Ökonomisches Rehabilitations-management bei chronischen Rückenschmerzen

Zusammenfassung.

Fragestellung:

Ziel des Beitrags ist die Entwicklung eines Konzepts für ökonomisches Rehabilitationsmanagement auf der Grundlage des Managed-Care-Ansatzes.

Methodik:

Die Konzeptentwicklung teilt sich in einen theoretischen und einen praktischen Teil auf: Die Methodik des theoretischen Teils besteht in systematischen Literatur-, Gesundheitssystem- und Anreizanalysen. Im empirischen Teil erfolgen eine Messung der langfristigen Effekte (mit dem psychometrisch geprüften EuroQol) und Kosten der Rehabilitation, die statistische Analyse der Kostenverteilung und eine regressionsanalytische Bestimmung wichtiger Prädiktoren der Managementzielgrößen.

Ergebnisse:

Die wesentliche Managed-Care-Strategie besteht im Einsatz ökonomischer Anreizmechanismen: Die 3 – jeweils risikoadjustierten – Komponenten des Rehamanagements sind (1) ein kombiniertes Budget der Kranken- und Rentenversicherung als prospektive Vergütungsform für die Leistungserbringer sowie retrospektive Anreizzahlungen in Form von Bonuszahlungen an die Leistungserbringer, die (2) bei einer Einsparung von indirekten Kosten bzw. (3) bei einer längerfristigen Effektivität der Rehabilitation ausgezahlt werden. Die Kostenverteilung hat eine stark rechtsschiefe Form. Wichtige Kriterien zur Anpassung der Zielgrößen an die Fallschwere sind der Arbeitsunfähigkeitsstatus und die gesundheitsbezogene Lebensqualität bei Aufnahme.

Schlussfolgerungen:

Das ökonomische Rehabilitationsmanagement verspricht eine Verbesserung der Versorgungseffizienz; die Ergebnisse der explorativen empirischen Studie zeigen die konzeptionelle Machbarkeit eines anreizorientierten Managements und die Bedeutung der Risikoadjustierung der Zielgrößen.

Abstract.

Background and study purpose:

Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care.

Methods:

The concept development consists of a theoretical and an empirical part. The method of the theoretical part is based on a systematic literature review on managed care (not included in this article), health systems research and the analysis of economic incentives. For the empirical investigation, long term effects and costs were calculated. For the evaluation of effects, we psychometrically tested and used the EuroQol (EQ-5D) as a measure of health-related quality of life (HRQL). The calculation of costs (both direct and indirect) is based on routine data of payers, a cost diary and the internal cost accounting systems of rehabilitation clinics. We statistically analysed the cost distribution and identified predictors of the management targets (e.g., costs of care) by means of regression analyses.

Results:

The market-driven managed care approach is based on three tools: (1) a primary care system with case management and gatekeeping, (2) direct influence on providers by utilisation review and setting guidelines, and (3) indirect influence by setting supply-side economic incentives via the remuneration mode. The third managed care tool is most important when managing the rehabilitation of working age patients with chronic low back pain from an economic point of view. This concept consists of three components: (1) a case-based budget for direct costs; this is a prospective remuneration mode for an integrated primary care network including a rehabilitation facility, (2) retrospective bonus payments which are related to savings of indirect costs, and (3) retrospective bonus payments which are related to the effectiveness of rehabilitation, i.e. gains in HRQL. Common features of the three management components are a long-term perspective (e.g., from admission to a rehabilitation clinic until six months after discharge) and risk-adjustment of the three management targets (i.e., direct and indirect costs and gains in HRQL) in order to avoid selection and to limit the financial risk for providers. The EuroQol instrument shows acceptable psychometric properties in the rehabilitation setting for back pain patients. This instrument may yield two kinds of preference-based index values, one reflecting the preferences of the general population and one those of the patient. The Pearson correlation of these two approaches is fair, but there is a systematic difference. Empirical investigation shows that the distribution of both direct and indirect costs is skewed to the right. Statistically relevant predictors of the management targets are incapacity to work and HRQL at admission.

Conclusions:

Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.