1www.azq.de

Background of National Quality Policy Background of National Quality Policy

Background of National Quality Policy Background of National Quality Policy

G. Ollenschläger 1 G. Winker-Komp, C. Thomeczek 1

1 German Agency for Quality in Medicine AQuMed German Agency for Quality in Medicine AQuMed(Joint Institution of GMA and NASHIP, Cologne)(Joint Institution of GMA and NASHIP, Cologne)

2 German Ass. for Quality Assurance in Health Care German Ass. for Quality Assurance in Health Care

Workshop 1 ENQual ProgrammeNIVEL, Utrecht 28.11.2003

2www.azq.de

Germany – Some background information

Quality in health care – an actual topic in Germany

Health care reform 2003 and quality

OutlineOutlineOutlineOutline

3www.azq.de

Population in rural areas

Per capita GDP Unemployment People aged 60+

82 million 13 %

$25.468 9.8 %

23.2 %

Source: Statistics Division and Population Division of the United Nations Secretariat

4www.azq.de

Structure of the German Structure of the German Social Security SystemSocial Security System

SSoocciiaall SSeeccuurriittyy SSyysstteemm

SSoocciiaall IInnssuurraannccee SSyysstteemm

Statutory Insurance: Health Insurance Long Term Care Retirement Insurance Unemployment Accidents & Disease

(only work related)

FFeeddeerraall CCaarree PPrrooggrraamm Special Plans for Persons in the Service of the State: Policemen Soldiers Civil Servants etc.

WWeellffaarree SSyysstteemm Special Plans for Low Income Persons: Unemployed Persons Handicapped Persons Single Parents Elderly Persons etc.

Achberger 2000

5www.azq.de

German Health Care SystemGerman Health Care SystemBasic FeaturesBasic Features

• Statutory Social Health Insurance SystemStatutory Social Health Insurance System– covers about 90% of population

• Principle of SolidarityPrinciple of Solidarity– financial contributions differ– equal benefits to all insured

• PluralismPluralism– Federal government, state governments, self-regulating corporate bodies

• Delegation of power to non-governmental corporate bodies– Providers Associations – Sickness Funds Associations

Marcial Velasco Garrido, 2002

6www.azq.de

Who defines the Benefit Catalogue?Who defines the Benefit Catalogue?

PoPosssible Health sible Health BenefitsBenefits

Service Service FrameworkFramework

BenefitBenefit CatalogueCatalogue

German Parliament

Federal Standing Committee of Physicians

and Sickness Funds

Medical Review Board of the Sickness

Funds

Sickness Funds

Social Courts

Marcial Velasco Garrido, 2002

7www.azq.de

Health Insurance Systems in GermanyHealth Insurance Systems in Germany

SSttaattuuttoorryy HHeeaalltthh IInnssuurraannccee TTyyppee ooff IInnssuurraannccee PPrriivvaattee HHeeaalltthh IInnssuurraannccee

Compulsory Insurance Legal State Individual Contract

Non-Profit Organization Profit Orientation Profit Organization

Depends on Income (~ 13%),

not on Individual Risk

Insurance Premiums (half-and-half rule)

Depends on Individual Risk,

not on Income

Federal Plan,

Ruled by Law,

equal Access for all Members

Health Care Services Insurance Plan,

Ruled by Individual Contract,

Access depends on Individual

Risk and Contract

Insurance pays the Services

directly (Payment in Kind)

Reimbursement of the Health Care Services

Patient pays the Services,

amount will be reimbursed

9900%% RRaattee ooff tthhee eemmppllooyyeedd PPooppuullaattiioonn

1100%%

Achberger 2000

8www.azq.de

German Network of Quality Agencies German Network of Quality Agencies (Owned / sponsored by Self Governing Partners)(Owned / sponsored by Self Governing Partners)

KTQ(Cooperation for

Transparency and Qualityin Healthcare)

AWMFKBV DKGBÄK GKV BMGDPRPKV

Agency for Quality in Medicine

Committee ofPhysicians +

Sickness Funds

FederalOffice for

Quality Assurance

Guideline ClearingDisease Manag.

Programmes, HTAQuality Assess.

in Hospitals

Accreditation Progr,

Evaluation of Quality Programmes Stobrawa, 2002

RV

Germ. Assoc.for Quality Ass.

in Healthcare

9www.azq.de

Guideline Appraisal GroupsGuideline Appraisal Groups

AQuMed Steering Group (Representatives of German Medical Association and

National Assoc. of Statutory Health Insurance Physicians)

AQuMed Executive

Guideline Appraisal GroupsGuideline Appraisal GroupsGuideline Appraisal GroupsExpert Committees &

Panels

Office for CPG Implementation

German Guideline Clearinghouse

Center for Evidence Based Medicine

Patient Information Clearinghouse

German Agency for Quality in Medicine

Office for Quality Progr. Clearing

GGC Steering Group

GMANASHIPNat. Hosp. Ass.Statut. Sickn.F.Priv. Insuran.F.Publ.PensionInsur.Funds

PIC Steering Group

GMANASHIPDisabled People Ass.Health Care Consum. Ass.Self Help Gr.A.

Task Force Patient Safety –Error Prevention

ProgrammeManagement

Research and Development

Training,Education

Communication,Information

Journ. for CME, Qual.Ass. ZaeFQ

Websitewww.aezq.de

10www.azq.de

www.g-i-n.net

28

Agency for Health Research & Quality AHRQ, US Agency for Quality in Medicine ÄZQ, DEAGREE CollaborationAssociation of Scientific Medical Societies AWMF, DEBasque Office for HTA OSTEBA, ESBelgian Center for Evidence based Medicine CEBAM, BEBerlin Chamber of Physicians, DECenter for Health Policies and Services CPSS, RO Center for Reviews & Dissemination York CRD, GBClinical Epidemiology Center Lausanne CepiC, CHDanish Center for Evaluation and HTA DACEHTA, DKDirectorate for Health and Social Affairs, NODirectorate for Health Iceland, ISDutchAssociation of Comprehensive Cancer Centres ACCC, NLDutch College of General Practitioners NHG, NLDutch Institute for Healthcare Improvement CBO, NLevidence.at -Austrian Ass.for Quality in Healthcare, ATFederal Committee of Physicians and Sickness Funds FCPS, DEFinnish Medical Society Duodecim, FIFinnish Office for HTA FINOHTA, FIFlemish College of General Practitioners WVVH, BEHTA Unit, Ministry of Health Malaysia, MY Institute for Quality in Healthcare IQS, PTItalian Evidence-Based Medicine Group GIMBE, IJ .Briggs Inst.for Evid.Based Nursing&Midwifery, AU J osep Laporte Library Foundation, Barcelona FBJ L, ESNat.Agency for Accred., Eval in Healthcare ANAES, FRNat. Board of Health and Welfare (Socialstyrelsen), SENational Federation of French Cancer Centres FNCLCC, FRNational Institute for Clinical Excellence NICE, GBNational Institute of Clinical Studies NICS, AUNational Kidney Foundation NKF, USNew Zealand Accident Compensation CorporationACC, NZNew Zealand Guidelines GroupNZGG, NZ Polish Institute for Evidence Based Medicine PIEBM, PLProgram in Evidence-based Care, Cancer Care Ontario PEBC, CARegional Health Agency Emilia-Romagna ASR, IRoyal College of Surgeons in Ireland RCSI, IE Royal DutchAss. of Physiotherapy KNGF, NLScottish Intercollegiate Guidelines NetworkSIGN, GBSlovene Guidelines Group SGG, SISowerby Centre for Health Informatics at Newcastle SCHIN, GBSpanish Network for Research on Guidelines REDEGUIAS, ESSwiss Medical Association FMH, CHTrimbos Institute – Neth.Inst.of Mental Health & Addiction, NLWorld Health Organisation Geneva WHO

11www.azq.de

10www.azq.de

1. France

2. Italy3. San Marino

4. Andorra5. Malta

6. Singapore7. Spain

8. Oman9. Austria

10. Japan11. Norway

12. Portugal13. Monaco

14. Greece

15. Iceland16. Luxembourg17. Netherlands18. United Kingdom19 Ireland20. Switzerland

21. Belgium22. Columbia

23. Sweden24. Cyprus

25.25. GermanyGermany26. Saudi Arabia

34. Denmark37. United States

WHO Evaluation 2000WHO Evaluation 2000OOverall Health Care System Performance verall Health Care System Performance -- Efficiency Efficiency

Quality problems in Germany ?Quality problems in Germany ?Where is the evidence ?Where is the evidence ?

12www.azq.de

Problems with the German Problems with the German Healthcare System ? Healthcare System ?

• Deficits in quality, economic efficiency, transparency and Deficits in quality, economic efficiency, transparency and patient orientation.patient orientation.

• Challenges for health insurance due to aging population, medical progress and changes in people's working lives.

• Financing of health insuranceFinancing of health insurance, being solely dependent on income, leads to increasing incidental wage costs and therefore to negative effects on the labour market.

Press Release, Fed. Government 2003-08-01

13www.azq.de

Outcomes in German Health CareOutcomes in German Health Care

Busse 2002

14www.azq.de

US CA EN SC DE% confident that their patients are able to manage their own care when discharged 33.8 30.0 59.7 56.1

80.9% who say the quality of care in their hospital has deteriorated in the last year 44.8 44.6 27.6 21.5 17.2

Nurse assessed quality of care, 98/99 Nurse assessed quality of care, 98/99 Aiken et al, 2001Aiken et al, 2001

Busse 2002

15www.azq.de

• Source: WHO 2000

10,5%

8,0%

13,7%

5,8%

10,1%9,2%

8,0%

6,2%5,3%

9,0%8,0% 7,6% 8,0% 7,6%

9,8%8,8%

6,5% 6,2%

8,2%

9,4%9,3%

Total Expenditures on HealthTotal Expenditures on Health - % of GDP -

Increasing contribution rates 13,5% to 14,5% (2002)

16www.azq.de

2003: the Year of the Reform2003: the Year of the Reform

Goals of the newest health care reform

• Stabilise contribution rates• Increase quality and efficiency of care • Develop competitiveness among providers• Strengthen patients rights• Uphold basic principles

• Solidarity • equal right to treatment for all insured citizens

17www.azq.de

Stat. Health Ins. Modernisation Act Stat. Health Ins. Modernisation Act 2003 - 2003 - MeasuresMeasures

Strengthening of patient sovereignty• Patient representative at federal level• Consumer information by Inst. for Quality and Econ. Efficiency in SHI

Improving quality of care• Inst. for Quality and Econ. Effeciency in SHI (foundation of self

governing partners): assessment of guidelines, recommendations on national disease management programmes, assessment of benefits of medicines, HTA.

• Standard quality management for in-patient and out-patient services. • Mandatory CME

www.azq.de

Feedback

NICE

AssessmentAssessment

IdentificationIdentification Appraisal & Guidance

Appraisal & Guidance

DisseminationDisseminationDisseminationDissemination

ImplementationImplementation

MonitoringMonitoring

Evidence-Based PracticeEvidence-Based Practicein Healthcarein Healthcare

NICE – A New Model for Germany ?NICE – A New Model for Germany ?

Littlejohns, NICE

19www.azq.deLittlejohns, NICE

What about Professional Self-regulation ???What about Professional Self-regulation ???

20www.azq.de

Implementation of systematic Quality oriented + Implementation of systematic Quality oriented + Evidence based Healthcare in Germany Evidence based Healthcare in Germany

(by Self Governing Partners)(by Self Governing Partners)

Perleth & Schwartz 2001, modified

„„Orientation“ PhaseOrientation“ PhaseAnalysis of the international

state of the art

„„Development“ PhaseDevelopment“ PhaseDevelopment of methodological

standards, networking (international/ national)

„„Evaluation“ PhaseEvaluation“ PhaseTesting, assessment of tools / procedures „„Routine“Routine“

InstitutionalisationInstitutionalisation• Guidelines Clearinghouse

• Nat. Disease Manag. Programme• HTA for definition of benefits• Quality measure for hospitals• Peer groups for outpat. care• DRG‘s + TQM in hospitals

1996 20011997 1998 1999 2000 2002

21www.azq.de

Thanks for your patience !!!!Thanks for your patience !!!!

• www.azq.de

• www.leitlinien.de

• www.patienten-information.de

• www.g-i-n.net

FounderMember