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Chronic disease management programmes are critisized by doctors
Annette Tuffs
In our view, Annette Tuffs gives misleading information and reaches
incorrect conclusions in her news item on the new Disease Management
Programmes in Germany:
1. The new programmes have arisen following economic analysis showing
the importance of ensuring that health insurance funds should not be
penalised financially, as at present, when they have large numbers of
patients with chronic diseases.
2. The economic rationale for these programmes is not a simply to
fund deficits. There will be no „extra money“ put into the system.
Instead the existing risk adjustment strategy will be changed by taking
the higher costs for chronic patients (initially type 2 diabetes and
breast cancer) directly into account. Ultimately the government hopes to
implement a new risk adjustment model that takes account of all pre-
existing morbidity.
3. The Federal government’s new programmes have arisen following
recognition, using data from the OECD, in the latest report of the
Sachverständigenrat (the government’s Advisory Council) that Germany has
the highest level of health expenditure in Europewhile at the same time
facing questions about quality of care. The programmes aim to eliminate
overuse, underuse and misuse of care.
4. In the development of these programmes the German Medical Society,
the Statutory Health Insurance Physicians and the Hospitals Society
together with the health insurance companies all participated in the
working group and the political committee that recommended these
programmes to the Government. The physicians had the opportunity to
appoint their own experts into these groups and agree the entire
programmes for type 2 diabetes and breast cancer. All did, except for the
Hospitals Society, which opposed requiring an evidence base for specific
drugs. Thus it is hard to understand why the German Medical Society should
have agreed upon programmes that President Hoope now considers meet only
minimal standards.
5. On the contrary, condemning the new disease management programmes
as inferior to routine care is pure polemic. What is true is that, for the
first time in German medicine, such programmes have been built on a solid
basis of evidence based medicine following the philosophy of David Sackett
and combining the best available evidence with clinical expertise.
6. We can only conclude that the opposition of certain physicians to
these programmes results from the deep cultural shock felt by those who
thought that medical experts could never come into conflict with evidence
based medicine, which for the first time has become an integral part of
official governmental programmes. And the physician’s representatives are
not amused that the health insurance companies. showed their willingness
to become players rather than just payers in the development of these new
disease management programmes
7. These programmes will be updated regularly and must go through a
tough process of certification and evaluaton before they can become part
of the risk adjustment mechanism. We strongly believe that they will
enable us to overcome the important obstacles that we presently face in
providing integrated care for people with chronic diseases.
Prof. Dr. Norbert Schmacke
Dr. Dipl Psych. Jörg Lauterberg
Federal Association of the Local Health Funds (Bonn),
Kortrijker Strasse 1,
D-53177 Bonn
Misleading Information about German Disease Management Programmes
BMJ 2002, 17 August, p. 356
News extra
Chronic disease management programmes are critisized by doctors
Annette Tuffs
In our view, Annette Tuffs gives misleading information and reaches
incorrect conclusions in her news item on the new Disease Management
Programmes in Germany:
1. The new programmes have arisen following economic analysis showing
the importance of ensuring that health insurance funds should not be
penalised financially, as at present, when they have large numbers of
patients with chronic diseases.
2. The economic rationale for these programmes is not a simply to
fund deficits. There will be no „extra money“ put into the system.
Instead the existing risk adjustment strategy will be changed by taking
the higher costs for chronic patients (initially type 2 diabetes and
breast cancer) directly into account. Ultimately the government hopes to
implement a new risk adjustment model that takes account of all pre-
existing morbidity.
3. The Federal government’s new programmes have arisen following
recognition, using data from the OECD, in the latest report of the
Sachverständigenrat (the government’s Advisory Council) that Germany has
the highest level of health expenditure in Europewhile at the same time
facing questions about quality of care. The programmes aim to eliminate
overuse, underuse and misuse of care.
4. In the development of these programmes the German Medical Society,
the Statutory Health Insurance Physicians and the Hospitals Society
together with the health insurance companies all participated in the
working group and the political committee that recommended these
programmes to the Government. The physicians had the opportunity to
appoint their own experts into these groups and agree the entire
programmes for type 2 diabetes and breast cancer. All did, except for the
Hospitals Society, which opposed requiring an evidence base for specific
drugs. Thus it is hard to understand why the German Medical Society should
have agreed upon programmes that President Hoope now considers meet only
minimal standards.
5. On the contrary, condemning the new disease management programmes
as inferior to routine care is pure polemic. What is true is that, for the
first time in German medicine, such programmes have been built on a solid
basis of evidence based medicine following the philosophy of David Sackett
and combining the best available evidence with clinical expertise.
6. We can only conclude that the opposition of certain physicians to
these programmes results from the deep cultural shock felt by those who
thought that medical experts could never come into conflict with evidence
based medicine, which for the first time has become an integral part of
official governmental programmes. And the physician’s representatives are
not amused that the health insurance companies. showed their willingness
to become players rather than just payers in the development of these new
disease management programmes
7. These programmes will be updated regularly and must go through a
tough process of certification and evaluaton before they can become part
of the risk adjustment mechanism. We strongly believe that they will
enable us to overcome the important obstacles that we presently face in
providing integrated care for people with chronic diseases.
Prof. Dr. Norbert Schmacke
Dr. Dipl Psych. Jörg Lauterberg
Federal Association of the Local Health Funds (Bonn),
Kortrijker Strasse 1,
D-53177 Bonn
Norbert.Schmacke@bv.aok.de
Competing interests: No competing interests