Heinrich Schulte

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Examples of integratedcare systems from abroad
Heinrich Schulte
Endokrinologikum
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Our NHS, Our FutureInternational Clinical Summit
21st and 22nd November 2007, LondonProf. Dr.
med. Heinrich M. Schulte
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Guiding themes when founding POLIKUM

• 1. LeitmotivRequirements of the patient
• complete care, professionally and temporally
  (every specialty at any time)
• high quality
• physicians working as a team
• result-orientedness
• quick appointments
• short waiting times
• 2. LeitmotivRequirements of the physicians
• Unrestricted diagnosis therapy
• Medical care main occupation
• safety professional perspective
• Ideal working environment
• personal professional development
• 2.b Nurses requirements

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Specialties at POLIKUM
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POLIKUM Friedenau Geography

• Large potential patients base
• Approx. 170.000 people living in about 3 km
  diameter
• Direct access from the inner-city expressway (3
  min.)
• Positioned in an established medical are (on the
  area of a 100 year old hospital)

Berlin
POLIKUM Grazer Damm (amb. OP)
POLIKUM Friedenau (Main building and pediatrics)
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POLIKUM Friedenau Current status

• Biggest MVZ in Germany
• 48 physicians employed (May 2007) on approx. 40
  full-time licenses
• Approx. 3.200 square meters (Phase I)
• Another 3.000 sqm will follow in Phase II
• Approx. 58.000 patient contacts in Q IV 2006
• Opened October 2005 with 16 physicians
• Only two major specialties missing OB/Gyn
  Urology

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Centralised Digital Patient Record

• Features
• Highest demand on data protection
• Distributed access to all patients data at all
  terminals
• All technical diagnostic devices feed directly
  into the record
• Example ECG
• Complex appointments anywhere
• Interfaces to hospital software third parties
  (work in progress)
• Main advantages
• Process flexibility (e. g. change of receptions /
  rooms depending on demand)
• Zero-redundancy
• Integrated control
• Process management (integrated care / clinical
  studies etc.)

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Other unique aspects of POLIKUM

• Doctors are employed with POLIKUM
• Central administration caters for all non-medical
  aspects like purchasing, accounting control,
  general controlling
• Self-organised management medical director /
  coordinators
• Concentration on medical care as core occupation,
  but project work
• Geriatrics Network
• POLIKUM Institute
• Clinical Studies
• Integrated Care / Cross-specialty clinical
  pathways / Case Management
• Supply follows demand (from 16 to 48 doctors in
  20 months)
• Smooth transition between specialties / no
  practice-barriers
• Perhaps most important Basis for Standardisation
• In similar situations all physicians act similarly

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Discussion Pros Cons from a single doctors pov

• Pros
• No financial investment
• Young doctor no risk
• Established doctor license sale at a (hopefully)
  favorable pricespeaking of license sales a
  quick digression
• No major deviation of the income scheme (on the
  average)and bonus contracts awarding individual
  excellence
• No reduction of personal autonomy of decision
  (but)
• Concentration on medical work no more red tape
  towards KV Co. no more of the proverbial
  toilet paper purchase no more software upgrading
  and keeping-up with the political development
• Highly reduced accountability no personnel, no
  leasing contracts etc.

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Discussion Pros Cons from a single doctors pov

• Cons
• Reduced personal freedom that goes with reduced
  responsibilityput in an exaggerated fashion I
  can no longer choose which toilet paper to use.
• Adherence to strict opening hours shift work!
• In-house competition / potential risk of being
  fired
• Hierarchies that I (possibly) loathed in my time
  at the hospital
• Loss of social status
• Pressure to advanced training and openness to
  criticism due to transparency principle (digital
  patient record)

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Structural Vision Regional complete care
network

• Co-operation contracts
• Integration in digital patient record
• Building of star alliance-like network
• Central management
• Integrated service offerings to health plans

• Co-operation contracts
• Service-level agreement (admission discharge)
• Joint resource usage
• Management of emergency room
• Integrated service offerings to health plans

P
P
P
H
P
P
P
H
S
H

• Similar contracts / co-operation ideas
• Foster homes
• Self-help groups
• Rehab clinics
• Local / regional initiatives

S
S
H Hospital P Partner Practice (outpatient)
S medical service partner
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Contractual Vision fee for service performance

• Outpatient care consumes only 25 of the
  budgetthat the three main sectors consume.
• However, approx. 85 of the spending in the three
  sectors combinedare triggered by outpatient
  care.
• POLIKUM estimates the cost reduction potential at
  approx. 20...

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Cost savings obstacles

• No incentive to reduce costs today
• The outpatient sector doesnt profit from cost
  savings.
• CHIs are not-for-profit.
• Most hospitals belong to the public service.
• Hospitals and drug producers are paid on a
  per-unit base.
• Patients dont profit from cost-effective system
  utilisation.
• Urban myth The system is working at maximum
  efficiency
• Corollary Cost savings mean Quality reduction
• Political parties cannot profit from cost
  reductions a) the lowest income-levels profit
  the least b) public feels entitled to maximum as
  opposed to optimal care (see corollary)
• From the hospitals and drug producers
  point-of-view the fragmentation in the outpatient
  market (see 5 in the first presentation) is
  divide and conquer-situation.

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Cost savings potentials (1 as shown at POLIKUM)

• Reduction of induced units utilised At POLIKUM
• there are no redundant prescriptions
• nor diagnostics
• nor other therapeutic treatments
• the house is open 14 hours a day (Mo Fr)
• the broad and complete spectrum of specialties
  fosters an atmosphere and ambition of hospital
  avoidance among the health care professionals.
• Reduction of unit costs Bundled demand on the
  buyer side ( the outpatient sector) combined
  with standardisation efforts (7!) yield
  profitable purchase conditions.

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Cost savings potentials (2 as politically
intended)

• The last three reforms (2004 / 2007-1 / 2007-4)
  have brought about considerable liberalisation to
  operate in the health care sector.
• CHIs can now contract directly with providers to
  take over the entire outpatient care for their
  patients. The budgets will be subtracted from the
  payments to KV (cf. 3 first presentation)!
• Providers are now incited to re-organise in order
  to become successful tenderers for the CHIs.
• Patients can be offered individual incentives to
  choose a provider (or a meta-provider), thereby
  voluntarily reducing their freedom-of-choice.

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The means to this end

• POLIKUM will become network managers in the
  entire system
• Build networks of strong partners
• Develop standards
• Enforce standards (quality management)
• Negotiate favourable contracts with CHIs(success
  bonuses capitation fees)
• Negotiate favourable contracts with neighbouring
  sectors (hospitals etc.)
• Attract patients on a voluntary basis
• (3 months period of cancellation at most!)
• Long-term vision Maximise the contribution
  margin over the expected lifetime of all patients

• Incentive to
• keep patients satisfied(no cancellation)
• long patients life
• early treatment
• effective treatment

expected costs morbidity-adjusted
actually incurred costs (each year)
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Thank you!
Prof. Dr. Heinrich M. Schulte ENDORKINOLOGIKUM
HAMBURG Zentrum für Hormon- und
Stoffwechselerkrankungen, Reproduktionsmedizin
und Pränatale Medizin Lornsenstraße 4-6 22767
Hamburg www.endokrinologikum.com