TRANSCENDING US PAROCHIALISM: LET’S LEARN FROM OTHER COUNTRIES by Nancy Turnbull

Earlier this month, I got a break from health reform in Massachusetts and spent a week in Germany doing research on that country’s health care system. Although we in the US most often compare our health system to those in Canada and the United Kingdom (maybe we think that speaking English is an important attribute of health system performance?), Germany’s health care system is actually much more similar to ours, and deserves more attention in the U.S.

Some similarities: In Germany, the health care system is not run by the government (although it is strictly regulated); employers provide much of the financing, through an assessment based on employee earnings that is split with the employee; coverage is provided through private health insurers, which compete for members (higher income people can opt-out and buy coverage from private, for-profit insurers but few people do); most of the delivery system is privately controlled–physicians work in private practice and most hospitals are structured as not-for-profit entities.

There are important differences, of course. One is that there is a national health insurance benefit package, with fairly low levels of cost-sharing. Health insurers can include additional benefits. The country employs lots of techniques for controlling costs on a regional and national level, including budgets for hospital and physician services, tough negotiation with drug companies, and national and regional planning of health system capacity, including expensive technology.

Of course, it’s always nice to spend time in a country that has a health system in which everyone has coverage, so that efforts can be devoted to other important issues, like improving quality and controlling costs. Germany has an impressive record in both areas. According to last year’s Commonwealth Fund report, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, Germany ranks particularly high on controlling health care spending, safe care, access to care, patient-centered care and living long productive life. Compared to people in the US, Germans have better access to care, lower out-of-pocket costs, less unnecessary ED use, lower death rates from potentially preventable causes, and much lower rates of obesity, among many areas of strength.

As in all countries, Germany has lots of room for improvement. It’s far behind many countries in adopting electronic medical records in physician offices (although doing better than in the US). Doctor dissatisfaction is high (perhaps in part because per capita spending on physician services, and physician incomes, are relatively low.) It’s been slow to measure and use patient satisfaction and experience as important indicators of system performance. Smoking rates are high (but falling fast). And coordination of care remains a challenge, partly because of the strict separation in Germany between doctors who practice in the ambulatory and hospital-based settings.

I was in Germany to learn more about at the Disease Management Programs (DMPs) that Germany began to implement in 2003. (They actually call them “Disease Management Programs” instead of using a German translation or term!) The goal of the programs is to reduce variation in care and improve quality. So far, the country has implemented DMPs for diabetes, coronary heart disease, obstructive pulmonary disease, asthma, and breast cancer on a nationwide basis. Although the programs are run by the German health insurers, they are strictly regulated by the national government to ensure uniformity and administrative simplicity. Programs must be accredited by the federal government. Unlike in the US, Germany prohibited DMPs run by for-profit vendors, including drug companies. Enrollment is voluntary for patients and physicians, but there are financial incentives to participate (for example, co-payments are waived for patients for services received through as part of a DMP). The national government has adopted evidence-based national treatment goals and guidelines that must be used by the programs. All the DMPs also use the same enrollment criteria, the same quality indicators, the same documentation forms, the same format for performance reports to doctors, and the same financial incentives for physicians. Health insurers have financial incentives to enroll members in DMPs because they receive additional payments from the German national risk adjustment scheme (which is designed to reallocate money from health insurers who attract healthier members to health insurers who have members with higher levels of medical need.) Every DMP is required to be evaluated and report its results publicly. But the actual organization and delivery of care is left to providers.

Although the programs are young and results so far are preliminary, early assessments are encouraging. Enrollment is increasing rapidly. Patient and physician satisfaction is high. There is clear evidence of improvement in certain processes of care, preventing complications, and reducing rates of smoking among DMP participants.

Lots of lessons for the US from these DMPs, and other features of the German health care system. For example, how much more effective could our efforts to improve care be in Massachusetts if health plans collaborated instead of competing in medical management, care coordination, and quality improvement? I’ve written about this issue before. My trip to Germany has convinced me that this is really an issue we should pursue aggressively in our quest to contain costs and improve quality in Massachusetts.

Nancy Turnbull
Harvard School of Public Health

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