Healthcare and Insurance – Should we try to incentivise the ‘right’ behaviours through technology? Part 1/2

Uli Kleber, TDI News Correspondent for Germany and Switzerland, got together with Henriette Neumeyer and Lukas Naab. Henriette is a medical doctor who now runs the Master of Healthcare Management program at NORDAKADEMIE in Hamburg, Germany while Lukas is the co-founder of MINDS medical – a start up from Frankfurt, Germany that uses Artificial Intelligence and Machine Learning to streamline administration and processes in the insurance and health care system, e.g. hospitals.

Uli: I am really excited to have you here with us: a medical doctor who has worked in consulting and is now focusing on academia together with a start up-entrepreneur who has hands-on client experience in both hospitals and insurance companies.

This is a great team to talk about how we can incentivize behavior at the intersection of healthcare and insurance. But my question is: why is this topic relevant at all?

To me a quotation comes to mind that is attributed to Heinrich von Pierer, the former Siemens CEO: “If Siemens only knew, what Siemens knows.” I think that’s a relevant saying, which we can also apply to the healthcare sector: if we create more data transparency in the interaction between the healthcare system, its patients and insurance companies that help to finance the system, then everybody should be much better off.

What is your view on this?

Lukas Naab, co-founder, MINDS medical

Lukas: To me, the digital patient file is truly the linchpin of the whole health care system, both for providing safe and effective treatments to patients as well as many downstream administrative tasks. This is why it is important that the health care system once again focuses on people and not on administration. To be able to do this right, we need to use technology. I always see this endeavor as a team sport for all stakeholders in the healthcare system and it is really high time for the team to come together. We need to let go of silo thinking and work together, solving the challenges step by step. Particularly with regards to interoperability and data protection.

Henriette: I actually find your statement quite exciting, particularly against the background of “if only you knew, what you know”. I think that is also true

Henriette Neumeyer, NORDAKADEMIE

for many healthcare professionals. I can tell from my own experience: if a patient comes to you and you do not have any patient data or not the right data, then you start from scratch. This typically means getting on the phone and talking to many different people until you get hold of a prior diagnosis or maybe find a caregiver who can tell you more about the situation of the patient. When in doubt, you will do another MRI or CAT scan to move the process forward although the imaging might already exist in some file of another institution that you do not know about or have access to. This is really frustrating and time consuming.

Everybody who has ever touched the health care system, whether as a patient or as a caregiver know these kind of stories. So, in my view, if we really have the right knowledge in the right place at the right time, we can do a lot to make the work easier and provide better care. Then we get to the point described by Lukas, where real people actually benefit from better use of data and are not burdened by another admin process that comes on top.

Uli: Great, so from your perspective, this is about breaking the silos and enabling open knowledge transfer to directly benefit the patients, like in the moment when the patient walks into the practice or the hospital and you have to start from scratch, although most of the diagnostics would already be available. I think these are important points and already look forward to touching them again a bit later in our discussion.

But for now, let’s broaden the subject and also throw in a bit of controversy: According to a study done by the Bertelsmann Foundation in 2019, 600 hospitals in all of Germany are quite sufficient. In 2018, we were at around 1.900 hospitals according to the official statistics from  the German Federal office of statistics. This means around three times as much.

So how many hospitals are enough? Do we have too many in Germany or – since we are just coming out of the Corona crisis – do we actually have too few?

Henriette: I find it hard to respond with a concrete number to this question based on health economic research because a simple number does not necessarily reflect effectiveness and efficiency. In recent years, renowned scientists have probably rightly shown that we have room for maneuver in this area. Above all, we have very little downward development in terms of the number of beds under the introduction of DRGs. (editor’s remark: DRG = Diagnosis Related Groups, a system that was introduced to identify procedures for billing purposes in hospitals) Instead, more and more cases have filled the same number of beds. But I don’t like to go along with this fixation on the one number because the construct is too rigid for me. The takeaway from the Bertelsmann study has been that this discussion should be all about quality. Whatever I do often, I typically do well. Therefore, I should probably not do the highly complicated, rare operations in the community hospital.

Now, if you look at the situation after Corona, then we also have a changed discussion on the political level. It would be very difficult for me to argue why hospital locations or beds in the regions should be eliminated now. We need a reliable planning mechanism that is geared towards quality and, above all, data-driven: who is good at which type of procedure and who is maybe not so good at something or does not perform it as frequently. By comparing these two metrics, we may then get to new insights regarding the discussion about beds. Perhaps the new figure will then be higher than the 600 or even the 300 that are demanded by some in extreme cases. On the other hand, it will be more based on quality and data and therefore closer to the reality we have on the ground.

Lukas: Another aspect is that we have to ensure that patients are taken care of holistically. In my view, the question we should always ask is: What kind of health care system do we want? Is it all about economic efficiency or about good treatment? I believe that good patient treatment should be paramount in a system that is based on solidarity and community welfare. Particularly, against the backdrop of Corona.

I have just read an interesting article about Italy, where it was precisely this centralised system of clinics which has proven to be fatal. During the pandemic, all people have streamed into these large clinics and, if they have not been infected before, have been infected there via the so-called superspreaders. In other words, this efficient system, which everyone had previously praised, has turned out to deliver the exact opposite results in this situation.

And I absolutely agree with Henriette that we need to be more data-driven. Who is best at performing which type of procedures or treatments and who can develop further competencies in this area? This does not mean, however, that we should neglect the variety and strength of the federal system in Germany. In other words, we should analyze these KPIs very closely to recognize what is best. Perhaps this means that we will have care centres that also provide beds, but are not maximum care hospitals themselves. These are viable paths that you can take, especially, if you know which type of patients you have. Working in a data-driven way means to know: this might not be the best place to treat this patient, but I can send them to the right place in a smart way. A smart flow of patients, both in admission and transfer. I think that is where we ultimately have to go. Then, perhaps, the question of how many clinics or beds we need, will not be as important in the end.

Uli: So, it is not only about efficiency but also about quality and patient care. So, maybe we should focus not only on costs but other indicators that give a more holistic view of what we actually want to achieve instead of a mere number of hospitals.

Also, I found Lukas’s point very interesting regarding the control of patient flows. Behavioral scientists have been doing a lot of research on the use of incentives to drive behavior, e.g. to reduce the consumption of health care services through monetary incentives. In Germany, we had a “doctor’s visit fee” that required patients to pay a contribution of around 10 Euros for the first visit to a medical practice in a given quarter. This fee was abolished after eight years, following a long time of protests and controversy. So, influencing patient behavior through incentives seems to have a bad reputation in Germany. Why do you think that is?

Lukas: Incentives are a strange beast. As far as I know – correct me, if I am wrong – there is no study that has proven that this method of patient control, e.g. the doctor’s fee, has improved care in any way. To the contrary, it often results in patients that are in the lower income brackets to delay going to the doctor. Thus, it results in higher costs for the system because of illnesses that could and should have been treated early on. Therefore, I do not see how financial incentives help to improve patient flow and treatment. We should rather focus on preventive measures instead of creating new access barriers to treatment.

Henriette: Even if the concept of the “doctor’s visit fee” has by now been shifted to a copay on drugs, we are still trying to influence patient behavior with these measures. And very often, as Lukas has pointed out, this has a negative influence on patients with a lower socioeconomic status, which means that we are putting patients with less money at a disadvantage. This often leads to less regularity in drug intake, which can be a big secondary risk factor for patients with chronic diseases. Now, if you consider the fact that patients with a lower socioeconomic status tend to suffer more often from chronic diseases, then incentivizing these patients to reduce the regularity of drug intake can lead to a higher number of hospital stays induced by this irregularity. So, you aggravate the situation for patients and the system. This is a vicious circle.

Therefore, my approach to incentives would be different: why not focus on prevention and on positive reinforcement of behaviors that are actually beneficial to your health? For this we should dig a bit deeper and not only focus on financial incentives but also include the aspect of gamification. If you can collect points and get rewarded in a fun way, I feel that this helps more than just boring advice or negative reproaches.

Lukas: Furthermore, I would like to add that the whole system of complex co-pays typically increases the administrative burden for patients, doctors and the whole system taking away from the valuable time that could be dedicated to patient care instead.

Henriette: I totally agree. The administrative burden from documenting all activities is enormous. Do not get me wrong, I think that it is important to understand how patients were treated to get a view on results. However, the current focus is mostly on the monetary outcome instead of treatment success. The whole documentation does not contribute anything to answering the question of how well the treatment has helped the patient. This is only covered through medical studies. If you truly want to reap the benefits of digitalization, then at least part of the data should be used to understand how well we are helping patients with our treatments and not only focus on the financials.

Part two of this interview will appears in the next edition of Digital Germany here.