Medical Specialties Providing Outpatient Palliative Care

A comparison across regions based on German statutory health insurance claims data

Palliative care at the end of life has attracted greater attention over the course of the past two decades. In most cases this care is provided outside the hospital setting. To date, it is largely unknown (with the exception of one publication in German [1]) which physicians are involved in outpatient palliative care and what services they contribute.

To cast light on the provision of outpatient palliative care nationwide and compare the data across regions in Germany, we evaluated statutory health insurance claims data from each of the 17 regions of the National Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung, KV). In doing so, we distinguished between primary palliative care (AAPV), especially qualified primary palliative care (BQKPmV), and services defined as specialized palliative homecare (SAPV).

The care category AAPV includes palliative services as defined by the fee schedule for German physicians (Uniform Value Scale, EBM), the “Oncology Directive” agreed between the National Association of Statutory Health Insurance Funds and the National Association of Statutory Health Insurance Physicians, and selective agreements for particular billing codes. BQKPmV services can be billed under the EBM by a physician of any specialty with an appropriate qualification. First or subsequent prescriptions of SAPV can be billed by physicians of any specialty in the EBM system; regarding SAPV services, the relevant information about the medical specialty is only contained in the billing data from Berlin and Westphalia-Lippe (2).

Method

As a component of the project pallCompare, financed by the innovation fund of the German Federal Joint Committee (G-BA), we analyzed physicians providing palliative care according to their medical specialty and KV-membership. This information we found in the last year of life billing data records of the members of the BARMER health insurance fund.

Results

AAPV was billed by between 14.9% (Berlin) and 41.0% (Bavaria) of primary-care physicians, by 38.4% of oncologists (Table), and by 10.2% of internists. Nationwide, 94.2% (79.4–97.4%) of AAPV was provided by primary-care physicians, 2.8% by oncologists, 2.0% by urologists, and 0.2% by anesthetists.

Table

Involvement of primary-care physicians and oncologists in palliative care by KV region of Germany

BQKPmV was billed by between 0.2% (Westphalia–Lippe) and 7.1% (Saarland) of primary-care physicians (national average 3.7%). The proportion of oncologists providing this category of care was greater (national average 12.1%) (Table). Nationwide, 87.0% of BQKPmV was provided by primary-care physicians.

SAPV prescriptions were billed by between 1.7% (Berlin) and 24.8% (Hesse) of primary-care physicians (Table). The proportion of primary-care physicians who exclusively prescribed SAPV without themselves billing for AAPV varied from 0.6% (Berlin) through 2.8% (Baden-Württemberg) and 3.2% (Bavaria) to 10.3% (Thuringia), 11.4% (Brandenburg), and 11.5% (Hesse). Nationwide, SAPV was prescribed predominantly by primary-care physicians (91.7%), but also by oncologists (4.1%). The proportions of SAPV prescribed by primary-care physicians were strikingly low in Berlin (39.8%) and Hamburg (69.9%). In Berlin high numbers of SAPV prescriptions were accounted for by oncologists (30.1%) and anesthetists (10.7%), in Hamburg by internists not engaged in primary care (16.6%).

The data available to us included billings of SAPV services only in the KV regions Berlin and Westphalia–Lippe. In Berlin, SAPV was billed by 16.7% of oncologists, 10.8% of anesthetists, and 1.8% of urologists, but by only 0.8% of primary-care physicians. Another group of physicians (specialty unspecified) exclusively billed for SAPV. With regard to all SAPV-providing physicians in Berlin (n = 76), this group (n = 35) accounted for 46.1% of billing for SAPV, followed by primary-care physicians (23.7%) and oncologists (13.2%). The situation was very different in Westphalia–Lippe, where 3.8% of primary-care physicians, 9.3% of anesthetists, and only 4.5% of oncologists billed for SAPV. With regard to all SAPV-providing physicians in Westphalia–Lippe (n = 235), 77.9% were primary-care physicians, followed by anesthetists (8.5%).

Discussion

This is the first study to show the considerable regional differences across the whole of Germany in the forms and extent of outpatient palliative care provided by physicians of different specialties. In all KV regions, AAPV is provided predominantly by primary-care physicians. However, the proportion of all primary-care physicians who provide palliative care or prescribe SAPV varies widely among KV regions. The data from Berlin and Westphalia–Lippe suggest large differences concerning the medical specialties providing SAPV. Greater transparency with regard to the involvement of different medical specialties in the remaining KV regions would be desirable.

The multiple reasons for the varying involvement of different medical specialties in outpatient palliative care are rooted predominantly in regional variations, partly historical in origin, in the organization and remuneration of such services (3, 4, 5). In view of the considerable demographic challenges to be faced, greater attention needs to be paid to determining which of these models meet existing needs efficiently and will continue to do so in the future, and what modifications are indicated and could be successfully implemented.

Bianka Ditscheid, Markus Krause, Ursula Marschall, Antje Freytag

Funding

G-BA Innovation Fund, FKZ 01VSF19026

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 24 October 2023, revised version accepted on 22 January 2024.

Translated from the original German by David Roseveare.

Cite this as:
Ditscheid B, Krause M, Marschall U, Freytag A: Medical specialties providing outpatient palliative care—a comparison across regions based on German statutory health insurance claims data.

Dtsch Arztebl Int 2024; 121: 298–9. DOI: 10.3238/arztebl.m2024.0017

References

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2. Ditscheid B, Meissner F, Gebel C, et al.: Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016–2019) und regionale Variabilität. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66: 432–42

3. Ditscheid B, Krause M, Lehmann T, et al.: Palliativversorgung am Lebensende in Deutschland: Inanspruchnahme und regionale Verteilung. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63: 1502–10

4. Radbruch L, Andersohn F, Walker J: Palliativversorgung – Modul 3: Überversorgung kurativ – Unterversorgung palliativ? Analyse ausgewählter Behandlungen am Lebensende. Bertelsmann Faktencheck Gesundheit 2015.

5. Freytag A, Meissner F, Krause M, et al.: Ergebnisqualität und Kosten der allgemeinen und spezialisierten Palliativversorgung in Deutschland im regionalen Vergleich: eine GKV-Routinedatenstudie. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66: 1135–45