Financing added health benefits requires a distinction between quality and benefit

Quality and benefit are also frequently used terms in the healthcare system, with which we emphasize that significant resources are used to ensure optimal “quality of care” and to create “benefits” for those affected. Examples are the proportion of medical manpower (approx. 20%) that is dedicated to quality assurance and the expenses that arise as part of the approval of medicines for the creation of benefit dossiers (approx. 1 million euros/dossier).
Quality and benefit are therefore used as different dimensions of added health value, where quality could be a necessary prerequisite to create benefit, but benefit is not necessarily a prerequisite for quality. The increasing scarcity of resources in health systems requires not only the critical analysis of new expenditure, but also the justification of existing expenditure. The not insignificant expenditure on ensuring the quality and benefits of health services can no longer be accepted as an end in itself1. On the one hand, they must be subjected to a “clinical-economic” analysis, through which the effort and the returns achieved for patients and society are compared. In addition, the differentiated analysis of quality and benefit opens up new considerations for the financing of health services. In order to carry out this analysis, it is first necessary to describe what is meant by “quality” and “benefit” in the healthcare system.

>> While the benefit that one individual feels does not have to be felt equally by another individual or from the perspective of society, experts largely distinguish between good and bad quality.
Experts can distinguish between different qualities without directly comparing different goods or services, while laypeople can often only make this distinction if they can directly compare the quality of different goods or services.
The assessment of individual benefit follows different rules. Not only experts, but also laypeople can distinguish between high or low individual benefits that a good or service provides based solely on their own expectations. A direct comparison of different goods or services is not necessary to evaluate individual benefits. The assessment of individual benefit is based on individual expectations based on individual experiences or accessible information.
Quality and benefit are relative values
Both constructs, quality and benefit, can be understood as relative values because the relationship between an observed and an expected result is formed. Both constructs are ranked higher the greater the ratio between the observed and the expected result.
In the case of quality, the observed result is compared with the expectations of the committee that defined the quality criteria. In the case of benefit, the observed result is compared with the individual expectations of the actor from whose perspective the benefit is assessed2-4.
In general, it can be assumed that an actor's expectations relate to the most pressing problem that, from his point of view, should be solved. A patient will define the limitation of his or her own health as a priority problem. Hardly any actor in the healthcare system will contradict this, but will still make considerations that solve their specific, professional problem, for example the balanced balance sheet of their company.
The patient wants to be guaranteed the greatest possible “perceived security” in solving his health problem. Possible restrictions on his quality of life (intangible costs) will not be insignificant, while the monetary costs of diagnostics and therapy will be insignificant for the patient if these are covered by his insurance. From the perspective of other actors, the costs or e.g. B. the applicability of a new technology is given high priority.
If the usefulness of a good or service is not in doubt, its quality can hardly be questioned. On the other hand, no benefit can be postulated if quality is proven. This indication of the asymmetry between quality and utility is compatible with the higher information content of utility.
Quality and benefit therefore represent independent dimensions of added value, with quality corresponding to a largely objective dimension, while benefit represents a subjective construct. Quality can be defined largely uniformly and assessed by experts largely uniformly. Benefit, on the other hand, corresponds to a perception. However, it should be noted that relative values can be influenced by a change in expectations, ie by information alone.
The considerations described can only be the beginning of a comprehensive discussion because they are based on a selection of personally preferred aspects. Any scientific opinion not cited distorts the considerations offered, while any opinion cited creates the impression of objectivity. In order to avoid this inaccurate impression and to remind us of the incompleteness of our considerations, we have limited ourselves to a minimum of quotations in this commentary.
In summary, it can be deduced that the criteria for assessing quality have less variance than the criteria for assessing benefit. Individual aspects are more important when discussing different forms of benefit than when discussing quality. However, the evaluations of both dimensions, quality and benefit, can be influenced by information.
The importance of information and expectations
Expectations are shaped by information. A person affected who has no information about successful treatment options will neither expect it nor ask specifically about it. On the other hand, everyone affected will expect and ask for successful treatment options if even a hint of hopeful information is available to them. Whether the requested treatment option ultimately provides benefit depends on other factors.
Since the amount and quality of freely available information is almost impossible to control, any information will induce desired and undesirable effects. Information that benefits some or is perceived as an advantage by one actor can harm others or be perceived as a disadvantage by them.
Numerous examples from advertising confirm that expectations, preferences and needs can be influenced by information. This ability to influence quality and benefit through information must be taken into account5.
When quality and benefit are used as the basis for further decisions, there are incentives to influence the evidence of quality and benefit in a desired direction. Results that are based on opinions or other statements that are difficult to verify are of only very limited use for decisions because they are easy to influence. In order to identify the parameters that are suitable for assessing quality and benefit, the constructs of the two dimensions must be discussed.
The constructs of quality and benefit
The levels of quality
The variety of properties and topics that are subsumed under the umbrella of quality is almost unlimited. This diversity also applies to healthcare. Examples of quality criteria include patient satisfaction, organizational management and patient safety. These criteria can be assigned to the levels of structural, process and result quality that are applied and required by the Federal Joint Committee.6
Among these three levels, measuring the quality of results is consistently rated as difficult and is carried out significantly less often than measurements of structural and process quality. When deciding on the allocation of resources to finance a good or service in the health system, data on outcome quality are more helpful than descriptions of the other two quality levels. The considerations regarding the distinction between quality and benefit in health care have revealed aspects that have not previously been discussed in this form.
Since confirmation of benefit requires information that is described with outcome quality, outcome quality can be understood as a significant interface between quality and utility. In addition, information should be given on the influence of quality and benefit results.

The target groups of the benefit
Since the benefits that can arise from a good or service will have to be assessed differently from the perspective of an individual than from the perspective of a disease-specific target group or from the perspective of society as a whole, we propose to assess the benefits of health services from the perspectives of different target groups describe. Analogous to the distinction between different types of quality (structure, process, result), different types of benefits can be represented based on the target groups.
This distinction according to target groups can be justified because different dimensions of benefit can be achieved with different target groups, different verification methods are required, and different decisions can be derived from the benefits of different target groups (Table 1).
When individual patients are cared for, from the perspective of many actors there is an interest in achieving individual benefit for the affected patient. The methods commonly used in everyday care are sufficient to demonstrate this individual benefit. In many cases, confirmation from the patient that his health problem has been resolved will be sufficient. The evaluation of the person who provided the service should be less important because “it is not the chef, but the guest who should judge the quality of the steak”.
The question of the optimally chosen endpoint must be decided similarly for a patient group as for individual patients. It is often the cause of discussion because of the problematic objectivity1. However, no consequences for the care of other patients can be derived from proof of benefit for an individual patient. To demonstrate group-specific benefit, studies must be carried out to show which proportion of test subjects will only achieve the desired endpoint through specific intervention.
Methodological aspects are also often the subject of discussion. The choice of suitable methods and endpoints is not unproblematic because consequences for the care of other patients should be able to be derived from the demonstration of a group-specific benefit.
It is unclear whether a study to demonstrate the benefits of care under everyday conditions must be randomized, because although randomization reduces the risk of selection bias (internal validity), it increases other risks. Potential study participants with a strong preference are less likely than others to take part in a randomized study. This increases the risk of sampling bias. Study participants with a weak preference are hardly prevented from participating in the study by randomization, but they are more likely to achieve a desired study result in a non-blinded study if they receive the preferred therapy (placebo effect). The effect occurs in any non-blinded, randomized study in which the study participants' preferences for the different therapies are unevenly distributed2. This undesirable effect is not reduced by randomization, but rather increased. The non-trivial difference between randomized and non-randomized studies was described under the architectural slogan “Porzsolt et al. Form Follows Function” was published.
The concept of target group-oriented benefit assessment (Table 1) makes it clear that the health-relevant questions are different for different groups in society. The methods for answering these questions and the consequences that can be derived from them vary for individual patients, patient groups and for society.
At the individual level, the only thing that needs to be clarified is that if there are impending or existing health problems, help in some form can actually be provided. The question of the effectiveness of a specific service must be clarified at the patient group level. At the social level, the financial feasibility needs to be clarified. One could conclude from this that the assessments from all three levels are useful in assessing the added value of health services.
Possible consequences for the
health care
The problem of benefit assessment in different target groups
Since it would contradict a fair assessment to have the benefit of a health service assessed by the service provider themselves, the actors who provide a health service or evaluate the benefit of this service should also generally differ in the healthcare system. In many cases of acute illness, those affected can specifically name the health problem. In many cases, those affected will also be able to assess whether the health problem has been solved and will therefore be able to carry out a benefit assessment.
Ensuring the quality of care is anchored in law and integrated into the budget. In contrast, there are hardly any comparable programs to ensure the benefits of health services. Critical analyzes of both areas could come to the conclusion that existing quality assurance organizations should consider expanding the existing tasks to ensure the benefits of health services. This expansion could increase the value of spending to improve health care.
By comparing quality and benefit, considerations could be formulated that can be used to optimize health care. The most important of these considerations relates to the necessary consideration under which conditions available resources should not only be used to ensure quality, but ultimately to demonstrate benefit. These considerations are worthless if they do not ultimately help to increase the value we are currently getting from our healthcare spending.
In SGB V, the legislature specifies four criteria (economic, sufficient, necessary and expedient) that should be met in order to justify spending on health. It is required that
• the proportionality between effort and income or between monetary expenditure and added health value is maintained (economic)
• undercare is avoided, i.e. realistically achievable care results are aimed for using appropriate methods (sufficient)
• overprovision is avoided, ie unrealistic care results are not aimed for or inappropriate methods are used (necessary)
• the care fulfills the purpose of health care, ie it solves the existing health problem and thus creates benefits (appropriate).
This defines the framework conditions for both values, quality and benefit. It is our joint task to find suitable actors and methods through which it can be proven that the legal requirements have been met.
The available models are suitable for this purpose to a limited extent because they always contain assumptions that sometimes differ significantly from reality. Examples of this are the Quality Adjusted Life Years (QALYs), which are still used for benefit assessment in Great Britain, or the efficiency limits, which were favored by German authorities, or the currently discussed methods for measuring preferences, such as the Analytical Hierarchy Process, or the Conjoint and Discrete Choice Analyzes .
Each of these models is based on a different number of assumptions, all of which should be met in order to use the model. Reality is always similar to the model conditions, but never matches them. This digression is simply a reminder that models are helpful in depicting reality as a model, but not as reality.
However, the discussion also showed that the constructs of quality and benefit can be easily influenced by external influences, such as information. Not all of these influences can be controlled; However, their effects can be taken into account when evaluating quality and benefit.
If the suggestions made here to differentiate between the choice of quality or benefit assessment based on the intended purpose and to orient the benefit assessment towards the target groups are considered feasible, the risks of incorrect assessment of health services can be distributed across the shoulders of several actors in the healthcare system . This solution will be no less equitable than previous solutions, but will facilitate consensus on the assessment of health leadership.
Targeted coupling of health and compensation
The considerations about the interfaces between quality and benefit have led to unexpected results. It is undisputed that medical and commercial expertise is essential for the successful management of a healthcare business. It is also undisputed that commercial skills increasingly determine the success of a practice or clinic, because the indication for providing a diagnostic or therapeutic service is more often based on the agreed remuneration than on the promised knowledge gain or treatment success.
What was unexpected was that the analysis of quality and benefit could be used to develop a model for linking the health and monetary benefits of health care.
The monetary equivalent of a service should not be based on a promise7 - as is too often the case up to now - but rather on the fulfillment of the promise8. The fulfillment of a health promise could consciously be understood as an incentive to make sensible use of the controlling effect of our compensation system. However, the fulfillment of the promise must be verified.
The higher the monetary valuation of a medical success is, the more frequently the necessary services will be provided, provided that the perceived general conditions allow them to be provided. This trend is irreversible, firstly because the opportunities to make profits through health services are decreasing rather than increasing and because an economic agreement offers considerably more security than a promise based on uncertain scientific evidence. In other words, the development of health systems is on an interesting path because the values of different areas can potentially be combined in a meaningful and targeted manner.
The solution to the problem could be approached by switching from performance-based compensation to incentive-based compensation. In an incentive-driven system, services that are considered necessary are compensated significantly better than services that are classified as dispensable (Fig. 1).
The system should be designed as a learning system by continuously analyzing which of the services provided increase the effectiveness and added value of healthcare. If identical care outcomes are achieved with and without the provision of a specific service, the incentive-driven compensation for this service should decrease. Similarly, incentive-based compensation increases if care outcomes are improved through the provision of a specific service.
This system requires comprehensive documentation of the care results. This documentation can be guaranteed without any problems because almost all of the necessary data for performance remuneration is already recorded.
In order to manage the system fairly, the care goals must be based on the benefits for those affected and be confirmed or modified by a commission at regular intervals, for example at annual intervals, with the involvement of those affected.
The influence of medical or commercial decisions on quality and benefit in the healthcare system cannot be demonstrated without a discussion about the content of quality and benefit.
Paul Teirstein showed in the "New England Journal" of January 8, 2015 that although the certification of doctors can describe their quality with numbers, it is largely useless for patients. That's why it makes sense to start a discussion about quality and benefits. <<