Abstract
Background: The development of integrated care in the German health care system lags far behind the expectations of legislators, stakeholders and the requirements of health care. A major hurdle in Germany is the diversity of funding agencies and an institution-centeredness of the care system instead of a patient-centeredness. This is a considerable disadvantage for patients, especially in mental health care. A regional global budget for mental health care within the framework of model projects according to § 64b of the 5th German Social Insurance Code Book is one of many innovative approaches in the German health care system to foster integrated care. This billing system, contracted with all participating health insurers, enables inpatient psychiatric care providers in Germany to provide cross-sector and patient-centered treatment in their region. The spectrum ranges from inpatient intensive care to day-care and outpatient care to psychiatric home treatment and various complementary psychosocial services. Despite diverse scientific evidence for the improvement of patient outcomes, the model is only applied in a few health care regions in Germany.
Methods: We therefore investigated the diffusion process and barriers to diffusion using established research approaches such as Rogers' model for diffusion of innovations using a qualitative research method. Twentytwo guided interviews with experts from different stakeholder groups (chief physicians, commercial staff, health insurance companies, associations) were analysed for content.
Results: The study identified key barriers to further diffusion such as a lack of trialability of the model, poor compatibility with concurrent standard care, lack of reversibility, and a perceived significant risk of implementation. Since successful contracting is only possible with complete consensus among very different groups of actors, contract negotiations are time-consuming in view of the multi-actor constellation that is typical in the German health care system. Favourable conditions were a regional monopoly position of the main provider and communal ownership.
Conclusion: The further implementation of integrated care with a global budget could be promoted by reducing the complexity of the model, for example by introducing it in partial steps, reducing the risk for non-communal providers, and by dissolving the multi-actor constellation in care planning and organisation.