Citation: Grote Westrick, M., Volbracht, E.: “Overcare harms patients and society – a search for clues”, in: “Monitor Healthcare Research” (01/20), pp. 61-67, doi: 10.24945/MVF.01.20. 1866-0533.2204

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>> The complex of overcare includes not only the potential for harm to the individual patient but also a social aspect. Financial and human resources are tied up and are therefore no longer available for better use. In current studies, the Bertelsmann Foundation approached the complex issue of oversupply with the following questions:
• In which areas is oversupply particularly visible?
• How do patients and doctors perceive the topic?
• What are the drivers and causes of oversupply?
• What measures can be taken against it?

Our analysis of the oversupply problem in Germany followed a combined study approach.
1. Literature analysis: The IGES Institute investigated evidence of oversupply in Germany and analyzed six medical areas in more detail (Bertelsmann Stiftung 2019).
2. In-depth interviews: In the summer of 2019, the Rheingold Institute asked 24 patients and 15 doctors in two-hour in-depth psychological interviews about how they perceive and experience oversupply (Hambrock 2019).
3. Telephone survey: At the beginning of September 2019, Kantar conducted a representative survey with a total of 1,004 people aged 18 and over using Computer Assisted Telephone Interviewing (CATI) (Kantar 2019).
There is numerous evidence of oversupply

In the analysis by the IGES Institute (Deckenbach et al. 2019), medical areas were identified that exemplify the wide spectrum of unnecessary service provision (see Table 1). Indications were selected for the inpatient area where, according to experts, there is a discrepancy between the actual number of operations and the necessary interventions. For example, For example, in thyroid operations, only about ten percent of all procedures actually result in malignant changes. Unnecessary screenings and a lack of in-depth diagnostics are considered to be the causes of premature surgery.
Even when it comes to IGe services, the benefits of which have not yet been clearly proven or are even questionable, there are many signs that they are “too much”. Around 15 million such services are provided every year. Patients pay around one billion euros for this. However, a number of consumer advocates and the IGeL Monitor of the Medical Service of the Federal Association of Health Insurance Funds criticize, in addition to the lack of evidence of benefits, the lack of transparency and the aggressive marketing by doctors and practice staff. Ultrasound examination of the ovaries for early cancer detection, for example, is the second most common IGe service and is performed more than two million times per year, often deviating from guideline recommendations. The examination carries a significant risk of false-positive findings and unnecessary follow-up procedures - which in turn can unsettle and psychologically stress patients. So far, only about ten percent of women who have undergone surgery actually have ovarian cancer; In 90 percent the suspicion is not confirmed.
The Bertelsmann Foundation also investigated the question of how patients and doctors perceive the issue of oversupply. In the population-representative survey, around half of the citizens agreed with the statement that medically unnecessary services are (very) often provided in doctors' practices and clinics (see Fig. 2). In addition, 59% of the population believe that too many medical services are carried out that are of no use to patients (Kantar 2019).
However, in-depth psychological interviews revealed that many patients are hardly aware of the fact that they may have already received unnecessary medical services when providing their own care (Hambrock 2019). They tend to demand a lot of services and largely consider these to be important and necessary. Patients' lack of awareness of excessive care in their own treatment can also arise from the fact that many patients are not able to critically question the medical services on offer (Ellen et al. 2018). In an international study, 54 percent of participants from Germany stated that they had considerable difficulty dealing with health-related information (Schaeffer 2018).
Oversupply has many reasons
The representative survey and in-depth interviews have clarified some of the causes and influencing factors for oversupply. Fears, health literacy, legal aspects, but also deeply rooted beliefs such as “More and newer is better” or “Action is better than doing nothing” play an important role (Hambrock 2019, Kantar 2019). In addition to these “cultural” factors, there are a variety of other influences and causes of oversupply (Gerber et al. 2016, Saini et al. 2017, Pathirana et al. 2017, Alber et al. 2017). Care structures and processes, commercial interests, medical technology developments, unclear evidence and disease definitions influence care and the individual doctor-patient interaction to varying degrees. The variety of areas of influence and factors is summarized in Fig. 3 and some aspects are briefly described in the following section.

Systemic framework conditions
The framework conditions of the health system influence what, where and under what conditions medical services are provided. The degree of insurance coverage and the scope of the service catalog play just as much a role as the size and distribution of structural and personnel offering capacities - hospitals, specialist and general practitioner practices, large equipment - as well as the coordination and information flows. Compensation incentives can also influence the quantity and quality of services provided.
Too much hospital capacity: In the hospital sector, excess capacity as well as insufficient concentration and specialization are criticized (Scientific Advisory Board 2018, SVR 2018, Loos 2019). The pressure to utilize existing capacities often leads facilities to attach medically inappropriate importance to economic considerations and to compensate for a lack of investment funds by expanding the volume of services (Scientific Advisory Board 2018).

General practitioners and specialists not distributed according to needs: In order to provide patients with the care they need, the even distribution of established general practitioners is more important than that of specialized specialist services (SVR 2018). However, over the past few decades, the ratio of general practitioners to specialists in this country has deteriorated to the detriment of primary care. There is also a spatial maldistribution of supply capacities with an oversupply in metropolitan areas and an undersupply in structurally weak regions (SVR 2014).

Quantity-related compensation incentives: Financial incentives for doctors and hospitals – and their behavior in line with incentives – can lead to overprovision (Saini 2017). Quantity-dependent remuneration such as individual service remuneration and flat rates per case encourage people to carry out medical services, even if they are not medically indicated. In our quantitative survey, 83% of the population suspect that medically unnecessary services are carried out because doctors and hospitals make good money from them (Kantar 2019).

Poorly coordinated care: Oversupply, structural problems and poor coordination manifest themselves, among other things, in the form of avoidable emergencies and hospital stays. These often result from structurally weak primary care and poorly structured and coordinated management of patients. Germany is probably one of the few countries that, with inpatient care and the system of resident specialists, has two structures with overlapping tasks without the respective responsibilities being clearly regulated (Scientific Advisory Board, 2018). The DEGAM guidelines for protecting patients from over- and under-care also see uncoordinated, specialist medicine as a source of over-care. The German healthcare system in particular, with its lack of a primary medical system and strong competition, leads to an uncoordinated coexistence due to the fragmentation of care and thus to under-, over- and incorrect care (DEGAM, 2019).

Low level of digitalization: The low level of digitalization attested for Germany also makes it more difficult for patients
control (SVR 2018) and thus promotes oversupply. Inadequate information exchange leads to unnecessary additional anamnesis interviews, duplicate examinations, worsening of the condition and avoidable additional treatments. The management consultancy McKinsey estimates that the use of digital technologies in the German healthcare system could save up to 34 billion euros annually. The greatest potential for use are electronic patient records and electronic prescriptions as well as web-based interactions between doctor and patient (McKinsey 2018).

No systematic provision of patient information: The German healthcare system has not yet been designed to proactively provide patients with information that is relevant to them. Studies show that good information and adequate patient involvement in the decision-making process increases patient satisfaction and compliance, reduces unnecessary care and unwanted regional differences (Fisher, 2018). Patients choose less aggressive and invasive therapies, thereby also reducing healthcare costs (Arterburn, 2012, Stacey, 2017).

Medicalization, overdiagnosis, unclear evidence drive overcare
Medical and technological developments can also promote oversupply. This concerns the pathologization of health conditions and the expansion of disease definitions, overdiagnosis and its follow-up activities, the handling of unclear or new evidence, and the influence of companies on medical knowledge and actions. Risk factors such as illnesses are treated and people without recognizable signs of illness are screened (Alber 2017). This underlies the intuitive narrative of the supposed benefits of early diagnosis and intervention, which has a lot of support both in the medical profession and in the population. However, participants in early cancer detection examinations are either rarely or not sufficiently informed about the benefits and possible disadvantages of the examinations. This is confirmed by a representative survey of more than 2,000 legally insured people for the “Early Detection Care Report” by the AOK Scientific Institute (Günster 2019).
Overuse can also be facilitated by insufficient knowledge or lack of consideration of the current state of evidence. In addition, medical evidence is often subject to varying degrees of uncertainty (Bedford et al. 2011) and many medical measures are not backed by evidence from clinical research. It is therefore possible that services with little benefit or high potential for harm are widespread and accepted, while other benefits that provide benefits are not (Eikermann 2019).

Cultural aspects and thought patterns influence oversupply
Attitudes, behavior and decisions of patients and doctors are subject to culturally influenced attitudes and developments. They shape demand and the actual provision of services. The survey and in-depth interviews have clarified some cultural causes and influencing factors for oversupply. Fears, affection, care, uncertainty, legal aspects, but also deeply rooted beliefs such as - more and newer is better - action is better than doing nothing - play a role. They influence the awareness of patients and doctors and their (often unconscious) demand for (over-)care (Hambrock 2019). Above all, patients want attention, care, active help and to be taken seriously from their doctor. Doctors and patients unanimously said in the interviews that active action is often better than waiting - which they equate with doing nothing (Hambrock 2019). The attitude is supported by the results of the population survey: 56% believe that any therapy is better than waiting and doing nothing (Kantar 2019).
There are deep-rooted, intuitive attitudes about the benefits of treatments (Saini 2017), such as more is better/new is better/more expensive is better/technology is good. The representative population survey confirms some of the beliefs: 62 percent of those surveyed agree with the statement that the benefits of treatment are often overestimated and its risks are underestimated (Kantar 2019). The qualitative survey commissioned by the Bertelsmann Foundation on the topic of oversupply shows similar thought patterns that both patients and doctors follow (Hambrock 2019). Patients often believe that many measures help a lot, especially in the area of diagnostics.

Indications have a special significance
Doctors are responsible for making needs-based and resource-conscious decisions based on scientifically based, individually tailored indications. The indication is the result of a complicated mix of scientific evidence, available resources, doctor and patient preferences, the care organization and financial conditions (Saini, 2017). By choosing how to proceed, doctors also decide whether a – possibly unnecessary – care cascade is set in motion (Alber 2017). It is estimated that physicians account for approximately 80 percent of healthcare costs (Crosson 2009). This means that the ultimate responsibility for making needs-based decisions and avoiding oversupply lies largely with doctors. The doctor-patient interaction is therefore a central starting point for reducing overcare (Lakhani 2016). Rheingold's in-depth interviews show that, beyond medical requirements, aspects such as care, comfort, caring and promoting the doctor-patient relationship play a role. But your own fears are also important to refrain from and financial aspects are important, especially when they meet patient expectations and pay off on the doctor-patient bond (Hambrock 2019). Even if some doctors denied in the in-depth interviews that oversupply was occurring in their own practice or clinic, everyone is aware of the problem. For many, the term is an irritating topic. The extent to which a doctor provides services that are not medically necessary depends on his assessment of the medical indication, the perceived pressure of expectations, time and finances, as well as his self-image as a doctor.
How can oversupply be avoided or reduced?
Overcare has significant consequences for individual patients and society. There are numerous international approaches to reducing oversupply. Many organizations have developed projects or campaigns (Wild and Mayer 2016). Due to the complexity of the problem and the variety of causes and influencing factors of oversupply, an equally diverse range of solution approaches is required. Changing systemic, organizational and cultural conditions requires an appropriate cause analysis and targeted implementation strategies (Ellen et al. 2018, Elshaug et al. 2017). Numerous measures are already being discussed in politics and the healthcare system, particularly the reduction of excess capacity in the inpatient sector and a more stringent focus on quality of care. The Health Advisory Council recommends
for a long time now there has been a more decisive, needs-based control and a modification of remuneration. It is not the quantity but the quality of performance that must be rewarded. Patient well-being must be the primary goal of care.
The general conditions of health care are among the key drivers of overcare: the number and distribution of hospital beds and doctors, the disconnected coexistence of outpatient and inpatient care structures, but also the way medicine is taught, provided and remunerated in Germany. The German healthcare system in particular, with its lack of a primary medical system and strong competition, leads to an uncoordinated coexistence due to the fragmentation of care and thus to under-, over- and incorrect care (DEGAM 2019).
In view of the oversupply in small and medium-sized hospitals, especially in metropolitan areas, it is recommended to reduce inpatient overcapacity, concentrate the range of services on fewer locations and convert hospitals into non-acute inpatient care facilities (SVR 2018, Loos 2019).
Improvement strategies should also address the actors involved and factors that control behavior. This includes economic and financial incentives that influence the behavior of patients, doctors and managers as well as organizational factors, education, training and information aspects. In their review article, the group of authors led by Elshaug (2017) also calls for addressing systemic drivers such as the number and distribution of hospital beds and doctors as well as the diverse incentives that affect doctor-patient interaction. Furthermore, doctors and their professional organizations are considered to play a key role in preventing over-provision in everyday care, in developing guidelines and implementing them.
The doctor-led Choosing Wisely initiative represents a promising approach to reducing overprovision. The campaign was started a few years ago by doctors from the USA and Canada. The approach has now become international
nally widespread, for example in Australia, Italy, the Netherlands and also in Germany. The core element of Choosing Wisely - in German "smart decision" - are lists developed by medical societies with services that should be questioned and, if necessary, not provided for the benefit of the patient. The challenge is to develop clever measures for everyday clinical and practice life so that patients no longer receive services that are of little or no use to them - or even harm them. Good information and information flows are considered a key to improving needs-based care and reducing unnecessary care. Experts are therefore calling for an expansion of the information infrastructure for patients, speaking medicine, a strengthening of shared decision-making and interdisciplinary coordination (Nothacker 2019).
The implementation of solution approaches is considered challenging due to the diverse systemic factors, the “more is better” culture that exists among the population and medical profession, and the limited willingness of political decision-makers to make politically difficult decisions (Ellen et al. 2018). A necessary prerequisite for solutions is that all institutions and people who bear responsibility for over- and under-provision accept this responsibility and recognize that they can and must contribute to solving the problem. In Germany, these include the federal and state health ministers, the patient representative of the federal government, medical self-administration, i.e. medical associations and statutory health insurance associations, health insurance companies, joint self-administration, medical specialist societies, patient representatives, patient groups and health self-help as well as doctors, patients and citizens (Klemperer 2015 ).
Against this background, the Bertelsmann Foundation believes that the following measures against oversupply are particularly necessary in order to endanger patients less, free up resources and enable needs-based and appropriate care:
Optimize planning and reimbursement: Health care should be planned and organized based on needs and across sectors. This includes hospital planning, the number and distribution of doctors, the control of patient routes and the planning of large-scale equipment and new examination and treatment methods. The remuneration for services must also be based more closely on their quality, especially the quality of the indication.
Clarify evidence: The benefits and risks of medical services must be made more transparent. This requires more systematic and sometimes mandatory information and decision-making aids that must be easily available to doctors and patients.
Assuming ethical responsibility: Doctors have a responsibility to discuss the benefits and risks of relevant treatment options with their patients. You should transparently explain your own potential conflicts of interest.
Avoid useless services: Practices and clinics should develop strategies to de-implement services that are proven to have little benefit and too many risks for patients. Second opinion procedures to confirm the indication must be expanded.
Raise awareness among the population: Patients must be made aware of the potential harm and risks of examinations and treatments. You must realize that it can be better and means just as much care if a medical procedure is omitted. <<