Integrated care

Integrated care is the idea of ​​a new " cross-sectoral " form of care in health care. It promotes a stronger networking between different disciplines and sectors ( primary care physicians, specialists, hospitals ) to enhance the quality of patient care while lowering healthcare costs.


Since about 1975

Approaches to replace the sectoral segregation in the German health care system through an integrated system has been around since about 1975 (eg Economic and Social Research Institute of the DGB ). Until the implementation, it took about a generation to deep divisions between service providers and their representatives, on the one hand and the payers ( health insurance companies) and their representatives, on the other hand, had in the meantime become.

The attempt at reform " integrated care " in health care reform in 2000 initially showed little effect. Integration contracts between providers and health plans could be completed only with the consent of the physicians' associations. Here seemed the tendencies to a status quo receipt to be dominant, so that the replacement collective agreement did not take place by selectively contractual agreements. On 1 January 2004, the red-green coalition managed with the SHI Modernization Act, the basis for the softening of fronts. In the newly created Integrated Care § § 140a to 140d Social Code V ( SGB V) has been determined that providers and health insurance companies can close together to integrate supply even without the consent of the physicians' associations contracts. In order to take the basis of individual contracts was created. The health insurance companies have under these regulations with a significant increase in power over the formerly superior associations of service providers.

§ 140a Integrated Care (IV ) (1) Notwithstanding the other provisions of this chapter may enter into contracts for a different service sectors and comprehensive care of the insured or an interdisciplinary, multidisciplinary care with the parties referred to in § 140b para 1, the health insurance companies.

§ 140b contracts for integrated care ( 1) health insurance, the contracts according to § 140 Abs 1 with

Complete. ... "

Since 2004

In the work of reform in 2004, a second important foundation stone was laid for the success of integrated care models: January 1, 2004 according to § 140d SGB V start-up funding in the amount of 1% of the total remuneration of outpatient and inpatient services has been provided to the hitherto hesitant use of the to speed up new possibilities. After initially stood until 2006, maximum annual 680 million euros available (220 million euros from the statutory sickness compensation and 460 million euros from inpatient care ). This period was extended for another year under the current health care reform. The initial funding reduced the budgets of the respective KV- districts in which the integration models are based. The initial funding provides only a temporary solution dar. For the long-term survival of integrated care are clear funding arrangements (budget adjustments ) necessary. The initial funding has ended with the entry into force of health care reform in 2009.

Development in the healthcare landscape in the field of IV - contracts: the end of 2004, there were about 300 integration agreements, in autumn 2005 the threshold of 1,000 contracts was achieved with a volume of compensation of 300 million euros. At the end of the 1st quarter, 2007, according to the Joint Registrar for implementation of § 140d SGB V ( BQS ) exactly 3,498 IV contracts covering a volume of compensation of almost EUR 611 million. Note: The number of contracts does not allow any conclusion as to the co-operating in the supply chain service provider.

The statutory health insurance has been in 2008, 41% more money compared to 2007 for integrated care. A large part of it accrue to the hospitals involved.

It is uncertain in what form the integrated care contracts will be evaluated. According to § 275 SGB V is the assessment and advice of the medical service of health insurance, in its assessment should be independently provided. Due to its sole funding by health insurance and nursing care insurance as the sole authority and its genesis, has been shown in the past that he is not. Unlike other medical services that health insurance can be integrated care currently often over others, in addition to a chargeable institutions, examine whose independence is less questionable. Only in isolated areas of the MDK is regularly entrusted with the review managed care contracts (for example, in North Rhine ).

Since 2011

On 1 January 2011 the list of potential contractors in SGB V has been expanded. This may, inter alia now pharmaceutical companies or medical device manufacturers as a direct contractor occur. Specifically, it has since been known in § 140b SGB V, Section 1 of this:

The health insurance can the contracts according to § 140a paragraph 1 only with individual approved for contractual medical care physicians and dentists and each other, pursuant to this chapter to supply the insured authorized service providers or their communities,


Contract design

Most IV contracts according to § § 140a to 140d SGB V refer to certain indications, but it is also possible to complete the so-called population- based contracts for all population groups. Often, the family doctors according to § 73b SGB V is embedded in IV contracts. This so-called " GP- based care " aims but more on the civil political or financial strengthening of primary care physicians as a true integration of health care providers. Some of these were " GP contracts " health insurance imposed by strike -like actions, in order to strengthen the financial base of Hausärzteverband. An improvement in the quality of care could thus far not been demonstrated.

Indication-specific IV contracts correspond to the classical case management, in which case a disease is treated tempered and standardized in a defined period (eg complex package). However, operational indications such as hip replacements for osteoarthritis by their high degree of standardization have a correspondingly clear scope with a calculable risk, there is a particularly large contract Examples of such indications. Critics refer to this as the likes of " IV light" or " old wine in new bottles ". However, since it is completely new cross-sectoral cooperation structures, indication-specific IV models are not last to be understood as " practice field" of the actors involved. It will be this way more complex models that treat more complex indications, approach.

Population -based care means in contrast to the indication-specific care that the care providers are reimbursed on capitation (English capitation ) or health premiums per insured eingeschriebenem, possibly limited to a specific region. In its pure form, as it is lived in the United States, any such contract continues to pose in Germany still in the pilot stage, but doctors' networks and federal state -wide GP-centered care models (AOK Sachsen, Barmer GP contract for specific areas in Germany ) represent the first steps in this direction

The long-term trend of simple indication-related to more complex contracts that span several sectors that include more difficult indications and develop all supply landscapes. After the often neglected in the German health principle "money follows power " will also establish itself in the future on a larger scale performance-based compensation structures that promise with the help of medical guidelines, a measurement of the recovery progress. The discussion of a guideline- based medicine is in German society not completed.

Some service providers as the contents of the contracts concluded with them on the Internet for free. From the insurers, however, contracts are not published with regard to compete or non-disclosure obligation usually. There is a database in the registry, which is operated by the BQS Institute for Quality & Patient Safety. Information are entitled to only the hospitals and doctors' associations, which are affected by subtracting the initial funding (up to max. 1 % of invoices ). Patients can be informed of their health insurance contracts, a contract and contractor.

Related forms of contract

The Integrated care can be viewed as a partial component of a modified managed care system on the U.S. model. This is designed primarily economic in contrast to the German health insurance model Bismarckian character and rather serves to maintain health (see Health Maintenance Organization ( HMO) ) than the insured previously incurred health.

Other managed care components that have been associated with health care reform in Germany in 2000 on the way, disease management programs ( DMP) and Diagnosis Related Groups ( DRG). Together, these actions aim endeavor to offer standardized treatment at standardized prices. The aim is to create transparency through better comparability of the services provided.

From quantity to quality model

The three approaches to so-called indication- based IV described below show an example of how to go beyond the now widely described model of the amount of scaling against price discount and instead monetary quality moments can bring to IV contracts.

About this indication- oriented three variants, there is still the population- based form of integrated care. In this the complete supply or one group of forms of care is provided by a health care provider community against a morbidity- adjusted capitation.