Continuous Case Management of a German Statutory Health Insurance

Article excerpt

INTRODUCTION

A serious or chronic illness often turns life upside down. To give support to insured patients, TK, one of the major statutory health insurances in Germany, established in 1990 a special service, the TK CCM. TK-insured persons who are affected by a chronic illness or disability can obtain this service by specially trained TK rehabilitation advisors.

This article shows that CCM is a valuable instrument to achieve cost savings, even in health care systems that are highly regulated like the German statutory system with its Social Code Books 1-12, and a historically developed segmented, sector-based health provision system. We show that a CCM is able to stabilize expenditures of a statutory sickness fund, when it is run under defined conditions.

TK at a Glance

The TK was founded in 1884 as the Registered Mutual Fund for Architects, Engineers, and Technicians in Germany and since then is operating throughout the Federal Republic of Germany. Membership figures have reached today more than 3.4 million and another 2 million family members coinsured at no extra cost according to German legislation. Today, still most of the insurees come from technology-related professions. As a not-for-profit statutory health fund the TK is subject to German social law with the special feature of a legally defined self-administration by elected representatives of the insured. The TK is directed by a professional Board of Management. The representation of the insured is guaranteed by the 30 elected members of the administrative council voted for in special nationwide social elections every 6 years. To be able to offer a wide array of services, TK contracts with multiple service providers, including hospitals, physicians, rehabilitation facilities, nursing home facilities, pharmacies, and specialists such as audiologists; all providers must meet special requirements and quality criteria. Over the years, TK has established a consistent base that will be continuously developed. The total budget in 2003 was 16.3 billion dollars.

Historical Development

In July 1990, TK founded a special service called rehabilitation advisory with 30 advisors. Since then the TK rehabilitation advisory service had undergone several adjustments concerning contents and structures, becoming a model of CCM.

At the start of the model, all cases of chronic diseases were handled by the rehabilitation advisors; the organizational structure was decentralized. The model was mainly hospital-sector-based. During the last 14 years, the German health care system has undergone many changes; i.e., the billing of inpatient benefits changed from daily rates to case based lump sums. In consequences, TK rearranged its CCM by redesigning the organizational structure and standard proceeding operations Aichberger, 2004).

The current TK CCM was set up in 2003. It serves more than 150,000 insurees each year based on a hospital stay. Today, there are more than 270 TK case managers acting throughout Germany. The service focuses especially on transsectoral diagnosis (1) which are in need of a special assistance and combines proximity to insurees with a centrally leaded management.

Goals and Main Issues

The goals of the TK CCM model have remained the same, providing supplementary assistance to insurees who are affected by a serious illness or disability in order to increase their chances of recovery or alleviating and to assist them in finding ways to handle everyday life as well as improving their quality of life (behavior modifying). Another goal would be to streamline insurees health care pathways with simultaneous optimizations in quality of care in order to allocate financial resources means in the most efficient ways. Like this, TK assures its long-term financial solidity and sustainability. Table 1 outlines additional goals that the TK CMM model expects to achieve.

In the German health care system, the inpatient hospital treatment stays is often followed by rehabilitation measures--differing slightly in between diagnosis. …