5.2. Patient pathways
The German health care system does not have a compulsory gatekeeping system; instead SHI-insured patients can freely choose an SHI-accredited physician whenever they seek treatment. According to §76 SGB V, SHI patients select a GP who should not be changed during the quarter, but in fact there is no control mechanism. Patients can also choose office-based SHI-accredited specialists directly (except for some specialties, e.g. radiologists), but GPs or specialists also refer the patient to other physicians, as necessary. SHI patients who are voluntarily enrolled in a “GP-centred model of care” (Hausarztzentrierte Versorgung – HZV) are required to consult their GP first and have a referral for specialist care (see section 5.3 Primary care). Patients with substitutive PHI coverage also have free choice of physicians and are not restricted to SHI-accredited physicians. Furthermore, patients can directly access and choose hospitals, either with a referral from a GP or specialist, or without a referral via after-hours and emergency care (see Fig5.1).
Fig5.1
A typical clinical pathway within the German health care system for a patient with chronic diseases is described in the following example. A patient, 54 years of age, suffers from type II diabetes and chronic obstructive pulmonary disease (COPD). She also has a leg ulcer, moderate retinopathy and is slightly overweight (body mass index of 27). The patient was employed as a cashier in a supermarket in the past, but has been unemployed for three years now, receives social assistance benefits and lives on her own.
In Germany the patient would almost always be insured under the SHI scheme and can therefore select any GP, who should offer participation in the Disease Management Programmes (DMPs) for type II diabetes and COPD. DMPs aim to deliver coordinated treatment of chronically ill patients according to best available evidence (see section 5.3 Primary care). The patient will receive two information brochures after initial registration on the DMPs: one for the DMP Diabetes and one for the DMP COPD. The sickness fund can additionally grant special benefits to a patient for participation in DMPs, such as cash or in-kind benefits, but participation is voluntary for patients and physicians. Treatment in the DMP starts with the patient being given a thorough explanation of the programme. On the basis of an assessment of the patient’s individual risk, the physician and the patient jointly draw up therapy goals – for glycated haemoglobin (HbA1c) and blood pressure, for example. An individual therapy plan is thus drawn up for diabetes and COPD. In addition, the GP should offer the patient the opportunity to take part in patient education courses.
Physicians who take part in the DMPs undertake to treat their patients according to their contract with the respective sickness fund. This is of particular relevance to the drugs prescribed for the patient, because the guidelines stipulate active substances or groups of active substances that should be given priority in the treatment of the specific condition. The coordination of care is carried out by the patient’s GP. Because of the patient’s retinopathy, the GP refers her to an eye specialist (office-based, contracted by the sickness funds) for an examination. An annual ophthalmological examination in order to exclude eye complications is also a fixed part of the DMP Diabetes. Because of the leg ulcer, the patient is also referred to a “foot clinic” (which can be an office-based medical treatment centre or in a hospital) to investigate possible consequential damage to the legs and feet. A referral to a qualified diabetes specialist can take place when, for example, a target blood pressure value of below 140/90 mm Hg or an individually agreed HbA1c value is not achieved, or when a change of treatment from oral antidiabetic drugs to insulin becomes necessary. The DMP COPD stipulates a referral to a qualified specialist when the results of treatment are unsatisfactory in spite of intensified therapy, when long-term treatment with oral steroids is required or when there are secondary disorders. After treatment by the specialist, the patient returns to the care of the GP.
A referral to a hospital, which should also be a part of the DMPs (but does not necessarily have to be), should be considered in a number of situations, including:
- when a dangerous metabolic disorder, severe metabolic crisis or an infected diabetic foot is suspected (DMP Diabetes); and
- if a life-threatening exacerbation is suspected or if there is a significant persisting or progressive deterioration of COPD in spite of initial treatment (DMP COPD).
The actual referral note can be issued by either the GP or a specialist (involved or not involved in the DMP).
The physician arranges regular appointments for examinations with the patient. On a quarterly or half-yearly basis, at registration and at the appointments for examination, one document is drawn up for each of the two DMPs (DMP Diabetes and DMP COPD). The documentation data are centrally recorded and processed by the DMP contracting parties. On the basis of these data:
- the coordinating physician receives reminders about the patient’s upcoming appointments;
- the coordinating physician receives a feedback report containing information both on patients who are being treated in their practice and on all patients treated within the framework of the DMP;
- the relevant sickness fund reminds the patient about upcoming appointments;
- a quality report for all DMPs in a region is drawn up; and
- an evaluation is conducted by the sickness funds.
Participation in a DMP is voluntary, and the patient can drop out at any time. The only entry requirement for patients is their active participation. The particular social situation of the patient (unemployment) is not specifically referred to in the guidelines for DMPs. However, the social situation is taken into consideration via the individual risk assessment required in the DMP and through the joint coordination of therapy goals. In addition, the coordinating physician always has the option of treating the patient outside the DMP framework. DMPs are standardized nationwide, but regional differences exist with regard to integrated care pathways (see Box5.4 in section 5.4.3 Inpatient care). So far, patients can only participate in integrated care projects in specific regions and with particular sickness funds in Germany, e.g. “Gesundes Kinzigtal” in Baden-Wuerttemberg (Gesundes Kinzigtal, 2020) or “Gesundheit für Billstedt/Horn” in Hamburg (Gesundheit für Billstedt und Horn, 2018).
Box5.4
