Implementing integrated care is not easy. ‘European healthcare systems are fragmented, with out- and in-patient care organised in separate and different systems,’ said Prof. Neubauer. ‘Additionally, emergency care is often a third sector. In Germany, Switzerland, Austria and Northern Italy, lack of coordination between out-patient care in a general practitioner’s (GP) surgery and in-patient care in a hospital is a major issue because the GP has no access to the hospital. So, when a GP has diagnosed a patient and refers him or her to a hospital, the doctors there must start from square one, for example, when the GP’s report has not yet arrived at the hospital but the patient has. With electronic data transfer this should not be a problem. However, the problem is that hospitals
usually do not accept the findings and results of the external physician. Once a hospital-based physician
has encountered a wrong diagnosis by the referring GP, he will never again rely on the findings of his external
colleague -- the trust has been destroyed. This scenario cannot be solved electronically, it requires joint training and joint consultations, where the hospital and the external physicians work together and get to know one another.’
Wouldn’t two exams reduce the risk of misdiagnosis, anyway?
‘We need risk management –not by superfluous, repeat exams -- but by communication. One possible solution would be for the GP to use the hospital equipment for his diagnosis. When a hospital physician sees X-rays or CT scans made in the hospital he contacts the radiologist if he has any questions. However, if the diagnosis was made by a GP there is no clear line of communication between the two. Thus, the doctors should meet in joint trainings.’
How does the approach differ in different countries?
‘In some – Italy, for example -- planning is rather strict. The public healthcare system is financed entirely through taxes and organised by regions so, to a large extent, out- as well as in-patient care is determined and controlled by the state and the state requires close cooperation between the in- and out-patient sectors. In smaller and relatively sparsely populated regions, such as South Tyrol, planning becomes much easier because it covers a small area where basically everybody knows everybody. However, in Germany you have many funding institutions, such as
statutory and private health insurers, accident insurers, pension insurers etc. Everybody involved, from the
municipality to the health insurer down to the hospital, follows their own guidelines and communication channels, which makes harmonised planning very difficult.
‘In contrast, the Austrian healthcare system is strongly consensus-oriented. The fact that there is only one health insurer facilitates planning. And, because the state also covers about half of the costs of a hospital stay it has a strong interest in coordinating healthcare and promoting out-patient care and capping in-patient care. However, they have two kinds of planning: out-patient care is the task of the physicians; in-patient care is the task of the state.
‘Swiss hospitals receive about 55% of their funds from taxes levied by the cantons, and out-patient and inpatient care is highly integrated. The state also operates out-patient clinicsthat are attached to the hospitals. That’s a good interface. Also, just like Germany, the country has a large so-called Belegarzt system, where GPs have special hospital admission rights, so they can treat patients in hospital. Efforts are underway to intensify this system by offering special reimbursement schemes and other financial incentives. When a patient is treated in hospital, health insurance covers only about 45% of the costs, the state must cover the rest. If the patient is treated by the GP pays 100%.’
How will the introduction of DRGs impact on the Swiss healthcare system?
‘DRGs include attractive reimbursements schemes for many patients. Nonetheless, there are two major concersn. First, the hospitals will prefer to treat patients on an in- rather than out-patient basis because they receive higher reimbursements for in-patient care. Then there is the whole area of rehabilitative care, which is currently closely intertwined with in-patient treatment. There is some concern that hospitals will try to reduce hospital length of stays and move a patient on to rehab as soon as possible because they are reimbursed on a per case basis and no longer based on length of stay. In Germany, where DRGs have been implemented, many patients, who in the USA would receive out-patient care because the patient has to pay for in-patient care, are “put to bed” in a hospital. Thus a reimbursement scheme is being developed that offers flat rates for in- and out-patient care.
Countries can learn from one another, he added. ‘The technological aspects of planning and the desire to coordinate in- and out-patient care providers are very similar, though we should keep in mind that planning pressure is higher in a situation where the state is financially more involved compared with one in which the state covers only a minor share of in-patient treatment costs. In view of this, we have to realise that a strict planning system will not work in Germany. We cannot simply copy what other countries are doing. Each country has to take its own circumstances into account.’