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

Abstract

ObjectivesIn 2012, Germany abolished copayment for consultations in ambulatory care. This study investigated the effect of the abolition on general practitioner (GP)-centred coordination of care. We assessed how the proportion of patients with coordinated specialist care changed over time when copayment to all specialist services were removed. Furthermore, we studied how the number of ambulatory emergency cases and apparent ‘doctor shopping’ changed after the abolition.DesignA retrospective routine data analysis of the Bavarian Association of Statutory Health Insurance Physicians, comparing the years 2011 and 2012 (with copayment), with the period from 2013 to 2016 (without copayment). Therefore, time series analyses covering 24 quarters were performed.SettingPrimary care in Bavaria, Germany.ParticipantsAll statutorily insured patients in Bavaria, aged ≥18 years, with at least one ambulatory specialist contact between 2011 and 2016.Primary and secondary outcome measuresPrimary outcome was the percentage of patients with GP-coordinated care (every regular specialist consultation within a quarter was preceded by a GP referral). Secondary outcomes were the number of ambulatory emergency cases and apparent ‘doctor shopping’.ResultsAfter the abolition, the proportion of coordinated patients decreased from 49.6% (2011) to 15.5% (2016). Overall, younger patients and those living in areas with lower levels of deprivation showed the lowest proportions of coordination, which further decreased after abolition. Additionally, there were concomitant increases in the number of ambulatory emergency contacts and to a lesser extent in the number of patients with apparent ‘doctor shopping’.ConclusionsThe abolition of copayment in Germany was associated with a substantial decrease in GP coordination of specialist care. This suggests that the copayment was a partly effective tool to support coordinated care. Future studies are required to investigate how the gatekeeping function of GPs in Germany can best be strengthened while minimising the associated administrative overhead.

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

“…The considerable decrease in GP-centred care after 2012 of particular concern. Found in a preceding ecological study based on the same data source and observing the entire Bavarian population [22], our current cohort analysis sheds light on the morbidity structure of patients switching from coordinated to uncoordinated care. After removal of the copayment, the uncoordinated patients exhibited high morbidity, as measured by the proportion with chronic illness and the number of medical condition categories (THCC/RHCC, see also Figure in S1 Fig) . Additionally, a higher proportion had a record of psychological disorder, which was previously found to be associated with both uncoordinated specialist contacts and higher costs of ambulatory care [15,20].…”

“…A patient was classified as 'coordinated' if every regular specialist visit within a quarter occurred as a result of a GP referral (coordinated patient, CP) [15,20,22]. In contrast, a patient who consulted at least one specialist within a quarter without a referral was defined as uncoordinated (uncoordinated patient, UP).…”

“…Assessing before and after in the same study will increase our understanding of the impact of care coordination on resource use in the German ambulatory healthcare system and how coordination of care can be affected in different patient groups. Previous time series analyses found a large decrease of coordination of care on a population-based level [22]. The aim of our cohort analysis is to analyse characteristics and differences between GP-coordinated and uncoordinated patients concerning morbidity and ambulatory specialist costs.…”

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

“…In comparison with common referral rates for patients in Germany, this number is rather high. In 2016, only 15.5% of the patients visiting a specialist have had a referral from a PCP due to the design of the health care system [ 24 ].…”

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

“…The analysis is based on large routine data of two cohorts with polymerase chain reaction (PCR) test confirmed or excluded SARS-CoV-2 infection, respectively. The anonymous ambulatory claims data was provided by the Bavarian Association of Statutory Health Insurance Physicians (BASHIP) and covers all 11.2 million statutorily insured persons in Bavaria, covering approximately 85% of the population [ 20 ]. During the evaluation period from February to the end of September 2020 (i.e., first to third quarter 2020), patients suspected to suffer from COVID-19 infection received naso-pharyngeal swabs for PCR testing in general practice.…”