Morbiditätsorientierung der regionalen hausärztlichen Bedarfsplanung

Since the 1990s, Germany has implemented a needs-related planning system regulated by the Gemeinsamer Bundesausschuss (GBA), that supervises the allocation of physicians to achieve even and accessible healthcare provision, based on factors such as demographics and morbidity. The key element is the regional physicians-to-population ratio (regionale Verhältniszahl), taking into account factors such as age, demographics, and morbidity. Despite the system, there are deficits and differences in the provision of outpatient health care in Germany. While the actual distribution of general practitioners (GP) has been extensively studied in literature, there is still a need of examining the desired ratio of GPs, particularly since the implementation of the morbidity factor. To achieve this, the correlation between the number of GPs required according to the planning guidelines and the regional prevalence rates for asthma, COPD, diabetes mellitus type 2 and coronary heart disease (CHD), as well as the correlation of the ratio ‘GPs per disease population’ and regional prevalence was examined using Pearson and Spearman correlation coefficients. This study also analyzed differences in the districts, except for counties in the Ruhr area, between the various federal states, East and West Germany, and between various structural characteristics from urban and spatial research using the Bayes factor. Additionally, correlations between morbidity-oriented planning and the German Index of Social Deprivation (GISD), which represents socio-economic deprivation, were analyzed using Spearman correlation coefficients. The results indicate that in counties with higher prevalence rates of diabetes, coronary heart disease, asthma and COPD, the needs-planning directives do not adjust adequately to target value. There is a negative correlation with large effect between 'increase in GP density per disease population' and 'increase in prevalence' (r(diabetes)=-0.89; r(CHD)=-0.93; r(COPD)=-0.92; r(asthma)=-0.85). The values differ between the federal states with a Bayes factor of >1000 for all groups. Referred to the difference between the structural characteristics, which considered e.g. population density, daily population or share of large cities, the association between the numbers of GPs indicated per disease population and prevalence are strongest for the diabetes and CHD population. Between the target value of GPs per diabetes or KHK population of a district located in Western Germany, the association is positive with a large or medium effect size (r(diabetes)=0.60; r(KHK)=0.45). In relation to the comparison of the different structure types, the correlation of both populations are positive and mostly of medium strength (r>0.3). Furthermore, there is a negative correlation of large effect size between GISD index and the specified number of GPs in the relation to the diabetes (r(diabetes)=0.54) and CHD (r(CHD)=0.70) population as well as a moderate negative correlation in relation to the COPD population (r(COPD)=0.44). Apart from that, there are no observed association with the COPD population and some reversed associations with the asthma population. Overall, the needs-based planning system was found to not be sufficiently morbidity-oriented with regard to the diabetes and CHD population and showed regional variations. Rural, less populated districts and districts in eastern Germany located alike are disadvantaged. The results could explain, among other things, the unequal distribution of the actual number of doctors, as often described in the literature and, more importantly, show major differences in the needs-based planning mechanism. More comprehensive, area-wide and uniform planning of contracting physicians could be achieved, by taking into account the socio-economic factor and more precise consideration of morbidity in the calculation of the regional ratio. To complement the present results, a more differentiated consideration of morbidity such as the use of DALYs (disability-adjusted life years) or the determination of multimorbidity, investigations of the quality of outpatient care by means of ambulatory care-sensitive hospitalization (ACSH) or a consideration of private health insurance as well as the inpatient sector could be implemented. Detailed analyses of the German needs-based planning system and the identification of disadvantaged areas help to explain and eliminate regional differences in outpatient health care. Nevertheless, it should be mentioned that nationwide, uniform and needs-based planning mechanism does not necessarily contribute to an improved care situation and manages the imbalance between need and supply of doctors.