[External and internal financing in health care]

The objective of this contribution is to characterize the functional and institutional features of the German health-care system. This takes place after a short introduction and examination of the ongoing debate on health care in Germany. External funding describes the form of revenue generation. Regarding external funding of the German health care system, one of the favored alternatives in the current debate is the possibility of introducing per capita payments. After a short introduction to the capitation option, focus is on the so-called health fund that is currently debated on and being made ready for implementation in Germany, actually a mixed system of capitation and contributions based on income. On the other hand, internal funding is the method of how different health-care services are purchased or reimbursed. This becomes a rather hot topic in light of new trends for integrated and networked care to patients and different types of budgeting. Another dominating question in the German health-care system is the liberalization of the contractual law, with its "joint and uniform" regulations that have to be loosened for competition gains. After a discussion of the consequences of diagnosis-related groups (DRGs) in Germany, the article is concluded by a note on the political rationality of the current health-care reform for increased competition within the Statutory Health Insurance and its players as exemplified by the health fund. To sum up, it has to be said that the complexity and specific features of how the German system is financed seem to require ongoing reform considerations even after realization of the currently debated health-care reform law which, unfortunately, is dominated by political rationalities rather than objective thoughts.

Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.

Health service use and outcome: comparison of low charge, integrated, comprehensive services with usual health care

We examined the effects of use of low charge, integrated and comprehensive health care services (Veterans Administration (VA) health care system) on health care service use and health-related outcomes. Data came from the 10-year (1986/87-1996/97) Duke Established Populations for Epidemiologic Studies of the Elderly, with 159 men aged 65-85 who primarily used VA health services compared with 1,100 men aged 65-85 who did not. In controlled analyses, no differences were found between the two groups on number of OTC medications used, or in speed or likelihood of entering a nursing home. However, veterans who primarily used the VA health care system reported more outpatient visits and prescription drugs, and increased likelihood of using an adjunct health care provider; entry into a hospital was quicker, and number of hospitalizations was greater. Although health status was controlled, because of eligibility requirements it remains possible that veterans were sicker. Nevertheless, no differences were found in health outcome (functional status or mortality). Readier access to better integrated health services appears to result in increased use of health services controlled by the health care provider, but not of services requiring the recipient's relocation, while functional status and mortality attained equivalence.

The natural evolution of haemophilia care: developing and sustaining comprehensive care globally

Comprehensive care is vital for patients with haemophilia to prevent early death and free patients from the complications that inhibit living normal lives. Experience has shown that once introduced in a country, there is a progressive restoration of normal healthy lives to the haemophilia community. Accompanying this progress is a gradual decreased dependency on the haemophilia comprehensive centre - except during brief periods when expertise contained within the comprehensive centre is mandatory for life-saving clinical management or to prevent severe morbidity. During each stage of the natural evolution of comprehensive haemophilia care in a country, challenges to the existence of the centre occur, which threaten the comprehensive treatment concept. The haemophilia community must understand this natural evolution and be prepared to work collaboratively with governments, physicians and other patients to ensure that centres retain the expertise to meet the emergent needs when they arise.

Partnered care in the Bahamas: A model of advanced healthcare delivery for developing countries

OBJECTIVE

To assess the delivery of advanced specialized medical care using The Partnered Care Model as a means of providing affordable access to all, irrespective of ability to pay.

DESIGN AND METHODS

A retrospective analysis of all persons presenting to a specialized, private, cardiac unit, The Bahamas Interventional Cardiology Center (BICC), over an 8.5-year period from March 1996 to September 2004 was conducted. The Bahamas Heart Center's Discounted Service System had been applied since inception to all patients in three groups including insured patients billed at 100% of the fee schedule of The Medical Association of the Bahamas for the procedures performed, private self-pay and government patients billed at 75% and 50% respectively. Their respective distribution and contributions to total revenue was analyzed. A series of financial models were constructed taking into consideration variables that could influence the percentages of revenues collected from each sector and the number of individuals served

RESULTS

One thousand five-hundred and forty-two patients received services in BICC over the 8.5 year period (56% males and 44% females age range: 0.25 - 96 years, with mean age of 55.7 years). One thousand eight-hundred and eighty-eight patient-procedures were performed, with 51% insured generating 69% total revenue, 18% Private producing 16% Revenue, and 31% Government patients generating 15%. Financial models were created to predict revenue behaviour in various scenarios.

CONCLUSION

Partnered Care is a viable alternative for Governments (Ministries of Health) of developing countries to provide costly specialized healthcare to their populations at minimal expense and capital outlay. Partnered Care reduces the otherwise overwhelming burden of healthcare cost to governments, particularly in developing countries, by sharing the burden of care between the private, user and government sectors.

Economic evaluation of a comprehensive self-management programme in patients with moderate to severe chronic obstructive pulmonary disease

AIMS

The main objective of this study was to investigate whether a comprehensive self-management programme, including self-treatment guidelines for exacerbations and a fitness programme, is an efficient treatment option for chronic obstructive pulmonary disease (COPD) patients.

METHOD

We randomly allocated 248 COPD patients to either self-management (127) or usual care (121). Data on preference-based utilities (EuroQol-5D), health-related quality of life (HRQoL), health-care resource use and productivity losses associated with exacerbations were prospectively collected. Quality-adjusted life years (QALYs) were calculated. The economic analysis took the societal perspective and the observation period was one year.

RESULTS

As we observed that the groups were equally effective in terms of QALYs and HRQoL (SGRQ), we described a cost minimization analysis only. The self-management programme-specific costs amounted to Euro 642 per patient. In the base-case cost analysis, the incremental cost difference amounted to Euro 838 per patient per year in favour of usual care. When only direct medical costs were included, the incremental annual cost of self-management relative to usual care was Euro 179 per person per year. If time costs for the fitness programme were set to zero, the costs for self-management diminished to Euro 542. Sensitivity analysis showed that these results were robust to changes in the underlying assumptions.

CONCLUSION

We conclude that the COPE self-management programme is not an efficient treatment option for moderate to severe COPD patients who rate their HRQoL relatively high. The programme was twice as expensive as usual care and had no measurable beneficial effects on QALYs or HRQoL.

Geriatric Versus Non-Geriatric Approach of Care to Moderate Pra Risk Senior Population

A total of 432 members of Senior Dimensions, a second-generation social health maintenance organization, residing in northern Nevada were identified as moderate risk by P(ra) screening criteria for the time period of July 1, 2002, through June 30, 2003. Of these members, 166 were impaneled to a practice that only provides care for seniors (age 65 years or older), Geriatric Care of Nevada (GCN), and 266 members were impaneled to multiple primary care providers with standard community-based practices (non-GCN). An annualized cost comparison per unit of service provided as derived from the adjusted use data showed an average savings of $760.00 per member per year for the GCN over the non-GCN population. These savings have occurred apart from the provider fee reimbursement. This represents a potential savings of more than $760,000.00 per year per 1000 moderate P(ra) risk members within a Medicare managed care program.

[Role of the medical institution in comprehensive medical care]

The diagnosis procedure combination (DPC) of Japan started in April 2003. It is a unique "per day" payment system that evolved from diagnosis-related group and prospective payment system, which was a "per case" system. After a trial of two years, various undesirable problems of DPC have been revealed. A review of those problems in major diagnostic classifications (16) is in progress. The main problems are: 1) the medical institution-specific coefficient; 2) up-coding; and 3) consideration for expensive medical equipment such as during cardiac catheterization. The inclusive payment system is described and the problems of DPC are discussed.

"Health for all" in a least-developed country

The World Health Organization's (WHO) concept of primary healthcare as the basis for comprehensive healthcare delivery for developing countries has not been effectively applied in many of these countries. The Kingdom of Lesotho, one of the world's least-developed countries, has been able to provide a fairly comprehensive healthcare system for its citizenry based on prmary healthcare principles and a strong commitment on the part of the government despite severe limitations of finance and human resource capacity as well as difficult mountainous terrains. This paper presents the highlights of this system of healthcare delivery with the hope that other developing countries would draw some lessons from the model.

Comprehensive care for haemophilia around the world

Comprehensive haemophilia care has been defined as the continuing supervision of all medical and psychosocial factors affecting the person with haemophilia family. Services offered by haemophilia treatment centres (HTCs) adopting the comprehensive care model include establishing prophylaxis and other treatment protocols, development of psychosocial, education and research programme, maintenance of a patient registry, genetic and reference diagnostic services and orchestration and management of a wide variety of multidisciplinary interventions. Most centres practising this model of care are based in developed countries and can meet costs for plentiful treatment products through government or insurance-company funding. Not all the programmes are dependent on the level of product supply, however, and many have been supported in countries with emerging economies as part of national healthcare systems, particularly in relation to blood management. In this paper we present perspectives from different areas of the world on how to adopt, adapt and achieve economically appropriate models of comprehensive care.

State-Funded Comprehensive Primary Medical Care Service Programs for Medically Underserved Populations: 1995 vs 2000

Objectives. We analyzed responses to the 2000 Comprehensive Primary Medical Care programs for Medically Underserved Populations Survey and compared them with the 1995 survey results to identify trends.

Methods. Surveys were mailed to all primary care program offices. State primary care program associations reviewed primary care program offices’ responses and completed surveys for offices that did not respond.

Results. We identified 30 qualified primary care programs in 24 states that had an overall funding level of $215 million. Most states allowed funds to be spent on expanding service areas, buying equipment, and hiring and training staff.

Conclusions. Although state funding has increased overall, many states do not have comprehensive primary care programs, and an increasing number of states are experiencing budget deficits that may lead to reductions in existing programs.

Mobile medical care units: an innovative use of Medicare funding

Medicare is an underutilized payment source for home-delivered health care services for homebound elderly. An innovative service provision for home health care, Mobile Medical Care Units (MMCU), is presented. MMCU consist of a multidisciplinary team of health care professionals who are responsible for following the health care needs of their elderly patients on a continuous long-term basis across settings. This comprehensive care has significant impacts on homebound elderly and the health care industry. MMCU have the potential to be covered more inclusively by primary or supplemental health insurance plans, including Medicare, Medicaid, and HMO's, or by special funding from state aging departments.

Interdisciplinary breast cancer care: declaring and improving the standard

The contemporary management of breast cancer is a complex endeavor that requires a truly collaborative team approach, characterized by ongoing communication and active information-sharing among the multiple disciplines involved. Programs designed to provide comprehensive breast cancer management by a team of multidisciplinary specialists were introduced in the late 1970s and have been increasing slowly. Patients attending comprehensive breast centers receive care from a broad-based multidisciplinary team that most often includes surgeons, radiologists, pathologists, medical oncologists, radiation oncologists, plastic/reconstructive surgeons, primary care physicians, gynecologists, nurses, social workers, patient advocates, and genetic risk counselors. At the heart of comprehensive, interdisciplinary breast care is the consensus planning conference that brings together team members on a regular basis to discuss individual patient cases and develop comprehensive treatment plans. This interactive and dynamic forum has become integral to the interdisciplinary management of breast diseases and results in an increased level of communication between the participating health-care professionals and the patients they treat. Several professional organizations, most prominently the American Society of Breast Disease, promote and support an interdisciplinary approach to breast care.

Comprehensive Care of the Epilepsy Patient-Control, Comorbidity, and Cost

Traditionally, control of seizures in patients with epilepsy is viewed as the most important clinical outcome. Yet, current antiepileptic drugs (AEDs) do not always achieve this. Around 30-40% of patients remain uncontrolled despite pharmacological intervention. Poor tolerability of AEDs is a large part of the problem and contributes as much to the overall effectiveness of therapy as efficacy. Comorbid conditions are present in many patients, and appropriate management of these can further improve seizure control and quality of life. Patients with epilepsy often experience--among other disorders--neuropsychological effects, migraines, and psychological problems (especially anxiety and depression). Sleep disturbances are also common and have been shown to contribute to the intractability of seizures in some patients. Many anticonvulsant treatments have the potential to improve--or in some cases worsen--these concurrent conditions, and these properties should therefore be considered in the total care of the patient. Finally, the costs of uncontrolled epilepsy are measured not only in terms of direct healthcare-related costs, but also in terms of lost productivity and opportunity. The indirect costs of epilepsy are substantial and account for 70-85% of total disease-related costs. Patients with uncontrolled seizures contribute disproportionately to healthcare costs, reinforcing the need for the development of newer AEDs with improved profiles of efficacy and tolerability, but with minimal adverse effects on behavior, cognition, and sleep.

Providing a medical home: the cost of care coordination services in a community-based, general pediatric practice

OBJECTIVE

To determine the cost of unreimbursable care coordination services for children with special health care needs (CSHCN) in 1 community-based, general pediatric practice.

METHODS

A measurement tool was developed to quantify the precise activities involved in providing comprehensive, coordinated care for CSHCN. Costs of providing this care were calculated on the basis of time spent multiplied by the average salary of the office personnel performing the care coordination service. In addition, data were collected regarding the complexity level of the patient requiring the service, the type of service provided, and the outcome.

RESULTS

During the 95-day study period, 774 encounters that led to care coordination activities were logged, representing service provision to 444 separate patients. When these encounters were examined on the basis of clinical complexity of the patient, the most complex patients constituted 11% of the population of CSHCN yet accounted for 25% of the encounters. In addition, care coordination activities for these clinically complex CSHCN engaged office staff 4 times as long when compared with less clinically complex CSHCN. Overall, 51% of the encounters were attributable to coordinating care for problems not considered typically medical and included activities such as processing referrals with managed care organizations, consulting with schools or other educational programs, and providing oversight for psychosocial issues. On the basis of national salary and benefits data, the annual cost of the time spent coordinating care for CSHCN in this medical home model ranged from 22,809 dollars to 33,048 dollars (representing the 25th and 75th percentiles, respectively).

CONCLUSIONS

The costs of providing care coordination services to CSHCN in a medical home are appreciable but not prohibitive. Standardization of care coordination practices is essential because it makes the medical home more amenable to quality improvement interventions. Mechanisms to finance unreimbursable care coordination activities must be developed to achieve the Healthy People 2010 objective that all CSHCN have access to a medical home.

Reducing clinical variations with clinical pathways: do pathways work?

OBJECTIVE

To test clinical pathways in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations.

DESIGN

Creation of indicators, specific for each clinical pathway, to measure variations in the care processes and outcomes. Pre- and post-analysis model to evaluate the possible effect of the clinical pathways on each indicator.

SETTING

We tested the clinical pathways in six sites, each with different clinical pathways.

RESULTS

Reductions in health care macro-variation phenomena (length of stay, patient pathways, etc.) and in performance micro-variation (variations in diagnostic and therapeutic prescriptions, protocol implementation, etc.) were shown in sites where pathways were implemented successfully. A significant improvement in outcome for patients who were treated according to the clinical pathway for heart failure was also demonstrated.

CONCLUSIONS

The overall purpose of clinical pathways is to improve outcome by providing a mechanism to coordinate care and to reduce fragmentation, and ultimately cost. Our results demonstrated that it is possible to achieve this goal. Although controversial elements still exist, we think that clinical pathways can have a positive impact on quality in health care.

ABC for health: funding medical home services for Wisconsin children with special health care needs

Medical home services for families with children with special health care needs can provide needed help for families struggling to gain access to coverage and needed services. Wisconsin, through Medicaid Early and Periodic Screening, Diagnosis, and Treatment Services, has an opportunity to provide this important and necessary service.

[Geriatrics: the day hospital as a part of comprehensive medical care of elderly patients--also or especially in threatened rationing]

The wrong conclusion of elderly people being the reason for increasing costs of public health is corrected by several differentiated statements. Geriatrics as a comprehensive medicine for the elderly can be realized in an exemplary way, even in a day hospital. An attitude of solidarity and a high level of interpersonal communication play the important and decisive part.

[Health care provider payment systems]

Health care provider payment systems regulate the relationship between patients, providers, and third payers in order to maximise benefits and minimise costs of the whole health care system. Health care providers could be paid by a price or a fee for service, by capitation systems, or by reimbursement of production costs. It would be interesting to develop innovative payment systems aimed to the payment of the entire health care pattern of patients. This would be particularly desirable for certain health conditions where it is impossible to divide the health care delivery pattern into single health services e.g. psychiatric care, long term and rehabilitation care.