Criticism of new German chronic disease management is unfair

Editor—Tuffs' news item on the new chronic disease management programmes in Germany is misleading.¹

The new programmes have arisen from economic analysis showing the importance of ensuring that health insurance funds should not continue to be penalised financially when they have large numbers of patients with chronic diseases.

The economic rationale for these programmes is not simply to fund deficits. There will be no extra money put into the system. Instead the existing risk adjustment strategy will take the higher costs for patients with chronic disease (initially type 2 diabetes and breast cancer) directly into account. Ultimately the government hopes to implement a new risk adjustment model that takes account of all pre-existing morbidity.

The federal government's new programmes have arisen after the latest report of the Sachverständigenrat (the government's advisory council) using data from the Organisation for Economic Cooperation and Development (OECD). Germany has the highest health expenditure in Europe with questionable quality of care. The programmes aim to eliminate overuse, underuse, and misuse of care.

The German Medical Society, statutory health insurance physicians, the hospitals society, and health insurance companies participated in the working group and the political committee that recommended these programmes to the government. The physicians could appoint their own experts and agree on all aspects of the programmes. All agreed, except for the hospitals society, which opposed requiring an evidence base for specific drugs. Thus it is hard to understand why the German Medical Society should have agreed on programmes that its president, Jörg-Dietrich Hoppe, now considers meet only minimal standards.¹

Condemning the new disease management programmes as inferior to routine care is pure polemic. For the first time in German medicine, such programmes have been built on a solid basis of evidence based medicine, combining the best available evidence with clinical expertise.

We conclude that the doctors' opposition to these programmes results from the deep cultural shock felt by those who thought that medical experts could never come into conflict with evidence based medicine, which for the first time has become an integral part of official governmental programmes. Physicians' representatives are also not amused that the health insurance companies showed their willingness to become players rather than just payers in the development of these new disease management programmes.

These programmes will be updated regularly and must go through a tough process of certification and evaluation before they can become part of the risk adjustment mechanism. We strongly believe that they will enable us to overcome the important obstacles that we presently face in providing integrated care for people with chronic diseases.