The Cost-Effectiveness Analysis of an Integrated Mental Health Care Programme in Germany
Annabel Sandra Mueller-Stierlin, Uemmueguelsuem Dinc, Katrin Herder, JuliaWalendzik, Matthias Schuetzwohl, Thomas Becker, Reinhold Kilian
International Journal of Environmental Research and Public Health​ 2022, 19, 6814.
https://www.researchgate.net/publication/361045103_The_Cost-Effectiveness_Analysis_of_an_Integrated_Mental_Health_Care_Programme_in_Germany

1. Introduction
Germany is one of the countries with the highest absolute and relative levels of expenditure on mental health care. In contrast to international guidance, the German mental health care system is characterised by fragmented services provided by mental hospitals, general hospital-based psychiatric inpatient units, office-based psychiatrists or psychologists, and hospital-based outreach ambulatory services, and these are complemented by a range of non-medical vocational, residential and psychosocial services that are provided by vocational rehabilitation centres, community mental health care centres and residential facilities. The threshold to access inpatient and other services is low in comparison with other countries. Evidence-based community-based integrated services such as Home Treatment and Crisis Resolution Teams, Assertive Community Treatment and Intensive Case Management Teams are scarce. The historical development of the legal, financial, and structural framework of the German health care system is considered by experts to be the key reason for its inertia with respect to the implementation of innovative treatment concepts. The German federal social legislative code hampers the implementation of integrated services. While medical services are mainly reimbursed by statutory health insurance, social services are funded by local and regional social welfare agencies on the basis of taxation. A change of the social legislative code in 2009 allowed providers of community-based non-medical mental health care services to offer managed mental health care packages including medical and non-medical service components on the basis of capitated payment by statutory health insurances.
Meanwhile, about 80 community mental health care providers across Germany offer integrated mental health care programmes called “Netzwerk psychische Gesundheit” (NWpG), and about 10,000 patients per annum are enrolled in these programmes. The expectation was that integrated and team-based mental health care on a capitated payment basis would result in improved effectiveness and cost-effectiveness. A prospective observational evaluation study indicated that NWpG programmes were not generally more effective than standard care with regard to clinical and non-clinical outcome indicators. Nevertheless, study participants enrolled in NWpG programmes experienced a higher level of shared decision making and were more satisfied with mental health care services than participants receiving standard care. No cost-effectiveness data have yet been available for this programme. In this article, we present the health economic evaluation of the NWpG programme. Within this evaluation, the utilisation of health care services, the related health care costs from a societal perspective and the net monetary benefits using the change of quality-adjusted life-years were compared between patients enrolled in the NWpG programme and a control group of patients receiving standard care alone.

Discussion
The economic evaluation, after adjustment for sociodemographic and clinical differences between study groups, resulted in no significant difference in total costs or in cost-effectiveness between the NWpG integrated mental health care programme (plus TAU) and treatment as usual alone.
The current study was a pragmatic, non-blinded, multi-centre-controlled trial comparing outcomes among 260 persons living with mental illness enrolled in the NWpG programme with a control group of 251 patients who received standard care alone. Societalperspective health care costs were estimated based on reported health service use in the previous months at baseline and at three follow-up assessments over a period of 18 months. We found that NWpG programmes were not generally more effective than standard care with regard to the primary outcome empowerment and other secondary outcomes. However, our study results suggested that the NWpG programme has the potential to increase treatment satisfaction and patients’ perceived treatment participation. Second, we evaluated the use of common health services and of NWpG services, the associated health care costs, and the individual net benefit as part of the health economic evaluation.

Conclusions
To conclude, no health economic benefit of NWpG (plus TAU) compared to TAU alone was found. The IVPOWER study showed no evidence for effectiveness or costeffectiveness, with the exception of secondary outcomes (satisfaction with and involvement in care). Further randomised trials would help. Adequate tailoring of integrated care interventions, a clear definition of target groups and robust strategies for implementing service innovation could be important in moving the field forward.