BMJ 2002;325:356 ( 17 August )
Annette Tuffs Heidelberg
The German government’s efforts to introduce so called "disease management programmes" for patients with chronic diseases is being opposed and partly boycotted by doctors. They fear that the quality of patient care will suffer substantially and that data on individual patients will have to be disclosed to the health insurance companies.
Health care in Germany is provided through numerous insurance schemes, which all but the highest paid workers have to join to receive treatment. These schemes are obliged to cover the cost of treating chronic disease. However, providing such care can be costly. The programmes offer a standard structure for diagnosing and treating chronic disease. The health ministry says that the programmes are necessary to ensure quality of medical care through evidence based guidelines.
So far, programmes for patients with type 2 diabetes and breast cancer are ready to be implemented; those for cardiovascular disease, asthma, and rheumatic diseases are being prepared.
The German health minister, Ulla Schmidt, points out that, despite major advances in diagnosing and treating diabetes, patients still have too many secondary complications, such as kidney failure and diabetic retinopathy. Also, too many women in Germany have unnecessary breast removals and radiation therapy. The programmes should also help to avoid repeat diagnostic testing by the general practitioner, the specialist practice, and the hospital.
Furthermore, the government wants to support health insurance companies that have a high proportion of chronically ill members. The companies will be paid extra money if their members are taking part in the disease management programmes. However, patients are free to choose whether to participate in the programmes. By avoiding unnecessary treatment, the government hopes for substantial savings in the long term, as 80% of the health budget is used to treat chronically ill patients.
Despite the fact that the treatments have been agreed by the joint committee of doctors, health insurance companies, and the Hospital Society (an umbrella group representing hospitals), Germany’s leading doctors still criticise the programmes.
The president of the German Medical Society (Bundesärztekammer), Jörg-Dietrich Hoppe, complained that the programmes were prepared under extreme time pressure. "The main mistake is that only minimal standards have been agreed."
The Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung) questions whether health insurance companies should be able to review all personal and treatment data in order to achieve financial advantages. The Hartmann Society, a powerful lobby group representing doctors, even asked their members not to take part and advised their patients against participation.
The quality of the diabetes care programme has been fiercely attacked by more than 10 scientific societies. They say that the health insurance companies and the government favour a minimal programme, which is based solely on studies with the highest level of evidence. The government has reacted to the criticism by including weaker treatment criteria. In future, the ministry said, scientific societies will have an earlier chance to suggest amendments.
But the future of the disease management programmes hangs in the balance,
with general elections in a few weeks' time. Shadow health minister Horst
Seehofer has already announced that if he takes over after the election
on 22 September he will not couple the introduction of the programmes with
financial advantages for that health insurance company.
© 2002, BMJ