Patient coaching: Innovative approach for more efficiency in healthcare

In the first part of this series of articles, the direct, indirect and intangible consequences of non-compliance and non-adherence were presented and it was derived that the role of patients in the treatment process must be strengthened through targeted measures if individual and collective health goals are to be achieved more efficiently. Patient coaching serves this purpose as one of the methods in the portfolio of various so-called Health Management Services (HMS). Patient coaching is defined by the German Society for Citizen-Oriented Health Care (DGbG) as follows: “Coaching is intended to enable patients to recognize and achieve their individual health goals in the long term by learning to develop their own abilities and skills for self-management of the disease as well as to select and use offers and structures in a targeted manner in order to increase their quality of life." This second part uses examples to show which efficiency reserves can be expected from patient coaching and that health insurance companies have already integrated patient coaching into their care management as pilot projects. A classification matrix is presented to make coaching offers more transparent. Ultimately, numerous open questions are addressed that appropriate health services research could help answer.

>> Discount agreements between health insurance companies and the pharmaceutical industry, which experienced a new boom in 2009, increase the risk of uncertainty for many patients, with the result that they increasingly react with non-compliance and non-adherence and, as a result of forced product changes, more treatment discontinuations with all this resulting consequences occur.
Professor Dr. Harald Schweim, head of the Institute for Drug Regulatory Affairs at the University of Bonn, put it succinctly: “Compliance questions caused by product changes (e.g. “The tablets were always blue, why are they now yellow?” is the product right?”) and loss of trust in healthcare professionals (e.g. “My pharmacist gives me cheap stuff and charges expensively”) are the most serious.”
Schweim sees the limits of the interchangeability of medicines “always where, based on either the disease (e.g. in pain patients) or the individual personality of the patient, an exchange leads to negative consequences for the therapy, measured in terms of patient-relevant parameters. This is the case much more often than politicians, who usually have no medical background, imagine.

“… With a volume of around 30 billion euros in 2008, the health insurance companies will save around 300 million euros, i.e. around 1 %. And what economically uncalculated effort is behind this, just when you look at the costs that are not included in the retail stages, for example the extra work in the pharmacies? I wouldn’t be surprised if it’s a zero or negative sum game from an overall economic perspective.”
(Schweim 2009)

The German Society for Citizen-Oriented Health Care (DGbG) eV also pointed out at the beginning of 2009 that patient adherence to therapy is jeopardized by discount contracts and that discount contracts cause more harm than good. According to a study by pharmacists, the additional organizational costs of implementing discount agreements in pharmacies alone amount to over 650 million euros per year. In addition, there is the additional effort in medical practices (estimated at up to 200 million euros) as well as the costs of the tendering process for manufacturers and health insurance companies. Accordingly, the implementation costs - so-called transaction costs - of the discount agreements must be estimated at almost one billion euros, even with the greatest benevolence.
At this point, we would like to point out once again the indirect costs of poor adherence to therapy mentioned in Part 1 of this series of articles, which, according to Volmer, Kielhorn and Hochgrefe, include avoidable hospital admissions caused by medication not taken, avoidable care services, additional doctor visits and emergency admissions, loss of productivity, Loss of employment income and premature deaths include. (Volmer, Kielhorn 1998, 1999: 55) These financial consequences must therefore also be included in the national economic accounting. For example, periods of incapacity to work in 2007 led to production downtime costs of 40 billion euros or the loss of gross value added of 73 billion euros and expenses for statutory accident insurance providers of 12.52 billion euros. Even if only a fraction of these costs were caused by non-compliance and non-adherence consequences, this consideration can still provide an indication that the indirect costs of poor adherence to therapy should not be lost sight of.
These follow-up costs are offset by possible savings, which are somewhat nebulously estimated by the AOK Federal Association as a likely higher three-digit million amount over the two-year contract period, but which “cannot yet be quantified precisely”. Insider circles suspect that the savings will amount to a maximum of around 500 million euros. Extrapolated to all statutory health insurance companies, the total savings potential would, at a broad estimate, hardly be more than one billion euros, i.e. approximately the same or less than the costs of implementation. Even if health insurance companies incur fewer drug costs, this still means a zero-sum game in the national economy, perhaps even a negative-sum game, as the expert Professor Schweim has suspected (Schweim 2009). Unfortunately, the discount process with all its facets is not transparent in this respect. It would be a worthwhile task for health services research to shed some more light on this.
Like Schweim, the DGbG also comes to the conclusion that the restrictions on drug selection and medication changes due to discounts can lead to uncertainty for many patients, with the result that the already inadequate adherence to therapy can worsen. This is often the case for 31 % patients, and at least occasionally for another 38 %, as shown by a study by the North Rhine Association of Statutory Health Insurance Physicians on the effects of discount contracts.
If, on the other hand, it were possible to halve the non-compliance or non-adherence damage by specifically promoting patient adherence, this would probably save 5 to 7 billion euros in unnecessary expenses. In this respect, an economic cost/benefit analysis of the consequences of drug discount contracts in comparison to the possibilities of patient coaching, i.e. improving compliance or adherence, is useful. The comparison of the estimated savings potential of discount contracts and patient coaching clearly shows in favor of coaching and thus patient-oriented and efficient medication supply. (Fig. 1).
Instead of forcing patients through a complicated and bureaucratic system, the DGbG calls for greater patient involvement in therapy in order to improve results and efficiency in the sense of modern care management. Therefore, the meaning of the discount agreements and their great effort must be questioned in view of the serious disadvantages.
Three examples of patient coaching projects
There are already various offers on the market in Germany under the name patient coaching or similar synonyms. Patient coaching can be offered either on a freelance basis by independent providers or by coaches employed by a health insurance company or a service provider, for example. What is important is professional competence, independence and a commitment to the well-being of the patient. Unfortunately, there are still no generally recognized quality standards for patient coaching in Germany. However, there are now some training courses that are certified by the IHK. The DGbG aims to define, in consensus with experts and users, a minimum standard against which every offer can be “measured” and classified.
The following anonymized projects are offered by German statutory health insurance companies. The number of participating patients varies from health insurance company to health insurance company and, depending on the health insurance company, is between 500 and 3,500 participants. One challenge is to attract suitable insured people to a coaching offer. There are prediction models for identification, but experience in dealing with them is still rather limited. The hindrance is that patient coaching is cost-intensive and qualitative and economic results cannot usually be proven within the health insurance companies' tight planning periods. Data protection requirements must also be taken into account, which represent relatively major challenges.
Classification of patient coaching programs
Successful patient coaching requires good training, the coach's social, technical and methodological skills, the client's ability and willingness to change, clarity in the clarification of the order, suitable settings or framework conditions, transparency, voluntariness and confidentiality.
At the beginning of the coaching process, the individually desired behavioral changes must be formulated with the participant in sub-goals and regularly reviewed and the criteria for achieving the goals must be defined. The different medical needs and requirements of patients must also be taken into account, depending on whether they are temporarily acutely ill, chronically ill without suffering (e.g. diabetes without symptoms), chronically ill with suffering (e.g. rheumatic illness), life-threatening illness (cancer), mentally ill or are demented. Due to the complexity of these questions, further details of the training of the coaches and the coaching process cannot be discussed in depth at this point. For such a comprehensive presentation, a teaching and manual for patient coaching is currently being developed in the DGbG series of publications.
In addition, it must be critically questioned whether, where it says patient coaching, there really is coaching in the actual sense. The question is therefore whether the criteria for coaching are met according to a recognized definition. To create transparency, a classification grid can be a first aid. The DGbG patient coaching working group has therefore put together criteria that can be used to achieve an initial overview (see classification matrix - Fig. 3).
Open questions
A whole series of questions still need to be answered. Some of them are listed here as examples:
• What are the target groups for patient coaching
identified? - On what database?
• How are patients sensibly addressed?
• How can a fruitful collaboration between doctor
and reach coach?
• How is data protection guaranteed?
• How do you anchor the coaches organizationally/institutionally?
• Who pays for the coach’s services?
• How do you prevent the payer from influencing the coach?
• Who can be a coach? (Personal training requirements-
tongues, qualifications, training curriculum, quality
security, certification)
• Who controls the coach?
• Which measurement variables are used as criteria for the result
control in question?
• Limitations of coaching
• Code of conduct, ethical principles
Questions for health services research
Empiricism, common sense and logic suggest that patient coaching has considerable potential for increasing benefits and economic efficiency. However, these effects still need to be proven through appropriate accompanying research. This involves, on the one hand, describing the respective initial situation and, on the other hand, the question of how and based on which criteria the achievement of individual and collective health goals can be demonstrated through patient coaching in model projects. The prerequisite for a general implementation of patient coaching in the healthcare system as well as the development of the professional profile of a patient coach will largely depend on whether the expected qualitative and economic effects can be objectified. Compliance and adherence play a major role as process parameters. However, the quality outcomes and the benefits for patients based on defined criteria as well as the financial effects are more important. Since we assume that the behavior and circumstances of citizens can influence health outcomes up to approx. 90 % and the costs of non-compliance and non-adherence are currently between 10 and 20 billion euros, it can be assumed that the The effort for appropriate health services research will be worthwhile.
There is also a wide range of possibilities for the use of coaching services in the healthcare system between patient coaching for chronically ill and multimorbid people and health coaching that serves to maintain health and improve health literacy among citizens. <<