[Diabetology in the German medical system in 1998]

In 1990, instruction of diabetic patients was not recognised by health insurance providers in Germany, and a practitioner received no remuneration for training patients. Moreover, no physicians specialised in diabetology were recognised by health insurance providers. Specialised diabetology was performed exclusively in hospitals. Physicians conducting their practice in offices and interested in caring for diabetic patients were in a rather difficult situation. In 1991, remuneration was provided for the first time in Germany for therapeutic training of Type 2 (non-insulin-dependent) diabetic patients. Health insurance providers paid physicians DM 60 per patient for 4 class sessions. Since 1993, physicians in the Brandenburg region have been receiving DM 250 per patient for 5 class sessions (thus DM 1,000 for a group of 4 patients) to provide therapeutic training for Type 2 diabetic patients on conventional insulin therapy. This programme has been assessed in two reported studies: one showing that this ambulatory programme is as efficient as training in a hospital and the other evaluating the setting up the Brandenburg programme. However, the number of patients receiving training in medical offices has remained inadequate (around 250,000 patients in total). In 1997/98, in order to improve this situation, a health insurance group, the VdAK/AEV (representing nearly half of the insured persons in Germany), raised fees for physicians from DM 60 to 200 per patient for the training of diabetic patients. Moreover, a book for patients (the "passport for diabetic persons" provided by the German Association of Diabetology) is distributed to patients during the training courses and reimbursed by the insurers. Within a few years in nearly all regions of Germany, diabetologists practising in medical offices have succeeded in obtaining special contracts for performance of ambulatory diabetology. This development began in East Germany but has now spread to most regions of West Germany. In 1998, an annual examination for diabetic patients was established for preventive purposes. Thus, remuneration is related to precise disease documentation (feet, nephropathy, retinopathy). This model is currently being evaluated in Wolfsburg for all diabetic patients covered by the insurers of Volkswagen AG. The first results expected in 1999 will be useful in extending this preventive examination to other regions of Germany.