In the second part of the MVF specialist congress “Prioritization Catalog of Health Services Research” spoke after Prof. Dr. med. Hon.-Prof. (DPU) Günther Jonitz (Medical School Berlin) Dr. Ursula Marschall (Barmer), Prof. Dr. Christoph von Kalle (SVR Health), Dr. H. c. Helmut Hildebrandt (OptiMedis AG) and Prof. Dr. Franz Porzsolt (ICE e.V.).

“How is the topic of patient needs anchored in the system?” Dr. started with this question. Ursula Marschall, head of the medicine and health services research department at Barmer, in her lecture, in which she focused on the patient's perspective.

Marschall: Quality of life in the area of tension between health and economic efficiency
In Marschall's opinion, the only point where quality of life can already be found in our healthcare system is the issue of quality of life in the area of the AMNOG process, but the general rule is: “We like to talk about patients, but we talk to patients less often .” Bringing the patient perspective into the innovation fund is therefore a challenge that must be faced. Your first question: “What could a patient ask not only us as a health insurance company, but also us in the system?” In order to find answers to this, the work of health services research is primarily needed. And also those that the health insurance companies themselves initiated. Marschall: “We don’t need health care research in an ivory tower, but rather clear representation and quantification of care deficits.” Because, says the Barmer manager: “Healthcare research is the beginning of changing care.” Funds have the immense advantage that data is available across sectors which can at least approximately represent the reality of care. However, this is with the restriction that only those details are included in the billing data.
information that is actually relevant to billing and revenue is documented. But that means that it is not enough to leave a data analyst, no matter how great, alone with health insurance data. However, the knowledge of how billing data can be used to generate important information for care is available in many health insurance companies themselves.
You also have to know that there is no uniform supply in Germany. Anyone who deals with health services research and especially the patient perspective not only has to generate meaningful data that applies to the whole of Germany, but also always represents regional peculiarities. This included information such as income, education and
social environments that could play an important role in generating solutions. Social data should actually only be stored for four years, but if you anonymize or pseudonymize it, you can also display longer time series.
When it comes to the Innovation Fund, one of the most pressing questions is why all of the data sources available in Germany are not networked. Your answer: Because it is anything but trivial. For example, in the “VersKiK” innovation fund project, statements are to be made about the long-term development of side effects in children with oncological diseases. To this end, an attempt is being made to link various health insurance data with that of the cancer registry in order to be able to make long-term statements about long-term side effects. Marschall: “If everyone involved didn’t have a cheerful obsession, we would have dropped all the spoons a long time ago and said that this question cannot be answered.” This is not only due to the data itself, but also to the amount given short project duration of 36 months, as well as the very practical hurdle of coding. Side effects of chemotherapy are usually not coded as such and are therefore difficult to find in routine data. That's why networking with cancer registries is absolutely necessary, but unfortunately this isn't even possible.
Marschall cited the “TRANSLATE-NAMSE” innovation fund project as another example. This project, which has now been completed and was designed and carried out with patients, could have demonstrated the benefits of exome sequencing. This type of sequencing can help find a correct diagnosis, which would otherwise usually take patients an average of eight to ten years. But now the project is over and the question must be asked as to how things can continue and how the networks set up for the project can be secured until the project at some point receives a hopefully positive recommendation from the G-BA for transfer to standard care. This is exactly where Marschall sees health insurance companies as responsible.
“How can we practically implement the patients’ legitimate wishes?” The Barmer researcher ended her lecture with this rhetorical question. In her opinion, data protection, collection and use must be designed in a patient-centered and flexible manner. Marschall: “We not only need data protection concepts, but also binding rules regarding access to data sources and their use.” Patients must also be involved in the innovation fund’s funding work at an early stage. There are applications in which patient participation is taken into account, but in which self-help groups or patient associations are not involved as consortium partners. This fails once again because of the benefit law because both groups are not approved service providers. In her opinion, discussing this role should be addressed urgently.

From Kalle: All-hazard approach
“Ultimately we came to the conclusion that we need an all-hazards approach,” said Prof. Dr. med. Christof von Kalle, director of the Clinical Study Center at Charité and BIH and member of the Health Advisory Council, should be considered. It is no longer enough to simply demand resilience to make the health system more resilient from one corona pandemic to the next. In times of climate change, wars and pandemics and consequences that can be related to each other, pressures would flow on the health systems that could only be managed with an all-hazards approach and a “Health in all Policies” strategy that focuses on prevention - and must include response measures. From Kalle: “We have to think about what different dangers can affect us – perhaps not at the same time – and how health can be thought of in all political measures.” You can read exactly what he means by this in the cover interview of this issue.
Hildebrandt: “participatory culture in the healthcare system”.

“The 10 most important questions for healthcare research from the perspective of public health and economic rationality” was the title of Dr. H. c. Helmut Hildebrandt (OptiMedis AG) gave his lecture. The first question that Hildebrandt wants to have answered from health care and systems research is: “How can the health and social system be prevented from being overburdened by an increasing burden of morbidity caused by demographics and lifestyles?” If this is to succeed, in his opinion, it must Prevention and health promotion should be organized across all social security systems. However, since there are large regional differences in the burden of disease, such an approach would also have to be examined regionally, deepened and then implemented.
His second question was: “How can the patient focus in care be systematically recorded?” PROMs and PREMs are important here, but also solutions that can improve communication between doctors and patients. In his opinion, there is a research gap between the psychometric validation of ever new measurement instruments on the one hand and the unreflective use and commercial expansion of PREMs and PROMs on the other. In addition, the outpatient area is still largely ignored. An evaluation also makes sense to find out how the data collected from patients can help doctors better assess symptoms, fears and physical functions. There is also a lack of knowledge about how PROMs can support patients’ self-reflection. On this detailed question, his company would be working on the patient-reported indicator survey that the OECD is currently developing.
His third question: “How can digital applications systematically and perhaps also in a hybrid form support healthcare?”
The fourth question: “Which specific measuring instruments and data sources can we use to systematically record the reduction in CO2 emissions from healthcare?” It should be taken into account here that every hospital stay that is avoided actually has a CO2-positive effect. But so far, the question of organizing supply processes has not been considered from the perspective of climate protection, which would make successful CO2 prevention possible overall.
Fifth question: “How do we create interest among service providers in improving the health situation of their regional population?” One problem, of course, is that every doctor does not pay attention to the collective, but rather to the individual patient. What would certainly have advantages for the individual would have the disadvantage that the focus on the collective of insured people in a region would be lost. In general, it can be stated that the current view of everyone involved - health insurance companies, politicians, service providers - is oriented towards the input, although the interest of the stakeholders must be more on the outcome. Hildebrandt: “How do we create more interest in this?”
“Which early indicators can we use to determine success in improving the health status of a regional population?” was his sixth question to healthcare research. The age at death is not a rapidly changing leading indicator, which is why other indicators have to be found in order to be able to detect differences for the numerous subgroups and evaluate their respective health outcomes. A previously unnoticed early indicator emerged, for example, in the analysis work in Kinzigtal: the starting point of long-term care. In a comparison between participants in one of the Kinzigtal health programs and a control group, it was found that the intervention group remained at the starting age of 71 years, while the others increased to 75 years. Hildebrandt added that both groups had the same information about the options for levels and levels of care in the region.
Seventh question: “Which competitive incentives actually lead health insurance companies to support their insured persons in their health better than their competitors do?” And, according to Hildebrandt’s addition: “Which false incentives hinder them in doing so?” So the morbidity-oriented risk structure compensation would be for one ensure a fairer distribution of resources, but make it possible to increase allocations through coding. It would be better to develop and implement a model that would incentivize health insurance companies more than they do today to invest intensively in the health of their insured people.
Eighth question: “Which international best practices have proven how optimized outpatient and preventive care can avoid emergency room visits and hospital admissions?” In general, in his opinion, the comparative view of results from abroad is not very pronounced in this country.
Ninth question: “Which international experiences can be used in Germany to change the orientation of as many service providers and health care providers towards the health benefits and value generated?” For example, it could be analyzed what effects the accountable care strategy has in the USA really produce. And how the assessment of the outcome benefit changes the thinking and actions of the relevant service providers. This is also primarily a question of incentives and therefore payment. An inside report entitled “The Moment of Truth for Healthcare Spending” was published at the World Economic Fund in Davos. The question of how different payment models could change the healthcare system will be examined here. Hildebrandt: “The economic basis shapes to a large extent the culture that emerges from it.” In this respect, we urgently need to devote ourselves to this topic.
This brought Hildebrandt to a final question: “Which forms of management and which culture between health insurance companies and service providers and between them and their employees appear to be the most promising when it comes to understanding citizens as producers of their health?” If citizens are to become co-producers of their health, this means that a working alliance must be developed. However, this can only happen if there is communication on an equal footing with the people to be cared for and everyone involved in the provision of the service. Hildebrandt's demand: “We need a participatory culture in the entire management of the healthcare system.”

Nagel: ChatsBots that are changing the world
Roland Nagel addressed the virtual audience of the congress with a lecture of a completely different kind. Under the title “Data makes the world go round? “What data can and cannot tell us,” the managing director of the Leipzig Health Forum had the OpenAI chatbot ChatGPT ask the most pressing questions that could move our healthcare system forward.
Open artificial intelligence generated the following 10 general questions for healthcare research:
1. What results do healthcare research projects achieve in terms of costs?
efficiency and quality of healthcare services?
2. How can the results of health care research best be integrated into the health insurance companies' care strategies?
3. What new approaches can be derived from health services research projects to improve the quality of care?
4. What factors influence health insurance companies' decision-making when implementing health care research results?
5. Which new technologies can support the results of health services research?
6. What role do health services research projects play in the development of guidelines and standards for care?
7. What new ways can be derived from health care research projects to promote patient participation in care programs?
8. How can the results of health care research best be integrated into the health insurance companies' prevention and health promotion programs?
9. What research results can health insurance companies use to optimize and standardize care processes?
10. How can the results of health care research best be used to ensure sustainable and efficient care?

To challenge AI even more, Nagel asked ChatGPT a question that Prof. Dr. Wolfram Herrmann from the Platform - Charité Health Services Research asked in his lecture, given in the first part of the MVF online congress (December 13, 2023): “How do we ensure that the (vulnerable) patients who need it most , get the best form of prevention, diagnostics and therapy for them?" The answer from artificial intelligence: "In order to ensure that vulnerable patients receive the best possible prevention, diagnostics and therapy, several measures must be taken. First, patients' needs must be identified and assessed to identify the most appropriate treatment. Available resources and financial means must then be assessed to decide which treatment options are best suited to patients. Furthermore, collaboration between all stakeholders, including patients themselves, should be improved to enable better communication and coordination. Finally, measures should be taken to ensure that patients are monitored appropriately and receive the best possible care and support.”
According to Nagel's comment, there are certainly many generalities among the questions and answers, but it should be noted that the technology is still relatively young and the results are quite impressive. Even if all the results that today's AI machines can deliver require qualification and must be questioned.
In his opinion, the way data is handled will also change the field of health services research. There are now synthetic study data, digital twins and medical robots. And now also completely new ChatsBots, which will also change the world of diagnosis. How the various options can be combined is a broad field that is becoming increasingly relevant in the context of health services research and that urgently needs to be addressed.

Porzsolt: Three recommendations for prioritization
Who Prof. Dr. Franz Porzsolt knows that the experienced oncologist and methodologist comes from Ulm. It was no surprise that in his lecture, which he gave with his ICE colleague Prof. Dr. Manfred Weiss referred to another, much better-known Ulm native: Albert Einstein, born there in 1879. In his decades of work, Porzsolt, who was a member of the board of the tumor center for ten years and, after his retirement, founded the Institute of Clinical Economics e. V. (ICE) always remembers a quote from Einstein that says: “You can never solve problems with the same way of thinking that created them.” Scientists who, like him, follow the Sackett school of evidence-based Medicine graduates should also have personally experienced that most research projects fail due to the vague formulation of the question.
This is exactly what Porzsolt and Weiß want to change with their “Three Recommendations for Prioritizing Health Services Research Projects”. Since the core problem has always been the financial viability of the health system, it can only be solved through a broad consensus - on the one hand national, perhaps even European. Above all, there needs to be a consensus that is no less difficult to establish to measure the added value achieved, which will only be politically supported and socially accepted if it is scientifically justified.
Therefore, in the opinion of Porzsolt and Weiß, the goal of health services research should be to demonstrate the added health value achieved. However, the “real world effectiveness” meant by this is not the proof of the effective principle that has been the aim so far. Porzsolt: “With randomized studies we can demonstrate efficiency or proof of principle, but certainly not real world effectiveness.”
To make the difference clear, Porzsolt referred to the well-known epidemiologists Sir Archie Cochrane and Sir Austin Bradford Hill in his lecture. The two stated that no new interventions should be established in health systems until three questions have been answered: Can it work? Does it work? Is it worth it?
The first question is answered by clinical research by proving the principle of action, which happens in an experimental study, a randomized controlled trial. The second question about “does it work?” is answered in the field of health services research – through proof of “real world effectiveness”. But never under experimental conditions, but always under real everyday conditions with their unstructured conditions of natural supply chaos. Porzsolt: “We are talking about care chaos because every patient has a different risk profile than the other, and every doctor uses a - often just a little - different strategy to manage this disease or problem, which inevitably leads to leads to different outcomes.”
According to the methodologists, in order to demonstrate real world effectiveness, four threshold values must be presented:
• the existence of a problem and
• the successful reduction of the problem requiring care and the added health value achieved.
Two additional threshold values are necessary for this:
• the clinical relevance (hypothesis) and
• the statistical significance (confirmation).

The rule is that for each piece of evidence, a clinically relevant, at least minimal effect must be defined, which can then be described using statistical methods. However, it is definitely feasible to evaluate the results of real care and to create structured conditions for this. What sounds almost like squaring the circle is possible through controlled, non-experimental observational studies (Bayes statistics) and pragmatic controlled trials, with which one can find a solution to the supply-analysis conflict.
His advice to health services research: “It is not enough to prove the principle of action in randomized studies, because proof of the added value achieved must be provided. However, this is only possible in controlled observational studies. In addition, added value can only be proven if data from the threshold quartet described is actually collected and reported back." <<
from:
MVF editor-in-chief Peter Stegmaier