Population-Based Disease Management in the German Statutory Health Insurance

Social healthcare systems in Europe must cope with aging populations and rising costs. For the German social healthcare system, which dates back to the 19th century, this problem is especially apparent, as soaring structural unemployment and the demographic transition of the population threaten the financial basis of the Statutory Health Insurance (SHI) [Gesetzliche Krankenversicherung]. In order to preserve free access to high-quality care and mandatory insurance for most of the population with affordable contributions, the traditional methods of healthcare delivery are challenged. As a result of its historic development, the system is tailored to acute care. Infectious diseases and accidents, however, have lost their relevance as main sources of mortality and morbidity of the population.Chronic diseases that can be influenced in their course by patient self-management and preventive measures dominate as causes of morbidity, mortality, and rising costs of healthcare. Since cost-containment measures can no longer stabilize cost development, structural reforms are strongly advocated. The implementation of a legal framework for disease management programs is the first of several structural reform measures implemented in the SHI.Diseases for which a legal framework has been approved include type 1 and type 2 diabetes mellitus, coronary artery disease, breast cancer, and asthma/chronic obstructive pulmonary disease. Quality requirements for the programs are high and include a central-accreditation process, evaluation in 3-year intervals by independent investigators, and specific quality management measures outlined for each disease. Major features of the programs include a population-based, patient-centric, and physician-based design. Since 2002, >1.6 million patients were enrolled in diabetes programs nationwide.Preliminary results point to positive effects of the programs on outcomes and process parameters, such as blood glucose and blood pressure readings or performed yearly eye examinations for patients with diabetes. Differences in the German and the US approach to disease management not only include a top-down versus a bottom-up approach; the German approach aims at secondary prevention regardless of risk state, co-morbidities, and possible cost savings, whereas in the US high-risk approaches are common. For the US, the German physician-based approach to disease management could be of interest in the evolving Medicare programs whereas German programs could become more effective drawing on US pay-for-quality experiences.Disease management, whether vendor or physician based, may not be the ultimate solution to all problems in the care of chronically ill patients, but it may facilitate change from a system traditionally focused on acute care to one focused on chronic care.