出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : The integrated care approach of Gesundes Kinzigtal has been in operation for more than 10 years, currently covering a population of about 33,000 people. During this time, the approach resulted in this population being both healthier and less cost-intensive compared to the overall population of the federal state of Baden-Württemberg, where the Kinzigtal is located (Pimperl et al., 2016). Cost savings are shared between the Gesundes Kinzigtal management company and the health insurance. A revision of the integrated care contract between the management company and the health insurances introduces a new financial model that grants partial budgetary responsibility to the company and the affiliated general practitioners (GPs) and specialists. Practice change, theory, current status and timeline : The primary and secondary care budget for patients that are members of the integrated care contract is commonly paid to doctors via a doctors’ association (“KV”), but will be shifted to Gesundes Kinzigtal with doctors requesting reimbursement from the company. The new model consists of a simplified accounting procedure (a combination of capitation and sessional payment) and financial incentives for GPs and specialists. At the same time, reimbursement data are transferred electronically, by further integrating practise information systems with the electronic patient record and a specialised accounting database. These data (containing diagnosis and intervention codes) allow for closer monitoring of health spending, and can serve as a proxy for population health, effectively providing a short-term regional health system performance dashboard. The model is currently in its implementation and testing stage, with full operation expected to begin in January 2018. When viewed against the background of a concept of integrated care such as that presented by MacAdam (2008), on the basis of Leutz (1999), Banks (2004) and others, this new model can be seen to shift Gesundes Kinzigtal’s integrated care model from the coordination type towards the full integration type and from the organizational integration level towards system integration. Innovativeness, impacts, sustainability, and transferability : The new financial model constitutes an innovation at least within the German healthcare system, potentially circumventing benefit shifts currently existing between health insurances, doctors’ associations, and doctors. The mixed payment model is expected to both improve cost-effectiveness and patient satisfaction, if implemented right (Barham and Milliken, 2015; Wranik and Durier-Copp, 2009). The performance metrics in combination with the simplified accounting and the financial incentives allow for early detection of cost increases, analysis of their cause and implementation of targeted remedial action, with doctors and the management company acting together on the basis of mutual trust and transparency. The shared-revenue model of the integrated care contract serves as the basis for the new model’s sustainability plan. The model can be transferred in a German context without further changes to framework conditions, and potentially also to other Bismarck-type healthcare systems. Beyond that, the model promises relevant lessons in particular with a view to the performance dashboard and the IT integration. References : 1- Banks, P. Policy Framework for Integrated Care for Older People. London. 2004. 2- Barham, V., Milliken, O. Payment Mechanisms and the Composition of Physician Practices: Balancing Cost-Containment, Access and Quality of Care. Health Econ. 2015;24:895–906. 3- Leutz, W. Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom. Milbank Q. 1999;77(1):77–110. 4- MacAdam, M. Frameworks of Integrated Care for the Elderly: A Systematic Review. Canadian Policy Research Networks Inc. 2008. 5- Pimperl, A., Schulte, T., Mühlbacher, A., Rosenmöller, M., Busse, R., Gröne, O., Rodriguez, H.P., Hildebrandt, H. Evaluating the Impact of an Accountable Care Organization on Population Health: the Quasi-Experimental Design of the German Gesundes Kinzigtal. Popul. Health Manag. 2016. doi:10.1089/pop.2016.0036 6- Wranik, D., Durier-Copp, M. Physician Remuneration Methods for Family Physicians in Canada: Expected Outcomes and Lessons Learned. Health Care Anal. 2009;18:35–59.
关键词：accountable care organization ; reimbursement ; performance measures ; health 4.0 ; trust
