The Role of Evidence-Based Guidelines in Managed Care Pilot Projects in Germany
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0092-8615199 Copyright Q 1999 Dmg Information Association Inc.
THE ROLE OF EVIDENCE-BASED GUIDELINES IN MANAGED CARE PILOT PROJECTS IN GERMANY REGINAKUNZ,MD, MSc (EPI) Department of Nephrology, University Hospital Charitk-Mitte, Berlin, Germany
LUDGERPIENTKA, MD, MSc (EPI) Clinical Epidemiology Unit, University Witten-Herdecke. Witten-Herdecke, Germany
Purpose: This paper outlines recent fundamental changes in the framework of the German health care system and presents diverse managed care projects and initiatives to standarize patient management using guidelines as a response to these changes. Main findings: Increasing health care costs and a decline in budget to the statutory health insurances have urgedfundamental structural changes in the long-existing German health care system. New legislation introduced competition between health insurers and pushed for pilot projects in managed care. The concepts of some of the new initiatives are presented. All initiatives recognized the need for standardization and disease management, supported by guidelines. The consensus-based guidelines produced by different stakeholders, howeveq did not prove helpful in patient management. Thefoundationfor an evidencebased, scientifically sound guideline development process has been laid by physicians’ organizations. Conclusions: The most recent changes to the health care system are promising. Their impact on urgently needed changes in the health care system remains to be seen. Key Words: Managed care; Evidence-based; Guidelines;Pilot project; Health care systems
LIKE MOST OTHER European countries, in Germany major changes are underway in the health care system. Managed care structures and guidelines seem to be promising approaches to help solve current problems. Many European health care systems have high expectations of these tools. There are large variations, however, in the organizational structures of different health care sysPresented at the DIA 34m Annual Meeting ‘Thinking Globally: Product Development, Registration and Marketing in the New Milienium,” June, 6-10. 1998, Boston, Massachusetts. Reprint address: Dr. Regina Kunz, MSc (Epi), Medical Clinic V, Department of Nephrology, University Hospital Charitk-Mitte, Schumannstr. 20/21, 101 17 Berlin. E-mail: [email protected]
tems, ranging from national health care systems with a strong emphasis on primary care and access to specialists through gatekeepers (such as in Scandinavia or the Netherlands) to more heterogeneously organized systems with public and private institutions providing health care (such as Germany, Italy, or France) (1). Therefore, the implementation of managed care and the use of guidelines has to be adjusted according to the existing national structures.
HISTORICAL DEVELOPMENT AND FRAMEWORK OF THE GERMAN HEALTH CARE SYSTEM
The foundation of statutory health insurers (SHIs) and mutual coverage of health risks 689
Regina Kunz and Ludger Pientka
690
goes back to the German Empire where Bismarck established social insurance for disease, disability a
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