Implementation of a health status based risk adjustment - how to define "chronic" and "severe" disease?

Presenter: Jürgen Wasem, University of Duisbrug-Essen

Abstract

Rationale: With the introduction of the health fund on January 1st 2009, a new risk adjustment schema between the health care funds has come into effect. With the latest health service reform German legislation has taken a step to implement a health status based risk adjustment (mRSA) encompassing 50 to 80 chronic or severe diseases to be identified by the German Federal Insurance Department (BVA). Definitions of the terms "chronic disease" and "severe disease" were not included in this regulation for the creation of a mRSA. A classification model and a set of calculation rules for the mRSA was published by the BVA in July 2008.

Objectives: Our research project's aim was to offer a list of chronic and severe diseases. Therefore adequate definitions and operationalisational aspects of the terms" chronic and severe" have to be identified.

Methodology: A systematic literature search in the databases MEDLINE and of the Centre of Review and Dissemination was conducted with an additional unsystematic internet search. Further on the German Social Security Code was searched for the terms “chronic” and “severe”. Characteristics for the definition and operationalisation were developed and compared with the approach of the BVA.

Results: There is no standard definition. Overall it seems correct to define the following characteristics for “chronic diseases”:
- Abnormal physical or mental condition.
- The disease lasts minimum 6 months.
- Unknown pathogenesis, whereby most cases will be of multifactorial pathogenesis. The impact of single factors is mostly unknown.
- The disease may start in a slow process or rapidly.
- Limited opportunities of healing (curative therapy), of symptom improvement (symptomatic therapy) and of abatement (palliative therapy).
- The disease has an influence on the life of the patient with significant social, mental, and economical consequences for the ill person, especially with the aspect of taking part on daily life.
- The disease requires continuous medical care as well as efforts for caretaking also from relatives.
- Life expectancy is often not affected

There is only one basic approach for a definition of “severe” developed by the Federal Social Court for a decision on the “Off Label Use” of drugs. According to this a severe disease has the characteristics of “life endangering” or “severe continuous detraction of quality of life”. In the context of the mRSA an operationalisation can best be realized with the criteria “abnormal physical or mental condition” and “disease duration”. The International Classification of Disease Code (ICD-Code) can easily be used in this context. The other criteria can partly be obtained on a qualitative basis by questioning experts, patients or relatives, though it is quite elaborate.

Conclusion: The results of our project are similar to the approach developed by the BVA, except that the BVA used only in-patient data for the identification of 'severe' diseases. But this does not adequately reflect all dimensions of restricted quality of life. Due to resource allocation decisions and improving health care for patients with chronic and severe diseases an harmonization of both terms should be achieved.