Telemedicine is a rapidly and dynamically developing field in the health industry that is directly linked to technological progress. It has been around for decades – currently it is being used more and more in Germany because of the medical benefits related to the specific application, the health economic advantages and the comfort and safety associated with its use.
The reimbursement regulations for telemonitoring of heart failure only provide for reimbursement for outpatient care providers. Are there nevertheless options for hospitals to offer telemonitoring for patients with chronic heart failure?
Telemonitoring in heart failure by clinics
Especially for clinics, some of which have been working for years to create the necessary evidence for the added value of telemedical co-treatment, the question arises as to how they can currently offer telemonitoring services and have them remunerated. Since infrastructure and personnel are available and the necessary process knowledge exists, the provision of services by clinics also seems obvious. This is particularly true since it is easier for hospitals to identify suitable patients directly in the hospital during acute care after cardiac decompensation and thus to ensure rapid inclusion in a telemonitoring programme. From a regulatory perspective, there are three options for hospitals to offer telemonitoring for patients with heart failure.
- Cooperation with a cardiology practice or an MVZ
- Operation of a TMZ in the hospital with special needs approval
- Selective contracts
Cooperation with a cardiology practice or an MVZ
Telemonitoring in heart failure requires the creation of an outpatient telemedicine centre structure. The telemedicine centre (TMZ) is a new service provider in the German health care market. With the decision of the G-BA, the implementation in the EBM catalogue and finally the defined quality requirements for TMZs in the realisation of telemonitoring of heart failure, basic structures of the TMZ have been defined. TMZ structures have also been established for the care of intensive care patients during corona infection as part of standard care.
A possible implementation of telemedical co-treatment by clinics can take place in cooperation with a cardiological practice. Possible advantages for clinics and the practices would be:
- direct contact with suitable patients after a relevant stay in hospital
- Direct exchange of discharge documentation
- availability of telemonitoring data in the clinic in case of (un)planned hospital admissions
- Ensuring 24/7 staffing with clinic personnel
Shared care with an outpatient partner also comes with some challenges:
- Cost-effectiveness for all involved
- Processes and organisation of jointly responsible care
- Technical implementation considering the existing infrastructure
- Legal regulation
Requirements for the TMZ structure
There is professional, technical and data protection requirements, but also organisational requirements and reporting obligations of the TMZ. To fulfil the professional requirements, TMZ physicians must hold the specialist title “Internal Medicine and Cardiology” and prove that they have been approved according to the QS Agreement on Rhythm Implant Control. Even if a TMZ wanted to specialise completely in the telemonitoring of patients with external devices, the TMZ physicians need the authorisation for rhythm implant control.
Both the implants used in telemonitoring and the external (measuring) devices and their accessories must meet the requirements defined in the quality assurance agreement.
Operation of a TMZ in the hospital with special requirements approval
In addition to fulfilling the above-mentioned requirements for a cardiologist in private practice, a TMZ in a hospital must have a special needs authorisation for the cardiology sector. This is applied for at the responsible KV
The legislator allows the statutory health insurance funds to agree on contracts for special care within the framework of § 140a of the German Social Code Book V. These are intended to improve the quality and efficiency of care for their insured. The temporary contracts are concluded with authorised service providers to test new forms of care and improve care processes. In the past, the funding agencies had already concluded selective contracts with various clinical service providers for the telemedical co-treatment of patients with heart failure. Examples are the cooperation of BARMER with Charité and the contract of DAK-Gesundheitskasse with the Heart and Diabetes Centre NRW.
Within the framework of selective contracts, services can be agreed upon that go beyond the scope of services provided for in the EBM. For example, a focus could be placed on coaching and empowerment of patients.
The new specifications will be reviewed regularly. It is quite possible that during the review, improvements will be made so that clinics can also offer telemonitoring services without detours via selective contracts, special needs assessments or necessary cooperation’s. In other areas, such as telemedical counselling of corona patients requiring intensive care, it was established in March 2022 that heart and lung centres make their expert knowledge available to other service providers and that this service is also remunerated. It is possible that, in the future, the expert knowledge of heart centres will also be made available to other hospitals for the care of heart failure patients. The step towards telemonitoring by the hospitals would then no longer be so great.
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