Money for value instead of volume: The Kinzigtal-way to develop and measure value and health gain in a local area

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1 Money for value instead of volume: The Kinzigtal-way to develop and measure value and health gain in a local area Helmut Hildebrandt CEO OptiMedis AG & CEO Gesundes Kinzigtal GmbH Borsteler Chaussee 53, D Hamburg Tel: , Fax:

2 The quality challenge: How to reduce total costs of care per patient without harming quality and our ethical pledge? Improve the health status of the population (together with the population) Reduce unnecessary interventions Do the right thing at the right place and at the right time right

3 Hot Discussion in the US: Better care, more health and lower costs

4 The solution: Population-based Integrated Care sharing the health gain Origins of the concept: Managed Care in US and Switzerland... ICDS = Integrated Care Delivery Systems Disease Management & Predictive Modelling Salutogenesis... Health sciences Organisational psychology Consumerism You ll need some integrator / organizer - dedicated and incentivized by health gain

5 The future of health care provision / German HC Advisory Board The old way: Fragmented health care provision, oriented towards the single provider s economic interest but not the health outcome. The new way: Reengineering the chain of care through integrated health care systems, oriented by contract to the outcome in the interest of the sickness funds.

6 Value not Volume : Study of the World Economic Forum (Davos) McKinsey&Co Fits perfect our concept High attention on the political and business-agenda

7 OptiMedis manages and develops ICDS- Systems in various regions in Germany GNU AEGR MedQN SOPRAN Entwicklungsvertrag bzw. Managementgesellschaft Kooperation QuE Nürnberg Angebot für Entwicklungsvertrag Most advanced

8 Gesundes Kinzigtal GmbH: Population-based Integrated Care for a whole Region Two convinced partners: A local physician network Ärztenetz MQNK and a management company OptiMedis AG that stems from a health science background means two partners with passion and motivation to prove the effectiveness of a better organized regional health care system in the hand of a dedicated Integrated Delivery System. Local experience and local contact to patients and other health care providers / knowledge of problems Health sciences know-how, management expertise + data analysing techniques + investment capabilities shares: 66,6% MQNK e.v. 33,4% OptiMedis AG 8

9 Sharing the health gain (contribution margin) over the next ten years Sickness Funds AOK + LKK Baden- Württemberg Managing the System - taking risk Providers - without risk

10 The goal: Producing better health + lower total costs of care (in relation to the rise of costs in normal care) Total costs p.capita in Normal Care Delta Total costs p.capita in Integrated Care Time

11 How to measure health gain for a population? Possible ways Epidemiological way: Problems High costs of studying How to relate epidemiolog. outcome to? Quality indicators: Indicators will never be able to measure everything / are there validated indicators? Focus of the system might be orientied only to indicators How to relate indicator outcome to? Contribution margin of the sickness fund: Health gain of the population must not be correlated to the contribution margin of the sickness fund Quality should be measured too

12 Our choice: A mixture of economic and qualitative measurement We use the contribution margin (actual revenues vs. actual costs) of the sickness funds as economic measurement if we are able to improve it, we are getting a share of the improvement In parallel we are subject to a thorough scientific evaluation and comparative effectiveness research (University of Freiburg in connection with Univ. of Cologne), getting all the claims and medical data of the sickness funds for the population of Kinzigtal and a nearly 20% control group of all insurees in Baden- Wurttemburg of these sickness funds

13 A specific positive situation: Morbidity adjusted risk adjustment over all sickness funds The revenues of sickness funds in Germany are not derived from the premiums they get but modelled after the morbidity, sex and age of each person being insured (via a federal agency = Bundesversicherungsamt) => for a 66 old female with diabetes type II with neurological complications the fund is getting around the mean costs of these 66 old patients of all sickness funds with this disease state => revenue = nearly mean costs The contribution margin of a sickness funds is best if a severely sick person is treated well and improves in its self management capacity (and does not progress in the severity of its illness)

14 Gesundes Kinzigtal invests into the health gain of the population Financial Invest Surplus fees to the providers & costs of programmes and admin & success incentives Know-how Invest Know-how of the local physicians towards therapeutical potentials Know-how of the management and OptiMedis AG (and intensive use of universities) Evidence Based Medicine + Prevention Implementing a paradigm of working fot the improvement of health Added Contribution Margin = added value Contribution margin (morbidity, sex and age adjusted revenues to costs) Sickness Fund Share of sickness funds Share of Gesundes Kinzigtal

15 Managing the economy of Gesundes Kinzigtal = the integrator/organizer Gesundes Kinzigtal does only earn money if it is able to improve the contribution margin of the sickness fund = than it is getting its share of the health gain BUT: To know whether it was successful all the data is needed = nearly one year later THEREFORE: Gesundes Kinzigtal gets money as a loan in advance Some example of a possible balance sheet Expenditures in Thousand Revenues in Thousand Local administration / staff 600 Sickness funds Data analysis / evaluation / calculations / developm. of programs 600 Foundations / grants for specific projects 250 Extra fees for physicians/practices 500 Bonusses for success 200 Taxes / interest 150 in total in total Distribution to share holders 200

16 Networking around 160 partners and 500 people involved in the care process... No Providers with partnership contracts Further partners in cooperation Family doctors, specialists, psychotherapists... around 50% of those working in the area Staff in the provider offices Hospitals...around 85% of all cases 6 Physiotherapists 7 Nursing homes 11 Ambulatory nursing agencies / psychosocial agencies 4 Pharmacies... around 70% of all p. 16 Self help, local enterprises, local government/administration Fitness-Centers... ca. 80% 6 Voluntary associations, sports clubs, social clubs, local industry and small enterprises

17 Time line of start of preventive and care coordinating activities Coaching high cost patients Health promotion programmes for the unemployed Reduction of antibiotic medication for various indications Music therapy for patients with chronic pain problems Health promotion for small and medium sized businesses and their employees Physical exercises and treatment for patients with back pain ( Mein gesunder Rücken ) Early detection and treatment of rheumatic disorders ( Beweglich bleiben Rheuma frühzeitig behandeln ) Hypertension and prevention of renal diseases ( Im Gleichgewicht meinen Blutdruck im Griff ) Improving medication adherence of elderly patients by distributing unit dose blisters Start of planning a health and fitness training center ("Gesundheitswelt Kinzigtal") Better management of major depression ( Besser gestimmt ) Start of central electronic patient record Medical care for the elderly in nursing homes ( ÄrztePlusPflege ) Healthy Kinzigtal gets moving ( Gesundes Kinzigtal bewegt ) Patient university classes Prevention of osteoporosis /osteoporotic fractures ( Starke Muskeln, feste Knochen ) Social case management ( Sozialer Dienst ) DMP asthma DMP COPD Lifestyle intervention for patients with metabolic syndrome ( Gesundes Gewicht ) Quit Smoking Programme ( Smoke-free Kinzigtal ) Active health promotion for the elderly ( AGil ) Intervention by psychotherapists/psychiatrists in case of acute personal crises ( Psycho-therapie akut ) DMP coronary heart disease Start of electronic integration Chronic heart failure ( Starkes Herz ) DMP diabetes mellitus type II DMP breast cancer Shared Decision training

18 Time line of start of preventive and care coordinating activities detail

19 Evaluationsergebnisse und weiteres Vorgehen Rauchfreies Kinzigtal 19

20 Starke Erfolgsquote des Programms: ca. 30 % der Teilnehmer ist nach einem Jahr rauchfrei! Entwicklung der Einschreibungen seit Programmstart (Stand: ) N= 159, Basis: eigene Auswertungen anhand Programmdokumentation Ärzte 20

21 Medikamentöse Entwöhnung ist mit 58 % die am häufigsten gewählte Methode unter den Erfolgreichen! Knapp die Hälfte aller Teilnehmer wählt die medikamentöse Entwöhnungsmethode Die meist gewählte Entwöhnungsmethode ist auch die Erfolgreichste. 21

22 Sehr gute Kostenentwicklungen im 2. Jahr nach Programmstart Die Ergebnisse der Kosten- Nutzen Analyse direkt nach Programmende konnten nicht überzeugen Im zweiten Jahr nach Programmstart zeigt sich eine sehr gute Kosten- Nutzen-Entwicklung, welche den Programmerfolg bestätigt 22

23 Deutliche Ziele in Zukunft sollen Erfolgsquote weiter erhöhen! Zielgrößen der Programmüberarbeitung: Durch das Programm Rauchfreies Kinzigtal sollen mindestens 35 % der Teilnehmer erfolgreich entwöhnt werden können 50 % aller Teilnehmer nehmen alle acht Arzttermine wahr Der BMI der Teilnehmer erhöht sich während der Programmdauer nicht stärker als 1 kg/(m) 2 Weitere Veränderungen. Einschränkung der Entwöhnungsmethoden auf drei Methoden 23

24 Praxiscockpit bildet Struktur-, Prozessund Ergebnisqualität ab Kennzahlen bilden Struktur-, Prozess- und Ergebnisqualität ab. Auf einem Blick: Qualität, Wirtschaftlichkeit und Effizienz Steuerungsinformationen und Benchmarking mit anderen Praxen (LP und NLP) 24

25 Lernen anhand des internen Controllings und externer wiss. Evaluation z.b. Versorgungscockpits: Abbildung der Struktur- /Prozess- und Ergebnisqualität für Leistungspartner z.b. Evaluationsberichte der PMV Forschungsgruppe zu Unter-/Über-/Fehlversorgung 25

26 Feedbackbericht an die Praxen zu ihren Verordnungen (Priscus-Liste) Aus den uns übermittelten GKV-Routinedaten erstellen wir Feedbackberichte, damit die Praxen sich selber im Vergleich zu einander sehen und in der Folge verändern können. Hier rot eine Darstellung der Quote des Anteils der über 65-jährigen Versicherten, die mind. einen Wirkstoff verordnet bekommen, der als inadäquat für die Behandlung älterer Patienten gekennzeichnet wurde (1. Q Q 10). Basis für die Klassifikation ist die PRISCUS-Liste (www.priscus.net), Nur hausärztliche Praxen hier ausgewertet (Auszug). D-Durchschnitt 28 % lt. WIdO!!

27 Important part of the contract: GK gets all data of the sickness funds (pseudonymized) Gesundes Kinzigtal GmbH gets all cost, claims, diagnosis data of the sickness funds for all the insured in this region (pseudonymous data) Analyses of diseases and of their development over time... to be able to learn and renavigate our efforts Beispiel: Depressionen Fallzahlen, Gesamtkosten nach Sektoren gesicherte Arztdiagnose: F32-F34 * 2.Q.07-1.Q.08 Anzahl der Fälle in % Arzneimittel ,8% Krankenhaus ,8% Arzt ,0% Arbeitsunfähigkeit / Krankengeld ,8% Kur ,8% sonstige Kosten ,8% Gesamt % * F32.- Depressive Episode, F33.- Rezidivierende depressive Störung, F34.- Anhaltende affektive Störungen Additionally we are able to inform our GPs about there data relative to other GPs... Example: How many of your chronic heart failure patients have got the adequate medication? 27

28 Integration of social care and health care Physicians realizing a social problem with a patient normally have few options to help the patients (in consequence just medication + suggestion to get help by social agencies but problem often will not be solved) In 2008 we started a pilot (and now it is running all the time) physicians realizing a social problem may get a social worker to come into the practise to help the patient Erweiterte Gesundheits- und Sozialberatung des AOK-Sozialdienstes in der BD Südlicher Oberrhein Johannes Schrempp Dipl. Sozialpädagoge (BA) AOK Südlicher Oberrhein CompetenceCenter Sozialer Dienst 175 patients up to now had the fortune of this joint consultation (resulting in sometimes longstanding interventions, sometimes just short help.. but 98% satisfaction)

29 In short: With higher Quality we achieve better health and a higher Contribution Margin Targeted and really tangible care management and organization of integrated health care Optimized health and disease management of those parts of the population that are under risk Attractive offers for the insurees - one partner provider = trusted provider by choice of the insurees (no restriction in the use of any provider) Improving the contribution margin of the sickness fund

30 Healthier and better (self) managed people need less hospitalization The number of hospitalization cases of LKK-assureds in the Kinzigtal increased by 10,2% between 2005 and 2010, whereas the increase in the comparative group amounts to 33,1%

31 Example of medical outcome: Surprisingly improved survival rate for Kinzigtal patients with chronic heart failure Control group: Same severity (NYHA III + IV), matched pair 100% 95% : Survival-Kurven Programmteilnehmer Starkes Herz vs. Starkes Herz Zwillinge 90% 85% 89,09% 80% 75% 80,00% 70% Zeitpunkt der Einschreibung +1 Quartal +2 Quartale +3 Quartale +4 Quartale +5 Quartale +6 Quartale +7 Quartale +8 Quartale Starkes Herz Starkes Herz Zwillinge n=55 n=55

32 Surprisingly positive Improvement of the Contribution Margin for the sickness funds... already within the first two-three years!! We standardized the contribution margin prior to the intervention for the whole population, whether part of the invention or not = Reference 6% 5% 4% 3% 2% 2,08% 3,38% 4,82% Only the surplus delta defines the success = in ,82 % Attention: The result refers to the contribution margin for a) all around insurees (but only enrolled insurees at the end of 2008) b) 2008 was only the 3rd year and the project was until 7/07 still in its inital phase. 1% 0% 120 EUR 100 EUR 80 EUR 60 EUR 40 EUR 20 EUR 2.HJ HJ HJ EUR 2.HJ HJ HJ

33 Reduced expenditures in per LKK-assured in the Kinzigtal in 2010 (vs / control group) = 16,9 % improvement of contrib.margin) The average difference per capita of all LKK-assureds in the Kinzigtal (regardless whether enrolled in Gesundes Kinzigtal or treated by providers that are not partnering with Kinzigtal). All costs of the main service sectors, which are suggestible by the health care provider, were included in the calculations (around 80 % of total costs). The main service sectors include the expenditures for drugs, remedies, home care nurses and hospitalization and exclude the costs for the physician and the dentist.

34 6 Critical Factors for the Success of a Populationwide Comprehensive Integrated Care 1. A body that is economically incentivised towards positive outcomes and that allows to rebalance the incentive and fee structures => Reconciliation of economy and medicine/health sciences => long-ranging contract certainty... prevention should have the possibility of ROI (return on invest) for several years (Kinzigtal = 9 y) 2. The right targets and the right know-how: Where do we have the biggest inefficiencies? What are the most relevant problems regarded by the patients? Where to invest with the highest and quickest ROI? 3. The right incentives for the payors/ sickness funds as well: Population health management must be better rewarded instead of risk selection german risk adjustment scheme works in this way

35 6 Critical Factors for the Success of a Populationwide Comprehensive Integrated Care 4. Data - Data - Data: only the actual operational availability of diagnosis, cost and utilization data allows for learning progress in processes of care management, another factor is IT- and data warehousing competency, and data protection know-how 5. Traditional hierarchical concepts of management fail: A new way of shared decision making and guidance has to be developed between patients physicians management and sickness funds. 6. Integration of health & social care & the communities: Health is not an outcome of a pure medical intervention it needs to set up a public health and health promotion initiative oriented to all aspects of life.

36 Discussion The economic contruct of the contribution margin of the sickness funds in Germany produces an incentive to improve health gain and care (in the economic interest of providers as well as sickness funds) Obviously it is consistent with the improvement of quality of care There is no problem of access and no problem of risk selection & patients are free to decide and to take part or to use usual care BUT: Usual care as well as care in the Kinzigtal-way always should be monitored regarding their outcomes, their quality and their access

37 We are looking forward to your comments & a lot of cooperation Invitation: We are looking for further partners in cooperation Please contact Helmut Hildebrandt, Vorstand, OptiMedis AG, Borsteler Chaussee 53, D Hamburg Tel:

38 Some Literature extra website on evaluation german/english Hildebrandt H, Richter-Reichhelm M, Trojan A, Glaeske G, Hesselmann H. Die Hohe Kunst der Anreize: Neue Vergütungsstrukturen im Deutschen Gesundheitswesen und der Bedarf für Systemlösungen [The art of setting the right incentives: new reimbursement structures in German health care and the need for systemic solutions]. Sozialer Fortschritt 2009;58(7): [in German]. Hermann C, Hildebrandt H, Richter-Reichhelm M, Schwartz FW, Witzenrath W. Das Modell Gesundes Kinzigtal. Managementgesellschaft organisiert Integrierte Versorgung einer definierten Population auf Basis eines Einsparcontractings [The Gesundes Kinzigtal model: A management company organises a population-based integrated care system on the base of a shared-savings approach]. Gesundheits- und Sozialpolitik 2006;(5-6): [in German]. Hildebrandt H, Hermann C, Knittel R, Richter-Reichhelm M, Siegel A, Witzenrath W. S Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract. International Journal of Integrated Care [serial online] Vol. 10, 23 June 2010 Available from: Hildebrandt et al: (2012): Triple Aim in Germany: Improving population health, integrating health care and reducing costs of care in the Kinzigtal-region to be published in short time 38

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