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From Rural Germany, Integrated Care Grows Into A Global Model

2020; Project HOPE; Volume: 39; Issue: 8 Linguagem: Inglês

10.1377/hlthaff.2020.01063

2694-233X

Michele Cohen Marill,

Health and Medical Studies

Leading To HealthDeterminants Of Health Health AffairsVol. 39, No. 8: COVID-19, Home Health & More From Rural Germany, Integrated Care Grows Into A Global ModelMichele Cohen Marill Affiliations This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Michele Cohen Marill ([email protected]) is a freelance reporter based in Atlanta, Georgia. Her travel and reporting for this article were supported by the Association of Health Care Journalists’ International Health Study Fellowship, which is funded by the Commonwealth Fund.PUBLISHED:August 2020Open Accesshttps://doi.org/10.1377/hlthaff.2020.01063AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractFifteen years after a precursor to the ACO formed in the Black Forest region, a value-based approach to health care gains traction.TOPICSAccountable care organizationsChronic diseaseQuality of careCost reductionGeneral practitionerPatient carePatient satisfactionCosts and spendingIntegrated health services networksChronic care managementSocial determinants of healthSocioeconomic determinants of health [C]Exercise: Located in Germany’s Black Forest region, Gesundes Kinzigtal offers exercise classes that improve balance and mobility. Prevention and care management programs such as Strong Muscles–Solid Bones have helped lower the risk for fractures among people with osteoporosis.Photographs by Silke WernetNermina gives a sheepish smile as she sits across from Martin Wetzel, her general practitioner. She left her last visit in tears after he warned her that her health was in peril because of her weight, and, frankly, Wetzel hadn’t been sure she would return. Nermina is just thirty, but she already has insulin-dependent type 2 diabetes and hypertension.In that last visit, Wetzel asked her to make a decision: Was she willing to change her lifestyle for her health? If not, even with increasing amounts of medicine, she would likely face a cascade of ailments. Think about it, he said, his brow knit and his baritone voice resonating in the sleek modern office. Then come back and tell me what you decide.And now here she is. He looks at her expectantly. “I will try,” she says. “I will do my best.”Wetzel practices just off the main street of the picturesque town of Hornberg, not far from the train line that transports tourists through the hills of the Black Forest in southwest Germany. But this conversation could take place in any doctor’s office across the globe. Nermina says she hasn’t stepped on a scale in more than a month because she was afraid to see the number. Wetzel explains how diet affects blood sugar, and why it is so important to reduce carbohydrates and sugar.Although he knows how difficult it is to make a dramatic life change, he offers her a path: an integrated care program called Gesundes Kinzigtal, or Healthy Kinzig Valley, which emphasizes prevention and management of chronic conditions. Since its inception in 2005, patients in Gesundes Kinzigtal have received nutritional advice, health coaching, and access to a reduced-price gym. Behind the scenes, physicians track their patients’ health metrics and receive quarterly reports showing how they compare with their peers on various cost and quality measures.Relief: Hubert Heizmann finds relief from arthritis by stretching and strengthening in the gym at Gesundheitswelt (Health World) Kinzigtal in Hausach, Germany. By working out two to three times a week, he has been able to resolve his knee and hip pain.Yet the core of Gesundes Kinzigtal is the partnership between physicians and patients. Wetzel takes out a form and asks Nermina to write down her goal for the next year: “My blood sugar will be in control.” The milestones she hopes to reach: “Lose weight. Become pregnant.” And the steps toward better health: “Exercise. Check weight regularly. Eat less sugar.” They both sign it, like a contract, and Nermina agrees to return about every six weeks to check on her progress.Wetzel’s support is essential, but so is Nermina’s determination to improve. “He is there to help me, but I have to manage the rest by myself,” she says. “And he helps me best if I learn how to help myself.”If Nermina manages to lose weight, improve her diet, and lower her blood sugar, she can reshape her future. The change is personal, but the benefit is collective. The power of Gesundes Kinzigtal comes from the cumulative effect of dozens or even hundreds of Nerminas.As the incidence of chronic diseases rises globally,1 Gesundes Kinzigtal offers a successful model for lowering health risks not just for individuals but also for populations. From 2007 to 2018 Gesundes Kinzigtal produced a net savings of more than 18.2 million euros (almost $20 million) while reducing avoidable hospitalizations and raising participants’ life expectancy2—achieving the “Triple Aim” of improving population health and individuals’ experiences of care while lowering costs.3Those goals become even more vital as health systems across the globe strain to meet the needs of aging populations.4 The burden falls heavily on primary care providers, who struggle to keep up with the demand for care. In Germany general practitioners spend just eight minutes, on average, in their visits with patients, which is enough time to prescribe medication but not enough to launch into difficult discussions about lifestyle or nonmedical approaches. (The average appointment length in the United States is close to twenty minutes.)5“If you want to change things, you have to create a win-win situation,” says Wetzel, the former chair of the physician network that started Gesundes Kinzigtal. In his view, the ideal system for lowering costs puts the patient at the center.Early InnovatorsThe towns nestled in the remote valley of the Kinzig River have a storybook quality, with centuries-old half-timbered houses and cobblestone plazas, but they share the same health care challenges as other rural communities. Older physicians retire without being replaced by younger colleagues. Some hospitals have closed. Meanwhile, inpatient and outpatient care are funded through different mechanisms, a siloed approach that hampers coordination. General practitioners and specialists from the Kinzig Valley began meeting to find ways to collaborate, and in 1992 they formed a network known as MQNK (Medizinisches Qualitätsnetz–Ärzteinitiative Kinzigtal, or Medical Quality Network Doctors’ Initiative Kinzigtal).Collectively, the physicians hoped to have more leverage with insurers and better coordination in their care of patients. In 2000, for the first time, Germany’s Statutory Health Insurance Reform Act allowed insurers to create integrated care programs with physician networks and health management companies. Still, little changed until the Statutory Health Insurance Modernization Act of 2004 removed some regulatory restrictions and permitted insurers to spend up to 1 percent of their physician payments on integrated care.6Curious about how such programs could help doctors address the needs of their patients, MQNK reached out to Helmut Hildebrandt, a specialist in health care management who was involved in crafting the reform framework.Hildebrandt was skeptical that the early innovators would come from the remote villages of the Black Forest, but nonetheless, he traveled from Hamburg (about an eight-hour drive) to present his ideas. As they talked informally, some of the doctors began reminiscing about the idealism they felt when they entered medicine. They broke into workgroups, and discussions ensued about how to prevent and manage disease, not just treat it. “That was the beginning of thinking we could really dare to develop something that was new and challenging,” he says.Hildebrandt later met with the CEO of AOK Baden-Württemberg, a regional insurance fund that is part of the AOK group, one of Germany’s largest insurers. “I asked him if he was interested in being part of a really revolutionary project,” Hildebrandt recalls.AOK and a small insurer of farmers, LKK (now SVLFG), signed on. About 86 percent of Germans are covered by statutory health insurance, the public system supported by wage-based contributions split between individuals and employers. Known as “sickness funds,” the nonprofit insurers compete based on the services they offer and on surplus premiums they charge (an additional percentage of wages, up to a cap). Together, AOK and LKK insured almost half of the Kinzigtal population, about thirty-three thousand people.The doctors from the MQNK and Hildebrandt’s management company, OptiMedis, formed Gesundes Kinzigtal in 2005, with Hildebrandt as managing director. The insurers agreed to split evenly any cost savings generated by the new partnership, signing a ten-year contract to give the fledgling organization time to prove itself. The shared savings contract requires the integrated care program to maintain high-quality care, measured by a set of outcomes and process indicators, and high patient satisfaction, based on surveys. It has since been renewed indefinitely. AOK provided startup funds of 4 million euros (about $4.8 million at the time), an investment enabled by the health reform legislation. Those funds included 1 million euros for external reviewers to conduct a scientifically rigorous evaluation. The project launched in 2006.Essentially, the partners had created an accountable care organization (ACO) several years before the shared savings model emerged from the Affordable Care Act in the United States. Each year, AOK and SVLFG compare health care costs in Kinzigtal with the nation’s benchmark costs, adjusted by age and health condition. The calculation includes everyone insured by the sickness funds in the region, not just those in the integrated care program. That guards against the possibility that the program selected healthier people as members. In fact, being part of Gesundes Kinzigtal is voluntary; at this time, about 58 percent of Kinzigtal doctors and about one-third of eligible patients participate.Gesundes Kinzigtal has produced savings every year since its inception. The doctors benefit as shareholders: MQNK owns two-thirds of Gesundes Kinzigtal and OptiMedis owns one-third. Much of that savings is invested back into the program—for example, in developing an electronic health record, which launched in 2007 and is being upgraded to allow for more data sharing and administrative support. The doctors receive bonuses based on meeting quality goals and compensation for spending more time with patients and for extra documentation. That extra time enables physicians to engage patients in shared decision making, guiding them through treatment options instead of just giving instructions. Other providers, such as physiotherapists and nurses, also receive compensation for helping patients manage their chronic conditions.Gesundes Kinzigtal is not just a financial arrangement. It is a new design for a value-based approach to practicing medicine.Ultimately, Gesundes Kinzigtal is not just a financial arrangement. It is a new design for a value-based approach to practicing medicine. “The focus on volume is not bringing the best results for the patients,” says Alexander Pimperl, former vice chair of the board of Gesundes Kinzigtal and now director of data insights and business intelligence for the pharmaceutical company AstraZeneca. “How can you shift the sickness system to a health system—to put more effort on prevention so you don’t even get that disease?”‘Cohesion’In theory, more prevention and less disease equals lower health costs. But the reality is more complicated. Many ACOs in the United States struggle to achieve their cost-saving goals as they manage the health of a population of patients.As of fall 2019, 995 ACOs held 1,588 accountable care contracts, covering 44 million lives.7 About 10 million Medicare beneficiaries get their care through a Medicare Shared Savings Program ACO. Although overall the Medicare ACOs have produced modest but steady savings, the models vary, and so do their results. Physician-led ACOs have generally fared better than hospital-led ACOs.8In their first three years, Medicare ACOs outperformed fee-for-service providers on quality, but one-third of them failed to save money.9 ACOs use various strategies to focus on patients with complex medical needs, a vulnerable group whose care is particularly costly. But a 2019 Dartmouth College study of 244 Medicare Shared Savings Program ACOs did not find that their care management and coordination efforts improved health outcomes or lowered costs.10“Many of these programs have disappointed in terms of savings, and the effects are smaller than expected,” says coauthor Carrie Colla, a health economist at the Dartmouth Institute for Health Policy and Clinical Practice. One challenge is that ACOs don’t dominate the US health care landscape. Providers treat most of their patients through a fee-for-service model, which means they have less incentive to overhaul the way they practice medicine.Add to that the natural inertia of the system. It’s incredibly hard to redesign care and to change long-standing patterns, says David Muhlestein, chief research officer at Leavitt Partners, a health care analytics and strategic consulting firm based in Salt Lake City, Utah. “What does it take to transform a health care delivery system? Think of it as a decade-long change,” he says. “That means you need leadership committed to the change—your CEO as well as the board of directors—and they’re willing for that to be a number-one priority for a decade.”The Centers for Medicare and Medicaid Services is trying to spur faster change by transitioning the Shared Savings Program ACOs to downside risk, requiring them to pay back a portion of overspending compared with benchmarks in addition to gaining from cost savings. Downside risk may force some ineffective ACOs to disband and spur others to improve as they take full responsibility for the health outcomes and costs of their patients, Muhlestein says.With almost fifteen years of steady success, Gesundes Kinzigtal seems to defy the odds. Reinhard Busse, a leading health economist and chair of the Department of Health Care Management at the Technische Universität Berlin, has a theory about why the model works in Kinzigtal while it seems so difficult to achieve elsewhere.In a word, it’s a matter of trust. The Kingzigtal doctors spent more than a decade building bonds through MQNK before forming the integrated care program. As with their counterparts in ACOs, they still see patients outside of Gesundes Kinzigtal and still get paid in part based on volume, yet they stay committed to the integrated care effort. Why don’t some doctors maximize patient volume while expecting others to do the more difficult care management that produces savings?“The cohesion among the providers in the Kinzigtal has to be so large that they don’t exploit their colleagues,” Busse says. “That explains a bit of the difficulty in transferring the model to other places. You need groups of providers, especially physicians, that share such a high level of cohesion that they don’t cheat.”Taking ResponsibilityUpstairs in Gesundheitswelt (Health World) Kinzigtal, a gym and “health academy” in the Kinzig Valley town of Hausach, about a dozen older women and men stand next to their mats, following the lead of the instructor as they gently lunge back and forth to soft, melodic music. The walls are floor-to-ceiling windows, opening the room to morning light and the views beyond the rooftops. Every person here has an orthopedic condition, and this rehabilitation class, known as rehasport, is the antidote. The Gesundheitswelt gym, fitness training, and classes are open to the public, but Gesundes Kinzigtal members pay a reduced rate. (The rehabilitation class is free to all but requires a doctor’s prescription.)Another class is taking place down the hall in a conference room where the mood is similarly mellow. Instructor Pia Roser attaches flipboard sheets to the wall, displaying the morning agenda and guiding principles: step-by-step problem solving, toolbox for self-management (breathing techniques, movement, healthy eating, mindfulness), and an example of a symptom cycle (pain and physical limitations worsened by stress and negative emotions).This INSEA class, based on a program developed at Stanford University, helps people rethink how they live with chronic illness. It is intensive. In six weekly classes of two and a half hours each, Roser and her colleague, Claudio Esposito, guide a group of six people who have chronic pain or physical limitations. “They’re not here to be victims of chronic disease,” Roser says. “They’re here to learn techniques. It’s to activate them to take responsibility for their own lives.”Today the group discusses how to deal with negative feelings. Roser prompts them to list reasons to feel grateful. At first, Kemal, a forty-five-year-old unemployed carpenter who has struggled with a chronic condition for most of his life, can’t think of anything. But this dialogue is “reactivating,” giving him some new ideas, he says at a break. “There are always one or two things you can pick out and use for your own circumstances.”Self-care is the centerpiece of Gesundes Kinzigtal, whether the goal is life changing or just a boost in fitness and weight loss.Self-care is the centerpiece of Gesundes Kinzigtal, whether the goal is life changing or just a boost in fitness and weight loss. It offers programs such as Strong Heart, Better Mood, and Healthy Weight—a roster that has grown over the years, along with the support of partnerships with other fitness clubs, employers, psychologists, physiotherapists, and other health professionals. Here, personal success contributes to population health, to the overall aims. “People who do not have optimized care have a great chance of going to the hospital again and again,” says Christoph Löschmann, who became managing director of Gesundes Kinzigtal in 2019.From 2006 to 2011 the interventions spurred significant improvements in six of eighteen care quality indicators compared with a control group, an independent evaluation found. For example, Gesundes Kinzigtal patients with osteoporosis had a lower risk for fractures, and overall, participants in the program had a lower mortality rate.2 About 92 percent of patients surveyed said they would likely or definitely recommend it to others.11 An updated study of outcomes through 2015 is under way.The message of taking responsibility for their own health resonates with communities that value self-reliance.The message of taking responsibility for their own health resonates with communities that value self-reliance, says Monika Schnaiter, a founding member of the patient advisory board. Years before Gesundes Kinzigtal began, Schnaiter created Landfrauen Kinzigtal, a local club that is part of a national association of country women, providing a social outlet along with education and local advocacy. “Landwives are first looking, ‘What can I do myself?’ ” she says. “That’s a big part of the solution to problems—to do what we can together to improve the situation.”On a clear day, a hazy view of France is visible from the top of the steep hill on Schnaiter’s farm, which has been in her husband’s family since 1899. They have about 25 hectares of meadows for their cows and horses, 50 hectares of forest, and an orchard of cherry and apple trees near the tiny town of Oberharmersbach. The farmhouse, with its distinctive half-hipped roof that fits like a shingled cap against wintry weather, has been renovated to include small apartments. Hikers and families are frequent visitors; tourism is now a bigger business in the Black Forest than agriculture.Still, the farming life is physically demanding, and in the past few years Schnaiter, age fifty-three, has developed back pain. The drive to Gesundheitswelt for strengthening and stretching classes takes a half hour, but if she does it regularly, the pain subsides. “When I am healthy at ninety years old, this is the benefit of Gesundes Kinzigtal,” she quips.Lessons For The WorldThe mission that drives Hildebrandt is sustaining health into the future. Even from the early days of Gesundes Kinzigtal, he envisioned spreading this integrated care model throughout Germany and across Europe. If ACOs similar to Gesundes Kinzigtal provided care to only 40 percent of the population of Baden-Württemberg, the southwestern German state bordered on two sides by Switzerland and France and encompassing the Black Forest region, Hildebrandt says his projections show a net savings of 6.3 billion euros (almost $7 billion) in health care costs over ten years.Yet even as Gesundes Kinzigtal gained acclaim, with visits from health ministers and white papers from leading think tanks over the past decade, the model failed to catch on more broadly. Hildebrandt’s efforts were hampered by a lack of funds for innovative projects and widespread skepticism of managed care, although members of Gesundes Kinzigtal can visit any doctors, whether or not they participate in the network. He struggled to forge partnerships with doctors, who were suspicious of outside influence on their practice, and insurance companies, who wanted to manage their own members. “Sometimes we had doctors, sometimes we had sickness funds, but they didn’t come together,” he says.A breakthrough finally came in 2017 more than 700 kilometers north of the Kinzig Valley. That’s when Gesundheit für Billstedt/Horn (Health for Billstedt/Horn) launched in two low-income neighborhoods in Hamburg that have a large immigrant population, a high rate of chronic disease, and low health literacy. Gesundheit für Billstedt/Horn was founded by OptiMedis and a group of physicians—a Hamburg physician network, NAV-Virchow-Bund (one of the largest associations of doctors in Germany), and a clinic. And it started with a healthy investment of 6.3 million euros (about $6.9 million) from a statutory health insurance innovation fund. Five insurers eventually signed on, covering 90 percent of area residents, or about a hundred thousand people. As with Gesundes Kinzigtal, Gesundheit für Billstedt/Horn seeks to reduce costs by preventing and managing chronic conditions, and it benefits from some of the shared savings.In addition to its care management activities, Gesundheit für Billstedt/Horn hosts training sessions for health professionals, provides health education for the neighborhoods, and supports an electronic medical record. Its most visible feature is the Gesundheitskiosk, or health kiosk, which resembles a neighborhood clinic, where nurses and other health guides provide counseling in six languages. In more than six thousand visits, patients have learned about their diabetes or other chronic diseases, received advice about how to improve their health, and gotten nutrition or psychosocial consultations. About sixty doctors refer patients to the two kiosks, and the insurance companies provide ongoing financial support. Patients do not receive direct care in the kiosks.At the end of 2019, OptiMedis transferred the majority of its shareholder shares in Gesundheit für Billstedt/Horn to the nonprofit association Gesundheitskiosk eV Hamburg, enabling community groups and patient representatives to play a stronger role in the health network. An evaluation of the first three years, conducted by the Hamburg Center for Health Economics at the University of Hamburg, is expected by the end of 2020.As other OptiMedis-related projects evolve, Hildebrandt still seeks partnerships with physicians, but he takes a broader view of how to initiate a population health program. In some cases, new projects begin with a focus on a single chronic condition. Longzorg (Lungcare) Nijkerk launched in 2015 as an OptiMedis-managed project in the Dutch town of Nijkerk, about twenty-five miles east of Amsterdam. Chronic pulmonary obstructive disease (COPD) is a leading cause of avoidable hospital admissions in high-income countries. In the Netherlands, COPD care is reimbursed through a combination of bundled payment and fee-for-service, but Nijkerk Health Centers, a physician practice, went even further in a contract OptiMedis developed with insurer Zilveren Kruis (Silver Cross).“We created a shared savings model based on Triple-Aim targets so we could create value…better health, better care experience, and lower relative costs,” says Sam Siemssen, director of Nijkerk Health Centers. “If we don’t achieve the targets, we are accountable and we have to partially pay the insurance back. If we’re successful, we get a percentage of the savings.”In the Netherlands, insurers typically reimburse general practitioners based on patient visits of about ten minutes, Siemssen says. Longzorg Nijkerk pays the doctors to spend a bit longer: twelve to fifteen minutes, or even twenty minutes if necessary. As with Gesundes Kinzigtal, OptiMedis analyzes data to look at patient risk stratification, care processes, outcomes, and cost, sharing the findings with providers. General practitioners work collaboratively with pulmonologists, paying them for their involvement from the fixed periodic payments that are received under the shared savings contract. And they enlist patients as partners in their care.In three years Longzorg Nijkerk saved about a million dollars. The program is using the savings to expand to diabetes and cardiac care, with plans to eventually offer fully integrated care. “We’re doing this step by step because it takes a lot of effort to change the way we work,” Siemssen says.Slowly, the Gesundes Kinzigtal model is gaining converts elsewhere. OptiMedis was selected by the Eurometropolis of Strasbourg, a metropolitan administrative entity, to develop a new integrated care project in the French city just across the Rhine River from the German state of Baden-Württemberg and in the Saverne region 40 kilometers to the northwest. It has been conceived as a pilot for the broader implementation of integrated care in France. A Chinese insurance company adopted the prevention-oriented approach and called it Healthy Huanghua.Donal Collins, a general practitioner in the English town of Fareham, about 80 miles southwest of London, visited Gesundes Kinzigtal and came away convinced that integrated care is the answer to the expanding needs of an aging population. In the National Health Service, general practitioners receive capitated payment—compensation based on the number of patients in their care. As patients develop more chronic conditions, they visit more frequently, which leaves Collins and his colleagues with less time to spend with them. “We were just running faster on the hamster wheel, trying to see the people coming in,” he says.Collins belongs to a primary care network known as Sovereign Health, which entered into a joint venture with OptiMedis-COBIC, a UK-based company that manages population health programs. The first integrated care project focused on preventing and managing diabetes. Data dashboards helped physicians track blood sugar metrics of their patients and compare their outcomes with those of other general practitioners. Collins himself had developed type 2 diabetes as his long work hours led to unhealthy habits, so he joined the program with his patients, weighing in at Weight Watchers and running or walking in Saturday morning five-kilometer “park-runs.” He lost more than thirty pounds, controlled his blood sugar without medication, and rediscovered the joy in his work.“We are really making a difference for our population,” Collins says. “People love coming to work and seeing how patients are responding to the interventions we’re putting in place.”In the wake of the COVID-19 pandemic, integrated care programs have the ability to respond rapidly in a time of crisis.In the wake of the coronavirus disease 2019 (COVID-19) pandemic, Hildebrandt points to yet another benefit of integrated care programs: the ability to respond rapidly in a time of crisis. For example, Gesundes Kinzigtal and the MQNK physician network worked with the Association of Statutory Health Insurance Physicians of Baden-Württemberg to quickly open a testing site and a COVID-19 outpatient clinic.A New Spirit Of HealthAt seventy-five, Ursula seems in good shape for her age. She walks her dog every day, practices yoga, and goes to a trainer specializing in older adults. Still, she has her health worries—stiffness from arthritis, extra pounds that crept up over the years, her husband’s type 2 diabetes. That’s why she’s sitting in the office of Luisa Schmidt, a nutritionist who works with the regional insurer BKK Werra-Meißner and Gesunder Werra-Meißner-Kreis, the latest iteration of Gesundes Kinzigtal, a new OptiMedis-managed integrated care program in the central German town of Eschwege.“It helps for people to write their goals down,” Schmidt suggests, poised like a scribe with pen and paper. “What do you want to achieve?”Ursula reveals a weakness: Every evening after dinner as she relaxes in front of the television, she aims to have just one candy for dessert, but then she goes back for more. And more.“That’s a great routine to only take one,” Schmidt says encouragingly. “One portion of sweets a day is OK.” Schmidt suggests putting a basket of apples or other fruit next to the candies, and if Ursula still wants something sweet after the first candy or two, she can grab