Disease Management Program Evaluation

A current focal point in our work is the scientific accompanying research (evaluation) of Disease Management Programs DMP (also called chronicals programs) in the indications Diabetes mellitus type 1 and 2, breast cancer, coronary heart disease, bronchial asthma and COPD, which have been taken up since 2003. We evaluate on behalf of several German health care associations (members of vdek, Betriebskrankenkassen, Innungskrankenkassen).

Chronicals programs were established by a law reforming the risk adjustment among the statutory health insurance funds („Gesetz zur Reform des Risikostrukturausgleichs in der gesetzlichen Krankenversicherung“), enacted on january, 1st 2002. They build an approach in medical care to coordinate and optimize treating and caring processes of patients during the whole course of a normally chronic disease and above the limits of individual sectoral suppliers on the grounds of consolidated scientific findings (EbM). The predominant aim is to improve the treatment of the patient and to reduce the disease-indicated limitations and secondary disorders.

The enacting of the fourth reform in risk adjustment among the statutory health insurance funds (Verordnung zur Änderung der Risikostruktur-Ausgleichsverordnung) on july, 1st 2002, which held for the first time concrete compulsory requirements for DMPs, enabled the health insurance companies to offer their insurants DMPs structured according to the law. With the beginning of 2003, the health insurance companies exercised this option for the clinical pictures Diabetes mellitus Type 2 and breast cancer as a start. Successively, the spectre of offered DMPs widened allowing the indications Diabetes mellitus Type 1, coronary heart disease, asthma, and chronic obstructive pulmonary disease. By the end of 2007, approximately 14.000 DMPs were registered or already re-registered respectively.

Founding on the fifth volume of the Code of Social Law (Fünftes Buch Sozialgesetzbuch (SGB V)) DMPs are to fulfill specific requirements with respect to the following topics :

• treatment according to recent medical scientific standards taking into account evidence-based guidelines or the best available evidence and as well the particular supplying sector,
• operation of Quality Assurance measurements,
• conditions for and way of inscribing any insurant in a DMP, encompassing the duration of participation,
• training courses for suppliers and insurants,
• documentation of findings, therapeutic measurements, and treating results, as well as
• evaluation of efficacy and costs of the DMP.

(Regionally) offered DMPs are to be scientifically evaluated due to § 137f (4) and § 137g (2) Code of Social Law V (SGB V) as well as § 28g risk adjustment regulation (RisikoStrukturAusgleichsVerordnung; RSAV). Thereby gained medical and economic evaluation results as well as the changes in subjective quality of life (measured with the instrument SF-36) are to be reported to the federal social insurance authority (Bundesversicherungsamt; BVA) to decide whether to re-accreditate the DMP for the respective offering health insurance company. The evaluation is to be executed by health insurance company- and supplier-independent experts on the basis of generally accepted scientific standards.

The recent version of evaluation criteria by the BVA can be found on the internet: 2009-09-29_Kriterien Version 5.0.pdf (German)

Since midyear 2007, the first closing reports for the DMPs Diabetes mellitus Type 2 and breast cancer are on hand. The reports were presented to the BVA and published by the health insurance companies. Additional risk adjusted results allowing for a comparison between DMPs among one another have been placed at the disposal of the BVA at the beginning of 2008.

Prospects: DMPs subjected to the conditions of GKV-WSG

With the law for the strengthening of competition among the statutory health insurance funds (Gesetz zur Stärkung des Wettbewerbs in der gesetzlichen Krankenversicherung (GKV-WSG)), coming into effect on january, 1st 2009, far-reaching changes will affect among others the financing of DMPs. With the implementation of the health funds (presumably on january, 1st 2009) every compulsory insurant shall pay the same premium rate. Then, each health insurance company will get a basic flat-rate out of this health fond to finance the maintenance of their insurants plus bonuses to adjust the differentiating supplying demands due to age, sex and morbidity. The BVA in collaboration with the scientific advisory council had already detected 50 to 80 serious and cost-intensive chronic diseases in advance, which should have been accounted for with disease-caused bonuses (morbidity bonuses) as soon as the health funds were in effect. An overview of the diseases finally defined by the BVA is given here: Bekanntgabe.pdf (German - 230 KByte)

The hitherto adjustment for increased standardized supplies by health insurance companies for DMP-insurants in risk adjustment will be omitted as from january, 1st 2009. Instead, as monetary aid, health insurance companies receive allocations out of the health funds for each insurant inscribed in DMPs (program expenses flat-rate) to correspond with the program costs for medically inevitable expenses plus documentating and coordinating effort. In addition to this flat-rate they get allocations out of the health funds to cover their standardized general administrative charges.