Costs of coordinated versus uncoordinated care in Germany: results of a routine data analysis in Bavaria.
The efficiency of a gatekeeping system for a health system, as in Germany, remains unclear particularly as access to specialist ambulatory care is not restricted. The aim was to compare the costs of coordinated versus uncoordinated patients (UP) in ambulatory care; with additional subgroup analysis of patients with mental disorders.



Retrospective routine data analysis of patients with statutory health insurance, using claims data held by the Bavarian Association of Statutory Health Insurance Physicians. A patient was defined as uncoordinated if he or she visited at least 1 specialist without a referral from a general practitioner within a quarter. Outcomes were compared with propensity score matching analysis.



The study encompassed all statutorily insured patients in Bavaria contacting at least 1 ambulatory specialist in the first quarter of 2011 (n=3 616 510).



Primary outcome was total costs of ambulatory care; secondary outcomes were financial claims of general physicians, specialists and for medication.



The average age was 55.3 years for coordinated patients (CP, n=1 629 302), 48.3 years for UP (n=1 825 840). CP more frequently had chronic diseases (85.4%) as compared with UP (67.5%). The total unadjusted financial claim per patient was higher for UP (€234.52) than for CP (€224.41); the total adjusted difference was -€9.65 (95% CI -11.64 to -7.67), indicating lower costs for CP. The cost differences increased with increasing age. Total adjusted difference per patient with mental diseases as documented with an International Classification of Diseases (ICD)-10 F-diagnosis, was -€20.31 (95% CI -26.43 to -14.46).



Coordination of care is associated with lower ambulatory healthcare expenditures and is of particular importance for patients who are more vulnerable to medical interventions, especially for elderly and patients with mental disorders. The role of general practitioners as coordinators should be strengthened to improve care for these patients as this could also help to frame a more efficient health system.
Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany.
Antonius
A
Schneider
Association of Statutory Health Insurance Physicians of Bavaria, München, Germany.
Ewan
E
Donnachie
Association of Statutory Health Insurance Physicians of Bavaria, München, Germany.
Martin
M
Tauscher
Association of Statutory Health Insurance Physicians of Bavaria, München, Germany.
Roman
R
Gerlach
Institute of Health Economics and Health Care Management, Helmholtz Zentrum München-German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
Werner
W
Maier
Institute of Health Economics and Health Care Management, Helmholtz Zentrum München-German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
Andreas
A
Mielck
Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany.
Klaus
K
Linde
Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, München, Germany.
Michael
M
Mehring
D000553:Ambulatory Care / Q000191:economics* / Q000706:statistics & numerical data; D002908:Chronic Disease / Q000191:economics* / Q000628:therapy; D017281:Cost of Illness; D005260:Female; D005858:Germany / Q000453:epidemiology; D017048:Health Care Costs; D006297:Health Services Accessibility / Q000191:economics* / Q000592:standards; D006801:Humans; D007345:Insurance Claim Review; D007348:Insurance, Health / Q000191:economics* / Q000706:statistics & numerical data; D008297:Male; D001523:Mental Disorders / Q000191:economics* / Q000628:therapy; D008875:Middle Aged; D057216:Propensity Score; D012189:Retrospective Studies
PRIMARY CARE; access to care; health spending; organization and delivery of care