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How to join Public Health, Prevention and Integrated
Care: some answers in a southern region of
Germany: Healthy Kinzigtal
April 4th 2014: CHUV centre hospitalier universitaire vaudois,
Institut universitaire de médecine sociale et préventive
Helmut Hildebrandt
OptiMedis AG
Borsteler Chaussee 53
D – 22453 Hamburg
Tel: +49 40 226 211 49 0
e-mail: [email protected]
Web: www.optimedis.de
© OptiMedis AG
Gesundes Kinzigtal GmbH
Strickerweg 3d
D – 77716 Haslach
Tel: +49 7832 – 974 89 0
e-mail: [email protected]
Web: www.gesundes-kinzigtal.de
1
The Triple Aim* of Good & Responsible
Health Care
Improve the
health of the
population
Efficient ( ow) per
capita costs of
care
Enhance the
patient care
experience
Who can take on responsibility on a local level?
* Berwick DM, Nolan TW, Whittington J. (2008), The triple aim: care, health, and cost. Health Affairs 2008 May/June;27(3): 759-69.
© OptiMedis AG
2
Who can take on responsibility for the
triple aim on a local level?
City
municipality
Knowledge ?
Entrepreneurship?
© OptiMedis AG
GP /
other Doctors
So many … ?
Enough organizing
Know-How?
Hospital
Enough public
health interest?
Insurance
Too much focus
on costs ?
3
Regional organized accountable health
cares systems (coop networks) can take
on responsibility
Regional Care Company
Owned partially by providers, hospital, municipality, civil
foundation, seniors organisation, sports club …. public health
organisation
Problem: Providers could create overload of services (higher costs)
Solution:
© OptiMedis AG
This RCC should be paid by the insurance for the achieved
health outcome (related & adjusted to the normal one) instead for
the number of disease/health services
4
Kinzigtal is in the Southwest of Germany
Start: 2006 with four courageous partners:
AOK Baden-Württemberg and LKK –
and Gesundes Kinzigtal GmbH
(2/3 shares MQNK e.V. and 1/3 OptiMedis AG)
Concerned Population: 33,000 insureds of AOK and
LKK
58% of all the GPs and specialists of the region are partners / altogether
around 500 staff from partnering providers in communication loop
Nearly 10,000 patients have already chosen the free membership, getting
surplus health care services, coaching and free preventive offers – but staying
free in their decision to chose any provider (like in the regular system)
Providers get their normal fee plus targeted add-on fees through Gesundes
Kinzigtal … around 5-10% surplus … for those services GK wants them to
deliver
© OptiMedis AG
5
The Kinzigtal region:
touristic + small business region
between the Rhine valley
and the middle part of the
Black Forest in SW Germany
© OptiMedis AG
Lovely region – lovely people
© OptiMedis AG
7
Gesundes Kinzigtal GmbH: Population-based
Integrated Care for a whole Region
Two convinced partners: A local
physician network „Ärztenetz MQNK“
and a management company
„OptiMedis AG“ that stems from a
health science background
Two partners with passion and
motivation to prove the effectiveness of
a better organized regional health care
system in the hand of a dedicated
Regional Care System
A company with a business model that
rewards investments in better health &
and better focused health care … if it
results in improved earnings for the
payor (= health insurance) = less costs
of care (in comparison with national
standard)
© OptiMedis AG
Know-how of regional
problems in health care
provision + links to all
institutions and providers
Know-how in health
economy, health sciences,
prevention, controllingand managerial issues
ownership:
66,6% MQNK e.V. (Ärztenetz)
33,4% OptiMedis AG
8
Networking – around 160 partners and 500
people involved in the care process
Nov 2013
Partners
Enrolled Insurees of AOK and LKK
Providers with
partnership
contracts
Family doctors, specialists, psychotherapists – around
56% of those physicians working in the region Kinzigtal
Staff in the provider offices
62
ca. 190
6
Physiotherapists
8
Ambulatory nursing agencies / psychosocial agencies
11
6
Pharmacies – around 70% of all p.
16
Self help, local enterprises (Network Healthy Companies
in Kinzigtal), local government/administration
42
Fitness-Centers – ca. 80% of those in the region Kinzigtal
Voluntary associations, sports clubs, social clubs
© OptiMedis AG
9,475
Hospitals – around 85% of all cases
Nursing homes
Further partners in
cooperation
No.
6
36
9
Just to get an Impression for the Numbers
Population of Kinzigtal
(71,000)
Insured GK cares for
currently (33,000)
Members of GK currently
(10,000)
Health care professionals =
partners of GK (around 500 in
network)
Staff of GK (20 health scientists,
case manag., health promotion,
social worker ….)
© OptiMedis AG
With Five Key Success Factors for Health
Improvement….
Pushing medicine from reacting to acute symptoms to
agreements between providers and patients about joint goals
Activation of patients & insureds & healthcare
professionals
Substituting medication through physical training
Scientific orientation and claims data analyzing to
improve health outcomes
Improving public health
© OptiMedis AG
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What we did: integrated care design
Users and carers
• The whole programme is free of surplus charge to patients – they just pay their normal premium
• Patients have free choice of providers
• Actively enrolled members receive enhanced care coordination across all sectors, access to
physicians outside normal hours, and discounts for gym memberships among other benefits
Care management and preventive programmes
20 different care management and preventative programmes including:
• Two variants of an intervention programme for patients with chronic heart failure (telephone
• a Multidisciplinary
Team
(MDT)
counseling led by
practice
staff for one, operated from a call center for the other - using practice staff
was equally as effective and cheaper!)
• A four option smoke cessation programme (medication, psychotherapy, acupuncture, hypnosis)
• Strengthening medical care for the elderly in nursing homes
Information sharing
• System-wide electronic patient record integrated into practice IT systems of all physicians – this took
over five years, over € 1m investment and required the development of deep trust between providers
Financial initiatives
• The usual reimbursement schemes and financial flows between statutory health insurers and individual
physicians have not been replaced. These payments constitute 80-90% of individual providers’ income.
• Direct fees for providers for specific activities
• Most physicians are members of the physician network that owns two thirds of the company shares
• Indirectly these members get a share of he company’s profit
“Activate the people
themselves – they
“Please
are provide
theam
biggest
quotehealth
from acare
service
user
resource”
perspective”
Integration of health and social care
• Previously physicians who identified that there was a social problem with a patient had few options to
help the patient, therefore the problem was often not resolved
• In 2008 a pilot was introduced whereby physicians were able to get a social worker to come into their
practice to help the patient. This consultation has now been provided for over 200 patients.
• Partnership with hospitals to coordinate post-discharge care to avoid readmission using a case
management approach
Visuals Copyright ©2013 Hildebrant H., et al. (2010)
Copyright ©2013 Integrating Care & the Local Government Association
Page 12
Who we did it for and why
Users and carers
• Patients were previously experiencing uncoordinated acute care that was not targeted to their chronic
needs. Now they receive targeted programmes developed around their needs, and free of surplus
charge on top of their regular insurance fees.
• Carers are receiving high appreciation by their patients for the increased time they themselves (or
other carers or staff members of Gesundes Kinzigtal) are able to give them using these programmes
• Patients are now experiencing improved health and wellbeing.
Workforce
• One third of GPs in Kinzigtal (same in other rural areas in Germany) are over 60 and are heading
towards retirement. GK developed a formation programme for young physicians for their training in
•Multidisciplinary
Team
(MDT)
general medicine
which
has already had 10 young doctors as participants (2 have taken posts in
practices after completion of their training) to enhance the sustainability of the workforce
• Improved training provision for all the providers and practice staff in health, communication and
salutogenesis
Organisational boundaries
• Co-ordination of electronic files – one system for all providers results in better communication, coordination and fewer time-consuming search processes for information between providers
• The historical division of health and social care services is connected to a reimbursement system
without incentives for outcome-orientated health care or prevention, meaning that quality and value
based incentives have previously been virtually non-existent
General public
• Securing proper health care for rural district populations is of great importance not only for the older
population but also for the economy, so that businesses are able to attract young, well-trained
employees (and their families) to stay in the area
• Good health status is vital to cities and communities to reduce social payments for nursing homes
and other social services
• It is also vital to the companies and farms for their workforce
“Healthy am
Kinzigtal is
good for me, my
family, my relatives
and all people in our
region - therefore I
strongly support the
project”
Visuals Copyright ©2013 www.ekiv.org
Copyright ©2013 Integrating Care & the Local Government Association
Page 13
Anticipated benefits
Benefits
Benefits
•
•
•
•
Reduce unnecessary
interventions
Better cross-sector
coordination of health and
social care services
Better cross-sector
information sharing
Benefits
•
•
•
•
Positive feedback from
patients
Better cooperation with
other practices
Reduced search for info by
system-wide EPR
Sustainable workforce
Copyright ©2013 Integrating Care & the Local Government Association
•
•
Health &
social care
systems
Users
Health
workforce
Public
“Do the right thing at the
right place by the right
people and at the right
time”
Individual treatment plans
Enhancing patient selfmanagement and shared
decision-making
Benefits
•
•
•
•
Improve the health status of
the population
Targets particular health
problems
Healthier workforce
Cooperation with voluntary
associations and schools
Page 14
Lessons learned
Long-term commitment
• Changing the traditional paradigm of healthcare is a tremendously challenging but very
rewarding task. It needs very dedicated and knowledgeable people, a timeframe of at least ten
years, and a lot of upfront investment money (but it results in enthusiastic patients and carers
and in substantial earnings).
• At least the first six years demand many more hours a week from the core group of carers. For
the following years we hope for fewer hours when everything is better organised and patients
need less attention as they will be more active in helping and training each other.
• One of the toughest tasks is keeping the spirit and improving communication skills towards
SDM. In the first three years evaluation showed little success and even some decline in
outcomes - but this has now changed.
Language
• GK seeks to create healthcare “efficiencies”.This term could raise concerns that the desire for cost
• Case
management
by a Multidisciplinary
Teamcare.
(MDT)
savings
may resultisinrun
providers
withholding needed
We remain explicit that we are focusing
first on improving quality and prevention and that increased efficiency is the result of this.
Communication & IT
• Through the implementation of a system that holds patient information which can be accessed
by a number of different providers, provision has improved alongside the improvement of
patients care. This is a direct result of better communication and coordination.
• Better communication results in improved follow-up care, co-ordination of medication
prescriptions, a reduction in redundant services and unnecessary costs. This in turn reduces
confusion, increases patient compliance and reduces unnecessary risk.
USA
“Do the right thing at
the right place by
the right people and
at the right time
right”
Next steps for Gesundes Kinzigtal
•
•
•
•
•
Integration of health and social care with special emphasis on vulnerable groups
Integration of health care and health promotion at the workplace
Securing a competent and sufficient workforce (physicians and nursing)
Empowering patients and reducing health illiteracy
Securing investment for the expansion of integrated care in other regions of Germany
Visuals Copyright ©2013 Hildebrant H., et al. (2010)
Copyright ©2013 Integrating Care & the Local Government Association
Page 15
Kinzigtal: Continuous Improvement and
Extension of Interventions
Activation
Patients & Providers
Training of Providers in
Communication
Shared development of
health goals
Encouraging physical
exercises (rebates wih fitness
centers)
Series of lectures for patients
Cooperating with sports clubs
Preventive Services
Smoking cessation
Health Fairs with over 10,000
participants
Patient involvement surveys
Polypharmacy-Forum
© OptiMedis AG
Integration
„Trusted Physician“
(selected by patient)
coordinates care
Shared Electronic patient
record over all physician
practices
Pharmaceutical
cooperation with hospital
Shared geriatric
assessments in nursing
homes + after-hour-avail
Case Management with
social worker + CM-nurse
Shared pathways for
around 20 diseases and
situations
Patient as co-producer of
health“
Evaluation and data
mining for gaps in care
Health Improvement
Lessons in Schools
„Memory Walk“ in Community /
„Exercise Walk“
„Healthy Company Network“ in
development
„Health Academy“ for training
professionals + patients (peerto-peer)
Certified Quality Management
(practices, GK-office)
Quality Indicator
Benchmarking
Continuous Evaluation of
programs
Ambient Assisted Living for
seniors
Plan: Building an own health
training facility
Plan: Developing an
oversectoral CIRS-system
Our Conceptual Framework is similar to
Population Health Management
© OptiMedis AG
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Measuring the „Triple Aim“ in Gesundes
Kinzigtal – over 2.5 years
Intervention vs. Control / propensity score matching n = 2 x 4.596
• Indicator:
Health
outcome
Mortality rate /
average age at
death
IV = 73 verstorbene Versicherte (1,58%) vs. Nicht-IV = 134 verstorbene Versicherte
(2,94%) / 1,5 year postponement of average age at death
• Indicator:
Economical
outcome
Patient
experience
Development of
contribution
margin
• Indicator:
Change rates
+ 151 € p.
person within
2 years
55% less insureds left the
sickness fund
(IV = 129 Insureds (2,8%) vs. Not-IV =
200 Insureds (4,4%), n = 4.596)
© OptiMedis AG
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The Rationale – a Cooperative Social
Business Model, based on scientific
evidence
„No free lunch“ for payors and providers: Gesundes Kinzigtal –
similar ventures will not occur if no business model is being offered
The prevailing business model of today is still the acute care
medical one and financially mostly „fee for service“ with the
incentive to deliver as much services as possible
Only if the business model will be changed to a health gain / health
improvement model for a defined population, physicians and other
providers will reorient care and invest in prevention
BUT: As Kinzigtal is demonstrating – such a cooperative social
business model is possible
© OptiMedis AG
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The Coop Result: Win-Win-Win-Solution
Win for society: for the region / cities (attracting physicians
and nurses, keeping the people healthy, improving the workforce
conditions for local enterprises) … for the insurance (lower costs,
lower premature retirement & longterm care)
Win for patients: getting better care, staying healthier,
having more decision over their care ….on the long run: lower
insurance premiums
Win for providers: getting surplus payment (from the „health
dividend“), having more positive feedback of healthier patients,
enjoying less regulations but getting back to the core of their
decision to work in healthcare
© OptiMedis AG
Six prerequisites to succeed in populationwide
comprehensive integrated Health Improvement
1. A business model that is more attractive than the prevailing
model of today and incentivises an „integrator“ agency for focusing
on the improvement of the health of a regional population
2. The „integrator“ must be furnished with solid financial power
and the ability and willingness to invest and needs long-ranging
contract certainty – prevention needs to have the possibility of
ROI for at least ten years
3. The “integrator” should be constituted by co-ownership and
strong basement in local physicians as well as clear foundation in
health sciences & management know-how – and why not some
public accountability through public co-ownership
© OptiMedis AG
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Six prerequisites to succeed in populationwide
comprehensive Integrated Health Improvement
4. The region should not be too large but should have some
cultural regional identity – cooperating partners should be able to
develop some trust in each other (difficult if numbers are not too big)
5. Data, Data, Data: only the actual operational availability of
diagnosis, cost and utilization data allows for learning progress in
processes of care management, another factor is IT – and data
warehousing competency, and data protection know-how
6. Benchmarking and transparency about outcomes to the
public, report cards and evaluation
© OptiMedis AG
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Again, what is central: The Incentive
Structure of the Health System
The economic system we put Health Insurances/Sickness Funds
(HISF) and providers in, has to be oriented towards outcomes
•
Health Insurance/Sickness Funds (HISF) must compete on efficiency and
health outcomes – and patients must be able to compare HISF for their relative
results
•
Providers must be able to get better returns by maximizing the health
outcomes instead of the number of interventions
•
Patients must be able to compare HISFs by their produced adjusted health
outcome
The central challenge in developed countries of today from a
systems perspective: How can we increase competition around
health status improvements and what kind of regulation we need,
what kind of incentives?
© OptiMedis AG
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„Transformative solutions will be needed“
says World Economic Forum (Davos)
“…The purpose of the project – and this report – is
to support strategic dialogue among various
stakeholders on what health systems are now, what
they might be in the future and how they could
adapt to be sustainable.
Sustainability is unlikely to be achieved
through incremental changes. Instead,
transformative solutions will be needed –
solutions that require cooperation across
industry sectors and governments, and
thereby challenge the current boundaries
of healthcare and established norms of
operation. …”
http://www.weforum.org/issues/scenarios-sustainable-health-systems
© OptiMedis AG
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Conclusion: The Kinzigtal way is working,
its replication to other areas is possible
The contractual basis develops an intrinsic coherent interest in
optimizing health care and prevention
Kinzigtal has always to strive forward in its way of optimization (if
not it will fall back in its revenues)
The participating partners have a substantial higher income than
their peers (but have to invest more time and intelligence as well)
Patients love the Kinzigtal-way and run towards those sickness
funds who are partnering
Sickness funds have a substantial improved bottom line in total
health care costs (and a better educated membership)
© OptiMedis AG
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Our „take-home-message“
„Smart contracting“
& health sciencebased „triple aim“
interventions are
able to achieve
significant results
„No free lunch“:
Integrated care needs
a lot of investment &
intelligent management
& contracting
…and it raises joy, professional pride and
spirit + provides real value for the society
© OptiMedis AG
26
26
Kinzigtal is in the Southwest of Germany (today we
are able to replicate the model in several regions of Germany and
as well in the Netherlands, Austria and Switzerland)
Cooperation Contract /
Regional Health Management
Company
Cooperation – in
development:
Austria
Switzerland
 Hamburg Billstedt-Horn
 Bielefeld
 Berlin/Brandenburg:
Koop. mit 6 bestehenden
Netzen
 Mannheim
 Greifswald
 Bayern: mehrere
Interessenten
 Leipzig
 Other Countries:
Netherlands
Austria
Switzerland
© OptiMedis AG
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We are looking forward to your
comments & cooperation
Helmut Hildebrandt, Vorstand,
OptiMedis AG, Borsteler Chaussee 53,
D – 22453 Hamburg
Tel: +49 40 226 211 49 0
e-mail: [email protected]
www.optimedis.de
See video + website
www.gesundes-kinzigtal.de
© OptiMedis AG
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For Discussion
Could Integrated Care in the Kinzigtal way be the
modern answer to the historical separations
within healthcare and between healthcare and
public health?
So: Integration of public and personal health
© OptiMedis AG
A short bio
Formation
Phamacist, studies in sociology and medicine sociology
Hospital management, health system development
 OptiMedis AG, Hamburg

Professional
expertise



Associations
© OptiMedis AG







Owner and CEO
- in parallel - Gesundes Kinzigtal GmbH (CEO) + Gesundes Leinetal (CEO)
Hildebrandt GesundheitsConsult GmbH, Hamburg
Owner and CEO
- in parallel - Kreiskrankenhaus Dannenberg
CEO –08/1999 – 31.7.2002
- in parallel - Hildebrandt Fox International, Hamburg-Redlands
CEO and principal consultant in the US and in Germany (Managed Care)
Institut für Medizin-Soziologie, Universitätskrankenhaus Eppendorf,
Hamburg
Scientific Investigator and researcher
World Health Organisation, Europäisches Regionalbüro, Kopenhagen
Consultant for programs like "Healthy Cities" and "Health Promoting Hospitals"
Several pharmacies – in and near Frankfurt
Exec.Board member: International Foundation for Integrated Care
Board Member: Bundesverband Managed Care
Co-President: Health Futures Comission of the Heinrich-Böll-Foundation
Member: Deutsches Netzwerk Evidenzbasierte Medizin DNEbM
Member: Deutsche Gesellschaft für Sozialmedizin und Prävention (DGSMP)
Member: Deutsche Gesellschaft für Qualitätsmanagement im Gesundheitswesen
Member: International Network of Health Promoting Hospitals and Health Services
(WHO-affiliated)
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Some Literature – extra website on
evaluation in german/english www.ekiv.org
Hermann C, Hildebrandt H, Richter-Reichhelm M, Schwartz FW, Witzenrath W. Das Modell
„Gesundes Kinzigtal“. Managementgesellschaft organisiert Integrierte Versorgung einer
definierten Population auf Basis eines Einsparcontractings [The „Gesundes Kinzigtal“ model: A
management company organises a population-based integrated care system on the base of a
shared-savings approach]. Gesundheits- und Sozialpolitik 2006;(5-6):11-29. [in German].
Hildebrandt H, Hermann C, Knittel R, Richter-Reichhelm M, Siegel A, Witzenrath W. S
Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain
approach and a shared savings contract. International Journal of Integrated Care [serial online]
Vol. 10, 23 June 2010 Available from: www.ijic.org
Hildebrandt H, Schulte T, Stunder B. Triple Aim in Germany: Improving population health,
integrating health care and reducing costs of care in the Kinzigtal-region – lessons for the UK?
Journal of Integrated Care, Vol. 20 Iss: 4, pp.205 - 222 (2012). Emerald Group Publ. DOI:
10.1108/14769011211255249
Siegel A, Köster I, Schubert I, Stössel U. Utilization Dynamics of an Integrated Care System in
Germany: Morbidity, Age, and Sex Distribution of Gesundes Kinzigtal Integrated Care´s
Membership in 2006-2008. In (Janssen C, Swart E, Lengerke T v. Ed) Health Care Utilization in
Germany. Springer 2014 DOI 10.1007/978-1-4614-9191-0 pp.321-335
© OptiMedis AG
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