Reinhard Busse, Prof' Dr' med' MPH FFPH

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Managing Chronic Disease in Europe Resource
Implicationsof Future Care Development

• Reinhard Busse, Prof. Dr. med. MPH FFPH
• Annette Zentner, Dr. med. MPH
• FG Management im Gesundheitswesen, Technische
  Universität Berlin(WHO Collaborating Centre for
  Health Systems Research and Management)
• European Observatory on Health Systems and
  Policies
• Dr. Fabienne Bartoli
• Inspection Générale des Affaires Sociales, Paris

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What is chronic disease management?
Chronic disease management (CDM) - the ongoing
management of conditions over a period of years
or decades - goes beyond CVD/cerebrovascular
disease, diabetes and asthma/COPD to include
cancer and HIV/AIDS (as survival rates and times
have visibly improved), mental disorders
(depression, schizo- phrenia, dementia/Alzheimers
) as well as certain disabilities (sight
impairment, arthroses ). Many but not all of
these are linked to an ageing society.
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Driving research questions
Given the increase in chronic disease in terms of
burden of disease and health expenditure, what
do we know about the health and economic effects
of better CDM (in the broadest sense, i.e.
including prevention, financial incentives, IT,
new roles for professionals etc.)? What are
the resource implications if CDM would be well
implemented?
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• 1. Introduction definition of chronic disease,
  purpose of study, scope of following chapters
• 2. Epidemiology and burden of chronic disease
  (focusing on Europe)
• 2.1 Currently (i.e. most recent data) by
  country, by age sex, by disease, by
  socio-economic status
• 2.2 Predictions (as published)
• 3. Economic consequences of chronic disease
• 3.1 Microeconomic consequences (individuals and
  households)
• 3.2 Macroeconomic consequences
• 4. Intervening against chronic disease what is
  being done?
• 4.1 Prevention and early detection
• 4.2 New technologies (pharmaceuticals, medical
  devices )
• 4.3 New provider qualifications (e.g. Nurse
  Practitioners) and settings (e.g.
  multidisciplinary policlinics)
• 4.4 Coordinating care for individual chronic
  diseases across technologies, providers and
  sectors clinical pathways, disease management
  programmes
• 4.5 Managing care across chronic diseases

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• 5. Intervening against chronic disease how
  effective?
• 5.1 Prevention and early detection
• 5.2 New technologies (pharmaceuticals, medical
  devices )
• 5.3 New provider qualifications (e.g. Nurse
  Practitioners) and settings (e.g.
  multidisciplinary policlinics)
• 5.4 Coordinating care for individual chronic
  diseases across technologies, providers and
  sectors clinical pathways, disease management
  programmes
• 5.5 Managing care across chronic diseases
• 6. Intervening against chronic disease how
  costly and how cost-effective?
• 6.1 Prevention and early detection
• 6.2 New technologies (pharmaceuticals, medical
  devices )
• 6.3 New provider qualifications (e.g. Nurse
  Practitioners) and settings (e.g.
  multidisciplinary policlinics)
• 6.4 Coordinating care for individual chronic
  diseases across technologies, providers and
  sectors clinical pathways, disease management
  programmes
• 6.5 Managing care across chronic diseases

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• 7. Preconditions for successfully managing
  chronic disease
• 7.1 Right mix of financial incentives (for
  insured/ patients, payers, providers )
• 7.2 Elaborated information management (for
  identification, management, evaluation)
• 7.3 Establish evaluation culture
• 7.4 Strengthen cooperation culture (between
  patients and professionals, across professional
  groups, between sectors)
• 8. A best case scenario The future of Chronic
  Disease in Europe if well managed
  effectiveness, costs, and cost-effectiveness
• 9. Future research needs and concluding remarks

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2. Epidemiology and burden of chronic disease
(focusing on Europe)

• The burden of chronic diseases (mortality, DALYs
  )
• Chronic disease and age
• The burden of CD risk factors (smoking,
  hypertension, high cholesterol, overweight,
  nutrition, physical inactivity)
• Selected CD epidemiology in Europe (CVD/
  cerebrovascular disease, diabetes, asthma/COPD,
  depression, dementia, selected cancer,
  HIV/AIDS)

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3. Economic consequences of chronic disease

• Microeconomic chronic diseases negatively affect
  wages, earnings, workforce participation and
  hours worked, lead to early retirement, high job
  turnover and disability many studies in US
  settings
• Macroeconomic CD is costly to health system AND
  CD impairs economic growth (-gt double burden)

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Costs of CVD in Europe (per capita, of health
exp.)
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4. Intervening against chronic disease what is
being done?

• Chapters 4 to 6 are uniformly structured
• .1 Prevention and early detection
• .2 New technologies (pharmaceuticals, medical
  devices )
• .3 New provider qualifications (e.g. Nurse
  Practitioners) and settings (e.g.
  multidisciplinary policlinics)
• .4 Coordinating care for individual chronic
  diseases across technologies, providers and
  sectors clinical pathways, disease management
  programmes
• .5 Managing care across chronic diseases

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5. Intervening against chronic disease how
effective?

• Crucial and weak point!
• Most publications report on relatively
  small-scale interventions without control group
  or inadaequate control (e.g. no randomization, no
  risk adjustment)
• (As for pharmaceuticals etc.) the weaker the
  study design, the larger the published effects
• Logic of Evidence-based Medicine applies best
  available evidence counts

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How effective are Disease Management Programmes? 1
Mattke et al. Am J Manag Care. 2007 13 670-676
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How effective are Disease Management Programmes? 2
Mattke et al. Am J Manag Care. 2007 13 670-676
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How effective are Disease Management Programmes? 3
Mattke et al. Am J Manag Care. 2007 13 670-676
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6. Intervening against chronic disease how
costly and how cost-effective?

• Even less published evidence if costs are
  reported in CDM evaluations, the methodology is
  usually flawed!
• On macro-economic implications, we have to rely
  on models and projections!

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Suhrcke et al. Health a vital investment for
eco- nomic development European Observatory,
2007
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7. Preconditions for successfully managing
chronic disease

• Right mix of financial incentives (for insured/
  patients, payers, providers )
• Elaborated information management(for
  identification, management, evaluation)
• Establish evaluation culture
• Strengthen cooperation culture (between
  patients and professionals, across professional
  groups, between sectors)

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Payer/purchaser
Financialpooler
What comes tomindfirst
Regulator
GP
Hospital
Population/ patients
Specialist
Nurse
Providers
7.1 Right mix of financial incentives (for
insured/ patients, payers, providers )
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Weaknesses of traditional ways of paying
providers for chronic care
Fee-for-service Ill patientsusually
attractive Overprovisionof Services
Underreferral No incentive forhigh quality
Capitation Ill patientsnot attractive
Underprovisionof services Overreferral
Quality bad results-gt more work
Case payments Very ill patients not
attractive Tendency toaverage provision Weak
qualityincentives
No incentives for appropriate continuity of
care across providers
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Current approaches

• Focus on
• Access
• Quality of structures (e.g. DMPs - disease
  management programmes, registers), processes
  (e.g. appropriateness of services and referrals,
  recruiting for DMPs, documentation and procedural
  quality) and outcomes
• Continuity of care
• But do financial incentives support these aims?

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Purpose of financial incentives and regulation
for chronic disease care
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Examples of new payment measures

• year of care payment for the complete service
  package required by individuals with chronic
  conditions (DK)
• Per patient bonus for physicians for acting as
  gatekeepers for chronic patients and for setting
  care protocols (F)
• bonus for DMP recruitment and documentation (D)
• 1 of overall health budget available for
  integrated care (D)
• bonuses for reaching structural, process and
  outcome targets (UK)
• pay-for-performance bonuses (US)

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2004
Very few well conducted trials (9!) mainly on
prevention and only one on chronic care!
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Paying for chronic care quality in the UK bonus
of 190 per quality point up to 1050 points
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New quality bonus system
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BUT

• If third-party payers/ purchasers spend
  appropriately more for chronically ill, then they
  will
• charger higher premiums/ contributions
• cream-skim potential insurees
• need to be adequately funded from the pooled
  resources

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An extended framework
B
(Re-)Allocation
Payer/ purchaser
Financial pooler
Resource generation taxes, contributions,
premiums
Provider payment/ reimbursement
A
Financing ofchronic care/ DM
C
GP
Hospital
Population/ patients
Specialist
Nurse
Cost-sharing direct payments
Providers
D
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Risk-adjusted capitation What is risk? Can risk
be measured by treatment parameter
(hospitalization, drug prescriptions)?Should DMP
participation increase or decrease capitation?
B
Payer/ purchaser
Financial pooler
Fee-for-service/ DRGs Badoutcomes more money?
Non-risk related contribution/ premium Bonus for
DMP participation?
Outcome-/ quality-based compensation Doesit
work? What isthe right balance?
Financingchronic care political andresearch
agenda
A
C
GP
Hospital
Population/ patients
Specialist
Nurse
Cost-sharingReduction? Specific
limits?Only for compliant patients?
D
Providers
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Concluding remarks

• Proof that CDM is effective in terms of health
  outcomes yet to come -gt inbuilt evaluation
  important
• For CDM to work, incentives, IT, new structures,
  new roles for professionals important
• CDM will most likely not lead to health
  expenditure savings but better health (if proven)
  -gt economic growth -gt more money available for
  health