Managed Care Programme: "Second opinion" / "Back to Work"

Cooperation of German health insurance and pain specialist society

1) "Second opinion for back pain patients" (Zweitmeinung)

In April 2010, German health care insurer (TK Krankenkasse) in cooperation with one of the German pain specialist societies started a project called "second opinion for back pain". According to a press release by the TK Krankenkasse insurance in Germany, every year about 230.000 patients are operated due to back pain.

Frequently, the original complaint - back pain - remains or returns. Patients often complain that after the back operation the pain became worse.
According to data provided by the insurance about 80% of these back operations (intervertebral discs) are not needed as they could have been cared of with conventional (pain) care.

For patients referred for a back operation, the insurance offers the possibility to get a very fast second opinion with a specialized pain care team without waiting time (within 2 days). In case the pain specialist and patient agree upon an pain therapy alternative to the back surgery the pain therapy is reimbursed. The pain treatment will then be performed by a cross-functional team where pharmaceutical treatment is only one of the available instruments. In case the pain treatment is unsuccessful the back surgery still can take place.

For the healthcare insurance the costs of a back surgery are much higher than pain care; for the patient the risk is much lower. For pain specialists the advantage is that they get to see the patient while measures still can be taken. The only ones losing in this managed care program seem to be the surgeons. Due to the long waiting lists they have not complained.

According to a 2011 German press article 85% of the patients within this programme were not confirmed for their back surgery.

Article on Ärzte Zeitung

2) "Back to Work"

The same cooperation initiated a project to bring back patients back to work. Patients unable to work due to back problems the insurance offers a managed-entry pain care program (medical doctors, psychologists and physiotherapists). This project was presented at the symposium on the Societal Impact of Pain (SIP) 2010 by the CEO of this insurance Prof. Norbert Klusen.

From over 3.700 patients included in this program in a 4 - 8 week therapy program 49% was free of pain after 4 weeks and 84% returned to work after 8 weeks. Six month later still over 90% of the former patients was still working. Modest calculations show the insurance saves at least 5000€ per patient (see "Informationsdienst Wissenschaft"). 

Specialised Outpatient Palliative Care

Specialised Outpatient Palliative Care in Germany

(SAPV - Spezialisierte ambulante Palliativversorgung)

About 25 years ago the “hospice movement” started - arising from a situation characterized by tabooing death and isolating deceasing persons. Since then a dynamic development has taken place in Germany. The hospice movement particularly actuated the societal change in awareness and attitude in dealing with severely ill patients. These changes were mainly driven by a citizens' movement and smoothed to way for palliative medicine.

Palliative care has the goal of maintaining, enhancing and improving the quality of life and self-determination of severely ill patients with an incurable very advanced disease and to allow them a dignified life up to death.

Since 1 April 2007, in accordance with the Social Code Book V (SGB V), patients with statutory legal insurance are entitled to specialised outpatient palliative care (SAPV).

Today there are about 1500 outpatient hospice services, 180 inpatient hospices and 230 palliative departments in hospitals. More than 80000 people get voluntary involved in hospice work. 

At this all severely ill and deceasing persons must benefit from progress in pain therapy and alleviation of severe physical symptoms.

The German Parliament decided in a sitting on June 18th 2009 the substantial changes in the Social Code Book V (SGB V) regarding hospice care within the context of the amendment of German pharmaceutical law (AMG Novelle). The German hospice and palliative society (DHPV) had started the corresponding legislative initiative after having evaluated the current situation of outpatient and inpatient palliative services in a considerable study in 2008.

To implement the new range of benefits, the statutory health insurance funds first have to make contracts with suitable facilities or persons (service providers), in so far as they are necessary for adequate care. 

More information available at the Bundesministerium für Gesundheit (German Ministry of Health). 
Report of the German Ministry of Health on the Specialised Outpatient Palliative Care in Germany
Additional information at http://www.dgpalliativmedizin.de/allgemein/sapv.html or at http://www.dhpv.de/themen_sapv.html