Impact of the abolition of copayments on the GP-centred coordination of care in Bavaria, Germany: analysis of routinely collected claims data

The ambulatory care of patients with post-acute sequelae of COVID-19

BACKGROUND

There is an increasing number of patients that do not make a rapid or full recovery from a SARS-CoV-2 infection, the Coronavirus Disease 2019 (COVID-19) and suffer from the so-called "long-COVID" or post-acute sequelae of COVID-19 (PASC). The long-term implications for health services are expected to be substantial. The objective of this analysis was to estimate the utilization of outpatient services from primary and secondary care. Further, we evaluated the multidisciplinary ambulatory care management of PASC patients in Germany.

METHODS

All members of the Physician network "MEDI Baden-Württemberg e.V.", i.e., 1,263 primary care physicians (PCPs) and 1,772 specialists working in secondary care were invited to participate in a questionnaire surveying routine data regarding the general care situation at the physician practice level of patients suffering from PASC. Bivariate analyses were applied to consider potential differences between primary and secondary care.

RESULTS

In total, 194 physicians participated in this survey (response rates of 9.6% (primary care) and 4.1% (secondary care). On average, each physician treated 31.9 PASC patients. Most PASC patients (61.2%) had three or more long-COVID symptoms. On average, 10.6 PASC patients visited a physicians' practice per quarter. The additional consulting effort for treating PASC patients was 34.1 min (median: 20 min) and higher in primary care. Most PCPs (71.1%) integrated secondary care in the treatment of their PASC patients. Less than half of the PASC patients (42.0%) sought secondary care with a referral from primary care. 5.7 patients visited the physicians' practices per week, who were concerned about suffering from PASC without any following medical confirmation. This caused an average additional effort for the physicians of 17.5 min per visit. There were no differences between rural and urban areas.

CONCLUSION

Our results reveal that there is a substantial additional consulting effort for treating PASC patients that is especially high in primary care. The additional consulting effort results from the consultation of a particular high number of patients that are concerned about suffering from PACS without a following medical confirmation. To guarantee a high quality and adequate provision of care for a potentially further increasing number of concerned patients, the ambulatory health services should be strengthened and adequately compensated.

Does the abolition of copayment increase ambulatory care utilization?: a quasi-experimental study in Germany

Due to a problematic situation with public finances, Germany introduced a copayment scheme for ambulatory care visits in 2004. In 2012, Germany achieved a balanced budget, and copayment was abolished on the 1st of January 2013. This policy change offers a rare opportunity to explore the impact of the abolition of copayment, compared to the much more frequently studied introduction of copayment. We therefore investigate the development of ambulatory care and inpatient care utilization following this policy change among people over 50 in Germany, as well as the heterogeneous impacts among vulnerable people, such as the low-income population, the chronically ill and the elderly over the age of 65. We use data from the Survey of Health, Ageing and Retirement in Europe and adopt a difference-in-differences approach with matching. We found that the abolition of copayment only caused an increase in ambulatory care use in the shorter term, while leading to a significant reduction in the longer term. In addition, we find a negative effect on inpatient care use, i.e., the hospitalization offset effect. Finally, we demonstrate that vulnerable people were more sensitive to the abolition of copayment.

SARS-CoV-2 infection and cardiovascular or pulmonary complications in ambulatory care: A risk assessment based on routine data

Background

Risk factors of severe COVID-19 have mainly been investigated in the hospital setting. We investigated pre-defined risk factors for testing positive for SARS-CoV-2 infection and cardiovascular or pulmonary complications in the outpatient setting.

Methods

The present cohort study makes use of ambulatory claims data of statutory health insurance physicians in Bavaria, Germany, with polymerase chain reaction (PCR) test confirmed or excluded SARS-CoV-2 infection in first three quarters of 2020. Statistical modelling and machine learning were used for effect estimation and for hypothesis testing of risk factors, and for prognostic modelling of cardiovascular or pulmonary complications.

Results

A cohort of 99 811 participants with PCR test was identified. In a fully adjusted multivariable regression model, dementia (odds ratio (OR) = 1.36), type 2 diabetes (OR = 1.14) and obesity (OR = 1.08) were identified as significantly associated with a positive PCR test result. Significant risk factors for cardiovascular or pulmonary complications were coronary heart disease (CHD) (OR = 2.58), hypertension (OR = 1.65), tobacco consumption (OR = 1.56), chronic obstructive pulmonary disease (COPD) (OR = 1.53), previous pneumonia (OR = 1.53), chronic kidney disease (CKD) (OR = 1.25) and type 2 diabetes (OR = 1.23). Three simple decision rules derived from prognostic modelling based on age, hypertension, CKD, COPD and CHD were able to identify high risk patients with a sensitivity of 74.8% and a specificity of 80.0%.

Conclusions

The decision rules achieved a high prognostic accuracy non-inferior to complex machine learning methods. They might help to identify patients at risk, who should receive special attention and intensified protection in ambulatory care.

Ambulatory specialist costs and morbidity of coordinated and uncoordinated patients before and after abolition of copayment: A cohort analysis

To strengthen the coordinating function of general practitioners (GPs) in the German healthcare system, a copayment of €10 was introduced in 2004. Due to a perceived lack of efficacy and a high administrative burden, it was abolished in 2012. The present cohort study investigates characteristics and differences of GP-coordinated and uncoordinated patients in Bavaria, Germany, concerning morbidity and ambulatory specialist costs and whether these differences have changed after the abolition of the copayment. We performed a retrospective routine data analysis, using claims data of the Bavarian Association of the Statutory Health Insurance Physicians during the period 2011–2012 (with copayment) and 2013–2016 (without copayment), covering 24 quarters. Coordinated care was defined as specialist contact only with referral. Multinomial regression modelling, including inverse probability of treatment weighting, was used for the cohort analysis of 500 000 randomly selected patients. Longitudinal regression models were calculated for cost estimation. Coordination of care decreased substantially after the abolition of the copayment, accompanied by increasing proportions of patients with chronic and mental diseases in the uncoordinated group, and a corresponding decrease in the coordinated group. In the presence of the copayment, uncoordinated patients had €21.78 higher specialist costs than coordinated patients, increasing to €24.94 after its abolition. The results indicate that patients incur higher healthcare costs for specialist ambulatory care when their care is uncoordinated. This effect slightly increased after abolition of the copayment. Beyond that, the abolition of the copayment led to a substantial reduction in primary care coordination, particularly affecting vulnerable patients. Therefore, coordination of care in the ambulatory setting should be strengthened.