to be no role for overly dogmatic economic guidelines in child health, but a high degree of innovation and flexibility is required on which stakeholders in society must agree. The economic models for child health care may have to be adjusted according to different age groups, conditions, settings, and countries.