Statutory Health Insurer: Techniker Krankenkasse

Transcription

1 Statutory Health Insurer: Techniker Krankenkasse Founded 1884 in Leipzig for Technicians Non-Profit Corporation under Public Law 8 Million Insurants Approximately 12,000 Employees 228 Offices Nationwide in Germany Budget: 21.3 Billion (2012) Compulsory Contribution Rate: 15.5% of Tax Income 7.3 % by E mployer 8,2 % by E mployee

2 Statutory Health Insurers in Germany are public bodies - but self-administered Private Company For-Profit Health Insurer Public Body with Self-Administration Statutory Health Insurer Governmental Body Ministry of Health

3 WINEG - Scientific Institute of TK for Benefit and Efficiency in Health Care WINEG Vision Interrelations and Interactions in German Health Care Funding and Health Services in German Statutory Health Insurance EU Cross-Country Comparisons Health Economics Research Competence in Health Behaviour Evidence-Based Information with Practical Rel evance Analysis of Decision Processes WINEG/ TK as Player Analysis and Evaluation of Health Service Models Health Services Optimisation Approaches Data-Based Health Services Research EU Cross-Border Care 3

4 Beveridge and Bismarck Beveridge-type System William H. Beveridge S tate health care system F unding bas is : tax-financed government budgets Univers al coverage for every citizen Integration of payers and providers Bismarck-type System Otto von Bismarck System of statutory health insurance Funding basis: income-based contributions Origins: Mandatory statutory health insurance for workers Separation between payers and providers

5 Mix of Public and Private Health Insurance Private Supplementary Health Insurance Statutory Health Insurance Private Health Insurance Statutory Long Term Care Insurance 70.2 Million SHI Insurants Possibility to opt out for employees with an income higher than 49,500 Private Long Term Care Insurance 8.5 Million Insurants

6 Why the Need for Integrated Care? Status Quo: Strict separation between 1. outpatient and inpatient sectors 2. financing and provision of care Lack of co-operation and co-ordination between care providers Future: Slow Trend in German Health Care of Increasing Co-operation and Integration

7 The Players in German Health Care Insurers Regulatory Framework Free Choice of Insurer Provider Contracts Insurants Free Choice of Provider Care providers

8 Healthcare Contracts between Insurers and Providers are mainly entered on Association s Level Most Negotiating and Contracting: 90% of SHI Health Expenditures Framework Macro-Level (State) Associations Level ("Länder") Most important decision-making bodies Some Selective Negotiating and Contracting Micro-Level (Providers, single organisations)

9 Advantages of Selective Contracts Care provider Income security Appropriate payment Competitive advantage Health insurance Individual provision of health care Consolidation of financial responsibility and contract competence Competitive advantage Insurant / Patient Improved health care provision through co-ordination and integration Freedom of choice and transparency of services and quality Improved services (information, consulting)

10 Types of Integrated Care Contracts 1. Economic efficiency and quality improvement Discount contracts (economies (of scale)) Contracts substituting inpatient care Contracts steering/optimising the quality of care 2. Competitive advantage and promotion of innovation Contracts for innovation in health care

11 EU Cross Border Care Contracts TK Hospital Service in the EU 131 hospitals in 8 EU Member States TK Cure and Spa Service in the EU 37 cure and spa providers in 6 EU Member States TK Dental Service in the EU 2 dental clinics in Hungary and Poland

12 TK Integrated Care Contracts Legal Basis: 140 ff Social Code Book V 2004 to 2010: 320,000 TK insurants 2011: 160,000 TK insurants (100 million ) More than 300 single integrated care contracts O rthopedics C ardiologie/cardiologic surgery Mental Health Oncology P ain therapy Ambulatory surgery P romotion of innovation

13 Evaluation of Integrated Care Contracts Evaluation of costs and benefits Comparison of health care and administration costs between IC contracts and equivalent collective contracts Lower costs due to improvements Payoffs should be visible within 3 years Comparative analysis: contract objectives/tk's strategic aims According to the cost benefit evaluations 85 % of the IC contracts have led to positive results

14 IC Contract 1: PET/CT Positron Emission Tomography and Computer Tomography Lymphoma, bronchial, mamma, prostate and bowel carcinoma Expert networks with oncologists, radiologists and clinics Specilialist qualification, highest quality possible Testing with 500 participants p.a. Objectives Increase of diagnosis and therapy safety Substition of e.g. x-ray, biopsy One single, pain-free, quick examination

15 IC Contract 2: Network Mental Health Complementing GP/specialist health care 24 hour reachability Personal co-ordinator/carer Stabilisation with family members Home instead of clinic Home specialist treatment/nursing Avoidance of inpatient treatment Incentive bonus for providers Flexible therapy options Sociotherapie Psychoeducation Optional (short term) psychotherapy 4 Additional options Outpatient rehabilitation Assisted living Socio-professional reintegration

16 IC Contract 3: Back Pain Combination of medical, training-therapeutic, behaviourtherapeutic and psychological approaches 35 locations in Germany Steering of insurants solely by TK (no referrals needed) Ususally therapies of 4 weeks (or 5 to 8 weeks) Follow-up examinations after 6 months to ensure long term improvement Participants: 4,000 Intensive Therapy with Pain-, Physio- and Psychotherapist - Around 9 Hours per Week

17 IC Contract 3: Back Pain (success rate: 80%) Diagnostic Screening Suit abl e 4 weeks therapy Unsuitable Alternative therapy 5-8 weeks therapy Able to work again Able to work again in the long-run Able to work Malus Not able to work again Not able to work in the long-run Bonus After 4 weeks therapy, 6 months permanently able to work

18 18 IC Contract 4: Second Opinion Back Surgery Option of second opinion by qualified s pecialis t Appointments within 2 working days P re-condition: Insurants have to have a referral for backbone surgery. F irs t evaluation results confirm the finding of s tudies that 80% of the surgerys are unnecessary. 100% 80% 60% 40% 20% 0% Studien IGV-Vertrag OP sinnvoll OP unnötig

19 IC Contract 5: Telemedicine for the Heart Continuous monitoring of weight and blood pressure Early intervention if health risks have been identified Avoidance of refferals to clinics and emergency health care Better patient understanding and compliance through provisions of training courses Health status stabilisation through guideline-based therapy Positive Impact on patient safety and reduction of mortality 24 hour reachability by phone of medical personnel Reduction of related costs

20 IC Contract 5: Telemedicine for the Heart

21 IC Contract 5: Telemedicine for the Heart

22 IC Contract 5: Telemedicine for the Heart 74% of 238 surveyed insurants (2007) were completely/very satisfied with the IC offer 68% rated the quality of this health care option as excellent/very good, recommendation rate: 92% 86% felt safer concerning the handling of their condition 96% rated provided information as important/understandable 83% felt strongly supported 38 % changed their pharmaceutic therapy

23 Thank you for your attention. Dr. Caroline Wagner