[General practitioner-centered care: a model with potential for improvement?] / Hausarztzentrierte Versorgung ­ ein Modell mit Verbesserungspotenzial?

General practitioner (GP)-centered care was introduced into outpatient care on the basis of the GKV Modernisation Acts (GKV, gesetzliche Krankenversicherung: German statutory health insurance) of 2004 and 2007. These are predominantly selective contracts according to § 73b of the German Social Code (Sozialgesetzbuch, SGB) V, which are signed between management companies such as the German GP Contract Association (Hausärztliche Vertragsgemeinschaft, HÄVG ) and the health insurance funds. The latter are obliged to enter into contracts, while participation by contracted physicians and patients is voluntary. The contract landscape of the AOK and the MEDI association in Baden-Württemberg, Germany, is considered a lighthouse project nationwide: here, approximately 5,300 general practitioners and 3,000 specialists participate in general practitioner (GP)-centered care, and about 1.7 million patients are enrolled. In addition to the higher remuneration for medical services, advantages include better control and continuity of care, the avoidance of misallocations, and the strengthening of the GP as a health guide. The increased administrative burden for participating practices and, on closer analysis, the predominantly economic focus of the contract contents, as well as the fact that they are exclusive to general practices, have proven to be disadvantages. Doing business on the basis of selective contracts leads to a division of the entire medical profession, and medical freelancing is at stake. In order to strengthen primary care in the long term, the collective-contract situation must be expanded and improved through special add-on contracts. At the same time, the risk of morbidity must not be unilaterally passed on to the medical profession through budgeting. A forward-thinking and transparently designed primary care can only be ensured with the full participation of internists in close cooperation with specialists.

[Medical care center structures in the outpatient sector: a model for the future of internal medicine?] / Strukturen medizinischer Versorgungszentren in der ambulanten Versorgung ­ ein Zukunftsmodell für die Innere Medizin?

Since the early 2000s, legislators have allowed the establishment of medical care centers to supplement and increase the flexibility of medical cooperation models. Several legal changes in subsequent years were unable to prevent that, contrary to the original intention, almost 90% of the newly founded facilities were established in urban cores and medium-sized centers; that concentration processes and monopolization were encouraged; and that the freedom of choice for patients was restricted. In order to counter the risk of undermining the free exercise of the medical profession and the dictates of economics over patient-oriented medicine in the outpatient sector, corporations, scientific societies, and professional associations are demanding more transparency and narrower limits for non-physician capital investors. There are currently more than 3000 medical care centers in Germany employing around 20,000 physicians, many of whom are internal medicine specialists. Regionally networked medical care center structures combine the advantages of optimized patient care with the growing desire of the younger generation of physicians for flexible working conditions within employment. With increasing acceptance on the part of the medical profession, networked medical care centers are able to create local structures for the expansion of modern intersectoral care and, at the same time, can be available for outpatient specialist training in internal medicine.

[Internal medicine between soma and psyche : Functional bodily complaints and depressive disorders in outpatient care]. / Innere Medizin zwischen Soma und Psyche : Funktionelle Körperbeschwerden und depressive Störungen in der ambulanten Versorgung.

Somatoform disorders are encountered in primary medical care with above-average frequency but are too rarely named as such in the differential diagnostics. The prevalence is approximately 30 % with a predominance of female patients. This patient group puts the physician-patient relationship to the acid test from the very beginning due to the fixation on organ-related symptoms, the expectations of repeated instrumental diagnostics and the special way of acting. The consequences are frequent changes of physicians, chronification and disappointment on both sides; however, a workable physician-patient relationship can be developed through an empathic but critically distanced fundamental attitude of the general internist based on a biopsychosocial illness concept. In the further course corrections in the understanding and expression of the illness on the part of the patient can be achieved with a pacing and leading strategy and with psychoeducative measures. The primary psychologization of functional complaints will not satisfy the affected person but outpatient psychotherapy should be initiated only after the patient has been well-prepared. Measures with medications mostly remain unspecific and serve only for relief of symptoms. For comorbidities with anxiety and/or depressive disorders the use of selective serotonin reuptake inhibitors should be considered.