It is the role of the case manager to advocate for the patient, often going to extraordinary lengths to secure the necessary treatments. Here, Johann Achim Beißel, a health insurance-based case manager from Germany, describes how he crossed oceans and international borders to navigate his patients’ pathways to health.
HOW DID THIS JOURNEY BEGIN?
In mid-2018, we had an 8-year-old patient, Xhenisa, suffering from epilepsy caused by a tumor located deep in the brain. Drug treatments failed and the number and intensity of daily seizures increased. In researching options, Professor Dr. Felix Rosenow, Head of the Epilepsy Center at Frankfurt University Hospital, and his team concluded that a new stereotactic laser thermal ablation technology (SLTA) from Medtronic was the only treatment option; however, it was not available in Germany.
There were attempts to secure the SLTA operation in Australia and France, but they were denied due to the complexity of the operation.
Dr. Daniel Curry from the Children’s Hospital of Houston accepted the challenge. Xhenisa was successfully treated with Medtronic’s SLTA technique in November 2018 during an eight-hour brain surgery. She spent only one night in the hospital’s intensive care unit and was then able to return with her parents to a hotel nearby for outpatient aftercare. The return flight to Germany took place two weeks later. As predicted by Dr. Curry, the number of seizures increased in the first year after surgery. Subsequently, the frequency of seizures steadily declined, and after a year, Xhenisa is now free of seizures and medication. Success!
WHAT WAS YOUR PRIMARY TASK?
My primary task was to establish contact with the Children’s Hospital of Houston, to organize flights, negotiate prices with the hospital and, ultimately, to be the liaison for the parents.
HOW WERE YOU ABLE TO SUCCESSFULLY NAVIGATE A FOREIGN HEALTHCARE SYSTEM?
My previous experience with the American healthcare system, which I was able to gain during my university internships as a hospital business administrator at Kaiser Permanente in Los Angeles, and my active membership in the Case Management Society of America came to my aid.
WHAT DID YOU DO NEXT?
I asked myself why this SLTA system was not available in Germany, specifically at the University Hospital in Frankfurt. The answer, of course, has to do with the DRG hospital reimbursement system and the funding of new and innovative services. If the costs of the SLTA technology are not reflected in the collective agreement system, a hospital cannot bill the service or can only bill with complex individual approvals. Without a selective contractual basis, this is insecure refinancing, with long waiting times for the insured and often the same work for the different cost units.
I followed with the question of how would a health maintenance organization in the USA solve such problems for its policyholders? They would act as a designer of medical care. And so, I came up with the idea of launching a “concerted action in healthcare” involving three different parties who all have the well-being of the patient in mind. Namely we as a health insurance company, together with a hospital and a medical device provider, would create a comprehensive contract that would enable us to work together to provide special care (SLTA technology) for the treatment of epilepsy patients in Germany.
HOW DID YOU FACILITATE THIS COLLABORATION?
After I had convinced the decision-makers at my insurance company (BIG Direkt Healthy) of the potential of my idea, I was able to establish contact with Medtronic at a medical trade fair in Munich. Also, Prof. Dr. Felix Rosenow found the idea of drafting a contract interesting. A workshop was held on the possible implementation of such a contract for special care. This workshop was followed by many more phone calls and votes, until finally, after a long contract development, the contract could be submitted to the Federal Social Security Office (BAS) in Bonn for review in August 2020. After approval by the BAS, the “Contract for the diagnosis, treatment and care of patients with structural, focal, therapy-resistant epilepsy using stereotactic laser thermal ablation (SLTA)” was signed on October 26, 2020, and put into effect. This means that BIG Direkt Healthy has actually gone from payer to player, to the designer of innovative inpatient care in statutory or public health insurance.
DID YOU FOCUS ONLY ON THE MEMBERS FOR BIG DIREKT HEALTHY?
Due to the fact the SLTA contract is designed for an orphan disease, it was my intention as a case manager to offer that service for as many patients in Germany as possible. So, from the beginning the contract was open for other insurance companies to join as a benefit for their members. And indeed, by mid-April 2021 the following companies with a total of 15 million members are participating: IKK classic, BKK Pfalz, Techniker Krankenkasse and IKK Suedwest.
WHAT WAS THE KEY ELEMENT THAT MADE THIS EFFORT A SUCCESS?
This was made possible by the willingness to cooperate on the part of Prof. Dr. Felix Rosenow, those responsible at Medtronic, Jan-Philipp Spierling and Dr. Lutz Herbarth. Without all those involved being open to this new way of bringing care into statutory health insurance, we would never have been able to conclude the contract and bring this innovative technology to our patients in Germany.