The Advisory Board: Q&A about Gesundes Kinzigtal

Helmut HildebrandtHelmut Hildebrandt presented the experiences and results of the population-based integrated health care system in Kinzigtal to a group of senior hospital managers at the Advisory Board Global Forum for Health Care Innovators. This was followed by a Q&A session, chaired by Mike Wagner, Executive Director Advisory Board Company. The Advisory Board Company is a global research, technology and consulting firm partnering with more than 230,000 leaders in more than 5,200 organizations across health care and higher education. We are grateful to the Advisory Board to being able to reproduce these questions and answers here.

For a background on the “Gesundes Kinzigtal” click here.

Q: In this everybody wins environment of “Gesundes Kinzigtal”, who would you say is the group of stakeholders that are least likely to win or are most resistant to this kind of transformation?

There is one losing organisation, and that is the other sickness funds who are not participating. Our model is so attractive for patients that they leave their sickness funds and join the funds that we are partnering with. It’s very easy in Germany for patients to leave one sickness fund for another.

Hospitals are potential losers because we reduce hospitalisations, but it is not only about the actual numbers, but also about the type of patients that they lose. One hospital told me they don’t lose money, because the patients we keep out of their hospital are those patients who they don’t earn income on anyway, such as patients who come in late in the evening with unclear problems that require heavy diagnosis but don´t really need a hospital stay.

Pharmaceuticals probably lose. We have reduced pharmaceutical costs for our patients but it is a small region (Kinzigtal), so they probably don’t notice it that much. On the other hand some pharmaceuticals may win with us because we have an interest in having the best pharmaceutical care for our patients. We’ll even buy products that cost more if they are more effective. But sickness funds look only at the cost of pharmaceuticals without looking at the cost of nursing homes. They don’t look over the cycle. This is our advantage in the population-based system.

Q: Do you have any strategies that are designed to get the 70% of the population who don’t sign up to be involved with Kinzigtal?

We think that we will have a higher proportion of people being involved with the new centre we just built. The problem until now is that there is an office space we work from but it’s not highly visible. For the patients here, this way of health improvement is new as well. They had to have some trust in our work, and to develop trust takes time and is difficult. So I think we’re OK as we are, and it will develop over time. We don’t need to have members who are healthy, because they’re already healthy.

Q: How does the potential for higher cost treatments that may deliver good care work in your business case?

We only have to compare us to the mean costs of care in similar situations. So if we look at oncological patients for example, and we see that patients in other parts of Germany are irritated by different doctors who offer different and strange services just to make a case for their own business, then it’s very easy for us to do better. If we increase the quality of care and they have less complications or hospitalisations, then we can invest as we think is the best for the patient.

Q: When talking about setting up an integrated care system in an urban setting, would you prefer to have a defined neighbourhood or catchment area? Would there be any kind of connectivity?

Yes, a neighbourhood, that has about 100,000 to 200,000 people, is ideal because then you have just a sufficient number for scaling interventions but the physicians and other health care providers are still near to each other and may get connected with some similar spirit. Better working with different regional companies for each 200,000 people than one for 800,000. Keep is small. You may compare it with the public transport systems. In Germany they developed a way to have competing public transit systems by catchment area. And they included quality indicators to measure how the companies who offered those services performed. That could be transferred to health care as well. So there’s a five or 10 year contract, and then a new competition has to be held. A problem with our model is monopolism, and we don’t want that. There must be some kind of competitive situation to foster development and innovation. There may be some centralised, shared services, to connect autonomous regional companies on the other side.

Q: How do you motivate your GPs? Do you use financial or professional incentives? And have you had any issues with data sharing?

It’s an art to work with physicians. We don’t use financial incentives too heavily, but more in a way to give them a reimbursement for the extra time they spend with us and with patients. We make it easy so they don’t have as much paperwork to do. The motivation comes from other sources, such as the patient who says their doctor has helped. That is much more motivation for doctor than having €200 more on his account. So is being a peer among other doctors and not a competitor.

A professional incentive is the benchmarking of performance. Initially doctors are uncomfortable if data is shared with another doctor, because they are concerned about the scrutiny and being challenged. Getting around that took time. But fortunately our doctors knew that this was a problem in Germany, and they wanted to be part of the solution. Up until now, many doctors couldn’t have access to a patient’s medical records. Now, our system has the data inside our own system and we provide regular feedback reports. It took some time to set up, and we now have two people on the ground with the physician offices and other four data analysts who only work on IT and data.

Q: What’s one word of advice that you would have for your colleagues, many of whom are taking on more risk as we move towards population health?

You had the example of Kodak and how it failed to innovate. There are three requirements for the possibility of disruption in health care according to Clayton Christensen. First, there must be changes occurring in technology. Second, there must be a new distribution model. Third, the revenue must be higher with the new model than with the old model. The last of these three is the most challenging. When I talk with hospital administrators in Germany, 80% said they would like to do work like ours, but feel unsafe about whether or not they could get their governing bodies to invest a significant amount of money in this. We now have an innovation fund in Germany being established. There will be 1.2 billion Euro over the next four years, the money being spent on health care systems innovations. I hope the problem of the first three years can be overcome with this funding to help develop 20 or 30 systems like ours, which will provide competition and a market to be developed. You need this kind of market development.

Lastly, partner with people from the health sciences universities or with researchers. This way you are aware of the new science and technology that is being developed.