The future of primary care in Germany

from the viewpoint of a health insurance fund

Johannes Bauernfeind
AOK Baden-Württemberg

First US-German Summit on Primary Care

April 8 – 10, 2010
Washington, DC

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC
Agenda

Statutory health insurance and the AOK

Current status of the German health system

AOK-objectives in provision of medical care

AOK-means to achieve objectives

Information technology as one key to success

Conclusion

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 2
Statutory health insurance and the AOK

Statutory health insurance provides a wide range of

services to its members

Without direct payment for doctors´ services

guaranteed by the „benefits in kind“ principle

Patients are free to choose their own doctor

Every person covered by statutory health insurance

funds pays a contribution of 14.9 % of earnings

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 3
Statutory health insurance and the AOK

The AOK Baden-Württemberg is an independent regional

health insurance fund

Over 3.7 million insured persons

More than 12 billion US-$ total expenditure in 2009

17 %, i.e. > 2 billion US-$, paid for doctors´ services

in the outpatient sector

Part of the nationwide AOK group (Federal

Association of the AOK) with approx. 24 million
insured persons

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 4
Current status of the German health system

Infectious diseases decreased and methods of treatment

of acute diseases became more successfull in the past
century

On the other hand, proportion of chronic diseases is

increasing continuously due to

Lifestyle and environmental conditions,

lack of exercise and

wrong eating habits

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 5
Current status of the German health system

Aging at the top

Aging at the bottom

Demographic changes in developed countries require

specific provision of medical care for different
generations - young and old alike

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 6
 Current status of the German health system

hypertonia

20 % of all persons with

health problems cause 80 %
Incidence of disease

of total expenditure in health

depression care

diabetes without complications

chronic ischemic
heart disease
heart failure carcinoma

juvenile-onset diabetes
COPD

Data: AOK Baden-Württemberg Standardized costs

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 7
Current status of the German health system

Provision of medical care is furthered by medical and

technical improvement, yet becomes more complicated
for all participants

Well-informed patients want their needs to be taken

seriously and to take part in making decisions

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 8
Current status of the German health system

Health insurance funds in Germany are regulated by

law to a great extent

Efficiency seems to decrease despite rising expenses

Traditional – anticompetitive – structures are changing

step by step

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 9
AOK-objectives in provision of medical care

The AOK Baden-Württemberg´s strategies in dealing

with new possibilities and options:

Discount contracts with pharmaceutical companies

covering generic and on-patent drugs

Introducing new contracts with independent

doctors´ associations (general practitioners and
specialists) to organize better outpatient medical
care

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 10
AOK-objectives in provision of medical care

Differentiation of the offered services and provision of

medical care between competitors

Offering alternatives to standard services for our

customers

Innovation in contract regulations

Increase in efficiency

Maintaining the regional option in write up and

negotiating contracts

Guaranteeing a safe coverage of needs

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 11
AOK-objectives in provision of medical care

Improvement of quality
applied to all insured persons
quality instead of quantity
focus on chronic diseases
Participation of patients both in treatment and in
prevention to
reduce mortality risk in lifestyle conditions, wrong eating
habits and lack of exercise
raise compliance by shared decision making
Doctors´ options in treatment must remain
Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 12
AOK-means to achieve objectives

Guidelines for medical treatment founded on evidence

based medicine
Pay for performance (P4P) as a relevant part of
payment with regard to
quality and
efficiency
Contract stuctures based on partnership
Mutual choice of methods
Combination of doctors´ services and supplied
AOK-own measures of prevention
Doctors who are our contract partners also support
our generic and on-patent drug procurement
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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 13
AOK-means to achieve objectives

All contracting parties are responsible for

documentation and directing medical treatment

Establishing and supporting management skills on the

part of doctors´ associations

Reinforcing doctors´ abilities and willingness to use

information technology in daily work

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 14
AOK-means to achieve objectives

Efficiency of medical care is determined to a great

extent by the way doctors prescribe drugs and
treatment
Economic and high quality prescription of drugs and
other benefits require
knowledge of guidelines and standards in treatment
as well as the resulting expenses is improved by
local doctors quality commissions
support of drug prescription by specialized software
programs
updated continuously
surveyed by a mutual drug committee
Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 15
AOK-means to achieve objectives

New methods must be established to communicate the

need for prevention to the patient
Prevention of cardiovascular diseases can be supported
by specific software programs
Data of corresponding risk factors can be recorded
and visualy accentuated to show the individual risk to
the patient
Specific AOK-own prevention measures can be
researched and displayed to the patient, including
information on
the contact person at the AOK and
coupons for the chosen prevention measure with
indivudual patient data
Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 16
AOK-means to achieve objectives
Our customers must be aware of additional value of the
offered services
Exclusive offers for AOK insured persons who are
enrolled in the contracts:
Comprehensive care by their chosen GP and treatment
based on guidelines on a high quality level
Coordination of all services in the health care system
Reduced waiting time in doctor´s office and extended
service hours
Electronic health record
Extended routine health check with individual
consultation on health risks
No statutory co-payment on drugs covered by discount
contracts
Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 17
AOK-means to achieve objectives

To enhance provision of primary care in the outpatient

sector, the AOK has also made contracts with
specialists´ associations
GPs and specialists who are parties to these contracts
will form networks to optimize outpatient care in quality
and efficiency
by realizing guidelines with graduated medical
diagnosis and treatment in the entire outpatient
sector
by supporting contracts of procurement covering
generic and on-patent drugs as far as possible
Enrolled patients also benefit from network in primary
care

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 18
AOK-means to achieve objectives

GPs take part in our new contract

and safeguard provision all over
Baden-Württemberg
Additional contracts with specialists
will start in 2010 in
cardiology and
gastroenterology
These specialties are first
priority because they show
more potential for improvement in
quality and efficiency than others

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1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 19
Information technology as one key to success

Competition between health insurance funds needs

differentiation of supplied services

Differentiation of supplied medical services isn´t possible

without using information technology (IT) in doctors´
offices

Use of defined software programs must be specified in

new contracts

Software programs can reduce time and administrative

efford and support communication among doctors and
the accounting centers

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 20
Information technology as one key to success

Specified software programs need

secure technical framework for online-updating

modules to administrate
enrollment of insured persons,
required medical documentation and
fee invoice management

an included prescription module with additional

information on costs of prescriptions in particularly on
discounted drugs

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 21
Conclusion

Changes in the health care system – demography,

increase of chronic diseases and legal regulations – call
for new solutions
Prevention must be furthered
Finance follows quality and efficiency: Payment
conditions must include „P4P-elements“
Competitive structures call for differentiation of medical
services on behalf of doctors and health insurance funds
Information technology is essential to make these
solutions work and to put new contracts into effect

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 22
 Thank you
for listening
Johannes Bauernfeind,
AOK Baden-Württemberg

Johannes Bauernfeind
1. US-German Summit on Primary Care, April 8 – 10, 2010, Washington , DC 23