>> “This is perhaps the beginning of a long and wonderful friendship,” explained Thomas Ballast, deputy chairman of the board of the Techniker Krankenkasse, in his welcome. However, he meant the fund itself, not the actual co-organizer, the TK Institute for Benefits and Efficiency in Health Care (WINEG), whose days are numbered. According to Ballast, their employees will be redistributed to individual departments, also because health services research is no longer seen as just a tip of the spear, but the entire TK should become an organization that deals with health services research; also as a “sign that we want to continue the successful work of WINEG within the larger framework of TK”.
As co-organizer of the forum, Ballast wanted to allow himself the freedom of research, to talk purely about the benefits, or more precisely about the topic that “a maximum of medicine does not automatically have to bring about the optimal result”. This was contradicted by keynote speaker Prof. Dr. mult. Eckhard Nagel, managing director of the Institute for Medical Management and Health Sciences at the University of Bayreuth, only partially. He spoke about the “measure of things” and “sensible medical care in the age of scientific progress”, but explained right at the beginning: “We cannot ignore the economy.”
However, anyone who wants to talk about the “measure of things” must first define what actually makes sense. According to the theologian and physician, this begins with a very fundamental question that can often be transferred to medicine: “What makes people special and what makes their life meaningful?” Only when this question has been answered can one talk about it. What constitutes sensible medical care always depends on the position of a particular person and the position of society. Over and beyond
There are a number of points that play a role in the discussion of the measure of things. Nagel: “First of all, that is the question of benefit, but similar to the meaning, you can also see the benefit from different perspectives.” This also includes the expectations of patients, which everyone involved in the healthcare system is confronted with. Another important point for Nagel is that this important topic should not remain in a professional discussion that takes place exclusively in specialist circles because health is one of the existential goods such as justice and freedom. “Health is a basic requirement for a successful life, and is therefore not only important for individual lives, but something that we as a society want to protect as a whole.”
Nevertheless, we have to talk about access, expectations and restrictions. Because it is precisely in this area of tension that one moves in the search for the “measure of things”, but – according to Nagel: “Expectations have no measure”. Therefore, one always has to look at how and whether it can be possible to put “the articulated excessiveness” – which he does not criticize, but which he stands behind – into a tradable context without being permanently disappointed, especially as one in one's existence endangered individual. It is not only a medical obligation, but also a social obligation to do everything that makes sense with regard to the patient who is in existential distress.
“You'll say that's a nice measure of things if it means everything,” says Nagel, and continues: “But the word 'everything' is limited by the term 'sense'." For this reason alone, one always has to differentiate, which really helps. Sometimes the best help would not be active action, but rather the classic concept of assistance, of mercy, as the focus of what we strive for. Hot mercy means nothing other than, despite all medical progress, at the appropriate time “not necessarily having to act, but rather providing appropriate accompaniment and support”. Nevertheless, Nagel warns against seeing medical progress as a cost driver, which is also not the truth given that the share of gross domestic product has remained fairly constant over many years.
If one wants to approach the “measure of things” and thus the benefit debate, the underlying benefits must be defined in terms of the meaningfulness of what we do. To do this, formulas must be developed to take EBM and other aspects into account. All of this is legitimate because comparability is fueled by rationality, not emotionality. But in the end, not everything can be taken into account in an appropriate formula. This applies above all to the preferences and self-determination of patients, who have to decide for themselves with regard to the ultimate meaningfulness and answer many questions themselves: with regard to the ability to tolerate pain and isolation. And in dealing with the existential crisis? According to Nagel, in the end only one term comes into play for the treating doctors: What justification is there for carrying out a specific medical procedure? This is the only important and relevant “measure of all things for the medical treatment order”. Can this be profit motive? Nagel answers this categorically: “I am convinced that we need a discussion in this country about whether everyone who makes a corresponding offer in the healthcare sector can have an expectation of profit in line with other service areas. I answer that with no.”
But we are far from there yet, as an analysis of health insurance billing data from patients who were treated as inpatients for tumors and died in the clinic showed. The focus, presented by Prof. Dr. Roland Linder, focuses on the last two weeks of life: at around 6 %
Of those affected, i.e. one in sixteen, chemotherapy was restarted shortly before death. Radiation therapy will be started again for just as many. And 4.5 % of the patients, i.e. one in twenty-two affected, were resuscitated at least once. “Extrapolated to the Federal Republic, it is estimated that more than 36,000 terminally ill people are affected every year, for whom very stressful therapies associated with serious side effects and complications are started again within the last 14 days of their lives,” explained Linder, still-WINEG and soon to be healthcare researcher the TK. According to him, these figures show that how patients are treated at the end of life is a relevant issue. Linder: “There are people behind all the numbers. Their well-being and wishes must be the focus.”
In addition to end-of-life care, the symposium also discussed the use of antibiotics in outpatient care and, in particular, the question of the actual benefit of polymedication for people who suffer from several illnesses at the same time. Analyzes based on anonymized routine data from the InGef research database, which Dr. Jochen Walker, managing director of InGef, showed that the number of active ingredients prescribed correlates strongly with the number of diseases and the number of treating doctors. “Seasonal variations in antibiotic prescriptions and the increasing proportion of prescriptions for reserve antibiotics make it clear that there is further potential for improvement here too,” explained Walker.
The question of how much therapy ultimately serves the patient's well-being was a common theme throughout the entire event. “The maximum possible medical care does not have to be the optimal care for the patient in his or her specific situation in every individual case,” stated
spectrumK managing director Yves Rawiel concluded in his conclusion: “The decision for or against a therapy should always be made jointly by the doctor and the patient.” Thomas Ballast added: “To support doctors in these complex decisions, there are platforms for exchange between practices and health services research – such as the symposium on practical health services research – is invaluable.” <<

Citation note.

Stegmaier, P.: “Nagel: Expectations have no measure”, in: “Monitor Healthcare Research” 03/18, pp. 38-39, doi: 10.24945/MVF.03.18.1866-0533.2080