Key figure management in healthcare – controlling the care process

The typical fields of action in health economics include the evaluation of care processes with regard to their cost-effectiveness and the development of process changes and incentive systems in order to trigger economic and quality-oriented behavior of all those involved. The aim is to use the resources available in such a way that the best possible healthcare can be achieved.

>> In addition to the scientific and expert treatment of these topics, it is now also part of the responsibility of the cost bearers to evaluate and compare care processes in order to be able to offer their insured persons the best possible care. Key figures that map the care process can be used to operationalize this task.

The German healthcare system is distinguished
through strong sectorization

The German healthcare landscape is traditionally divided into sectors, specialist disciplines and professional groups. On the one hand, this has led to care for the insured that is strongly driven by special interests, and on the other hand, to a lack of knowledge about a patient-centered care process. The perspective of the individual actors in the healthcare system is therefore also strongly focused on their respective spheres of influence. There is a systematic lack of endpoint consideration of the care process that is relevant to the patient.
This segmented view separates, for example, outpatient treatment from hospital treatment and rehabilitative care, even though an illness may require treatment in all areas. There is further differentiation within a treatment sector: care is provided by different specialist disciplines (family doctor, various specialists), professional groups (doctor, nursing, physiotherapy) and with the help of different benefits in kind (medicines, aids). All of these services and service providers are perceived individually and also represent their interests across sectors. Individual decision-makers often lack knowledge of upstream and downstream care episodes.
However, caring for a patient is a process that requires integrative and comprehensive care. The patient receives services from different service providers from different sectors; from the patient's perspective, it is a single overall process. In contrast to this, in its 2000/2001 report, the Advisory Council described supply deficits in the German healthcare system, which can often be localized at the respective interfaces between sectors, specialist disciplines and professional groups (Sachversichtenrat, 2002).
To remedy the identified supply deficits, several legislative procedures were initiated. Examples of results include family doctor-centered care with an integrative approach and integrated care with a comprehensive approach.

Performance management metrics
are collected on a sectoral basis

Key figures can be developed and used to control the supply process. In the healthcare sector, these key figures primarily reflect the three dimensions of finance, performance and quality. However, in their presentation, the key figures predominantly imitate the sectoral structure of the German healthcare system, particularly because the data from which the key figures can be formed is also collected on a sectoral basis.
A hospital manager, for example, will base his control of care processes on the contribution margins of individual services as well as the utilization and length of stay of defined organizational units and try to harmonize these with the published quality indicators of his facility; The manager of the neighboring medical care center, on the other hand, is interested in the operational key figures of his facility.
Already in the hospital, the senior nursing staff will deal with key figures from the nursing staff regulation or the recording of nursing services in order to defend their personnel budget.
The collection, analysis and use of key figures is therefore shaped by the interests of the viewer and is triggered, among other things, by financial incentives.
However, it can be observed that, as part of the increasing requirements for interdisciplinary service provision and process reorganization, tiered, comprehensive key performance indicator systems such as the Balanced Scorecard have already become established among healthcare service providers (Greulich, 2002). However, there is generally no transparency about the data collected and the control approaches. Furthermore, these key figures usually reflect the core processes of the respective sector, ideally taking into account the upstream and downstream treatment sectors. An overarching view cannot therefore be achieved.

Statutory health insurance data
were mainly processed sectorally

Health insurance companies have performance data of their insured persons from different sectors, so this data basically offers the possibility of a comprehensive representation of the care process.
However, the structure of a health insurance company has traditionally been focused on managing membership fees and paying the insured's service expenses.
Only since the mid-1990s has a change in requirements developed, supported by health policy initiatives with the aim of gradually giving health insurance companies more options to individually design and agree on attractive care offers for their insured persons. In order to meet these requirements, it is necessary to consider key figures from different sectors so that the design and evaluation of such offers can be successful.
Over the years, the health insurance companies' key performance indicator systems have been aligned with the statutory tasks at the time. These tasks consisted of processing the service expenditure of the insured in the respective supply sector in a mathematically and factually correct manner. Quality and cost-effectiveness have only recently received increasing attention and are mapped and controlled using key figures. The health insurance companies' view of their data and thus the key figures was predominantly sectoral.
Classic, well-known and published key figures include, for example, hospital cases and costs, length of stay and daily costs in the rehabilitation area, as well as the frequency of incapacity for work among insured persons and the duration of incapacity to work.
It is also worth mentioning that data on some care areas has only been available in usable quality for a comparatively short time, meaning that it has only been possible to derive meaningful key figures in these areas for five to six years.

The assessment of the care process
has not been the focus so far

A discussion about the quality of care in the healthcare system, taking the cost-benefit aspect into account, has only taken place in Germany since the 1990s, and on a broader basis only since the turn of the millennium. In order to conduct this discussion in a results-oriented manner, transparency is required about the implementation of the care processes, the application of guidelines and evidence-based medicine, and the results of the care process. This transparency did not exist and has so far only been achieved insufficiently.
Despite the wealth of data that has now been collected, a lack of reliable data and findings on the level of care is repeatedly described, particularly in the discussion about reform and further development of health care (Sachverleutenrat, 2002; Schrappe et al., 2005; Herholz, 2008). The improvement in data collection has only partially ensured increased transparency.
In the health policy discussion, assumptions about the care process and its quality are based less on analysis based on key figures and more on expert opinions. Likewise, the effects of changes in legislation are only inadequately evaluated. In this context, greater importance and better support for health services research are repeatedly called for (SVR 2002; Pfaff/Schmacke/Schrappe 2004).
Global data is available from federal health reporting in collaboration with the Federal Statistical Office. These allow an assessment of the disease and health status of the population at an aggregate level and can thus make statements about the development of population health and the development of the health industry as a whole. However, even with this data, it is not possible to evaluate the care processes using the information available.

The legislature encourages and requires this
Linking sectors and disciplines

The legislature has recognized, not least through several references from the Advisory Council on assessments in the healthcare system, that the sectorization of the German healthcare system represents an obstacle to high-quality, effective and efficient patient care. He has therefore taken initiatives to open up the sectors in several laws to further develop the healthcare system and has given health insurance companies an active role as partners in shaping care.
The results of this legislative process include the introduction of disease management programs, the strengthening of integrated care and care management, and the possibility of setting up medical care centers. Furthermore, the rigid outpatient/inpatient boundaries were broken through regulations on the provision of outpatient operations, highly specialized outpatient services in hospitals and, last but not least, through the passage of the law amending contractual doctor law.
The healthcare industry has recognized and embraced this trend. On the one hand, the steadily increasing number of contracts concluded for integrated care and, on the other hand, a similar development in the number of approved medical care centers in Germany can be seen as indicators of this.
The development of new forms of care involves asking questions about the difference to previous care and measuring the occurrence of a postulated possible improvement in the care situation.
Accompanying the rapid development of integrated care, a discourse about controlling and evaluation of the developed models has taken place. Particular attention was paid to the comparison between integrated and standard care. In addition to the complexity of forming comparison groups, the focus here is also on the combination of period- and treatment-related measurements of the indicators in order to avoid distortion due to the representation of care across different sectors. As a solution, Wasem recommends combining the results of individual measurement processes into a summative evaluation (Wasem et al., 2006). This corresponds to the consolidation of key figures from different sectors and at different points in time into an overarching view.

Health insurance companies look after their customers
cross-sector in the future

The statutory health insurance companies have also accepted their changed role and offer their insured persons a portfolio of additional and selective service offerings tailored to their needs on the one hand and various selectable tariff models on the other.
In addition to simply expanding and differentiating the offering, payers are also increasingly discovering their interest in playing an active role in the performance management of care processes. This has happened not least in addition to the opening of new legally defined options, driven by the competitive situation between health insurance companies and by cost developments, especially taking epidemiological effects into account (Wiesner/Grimm/Bittner 2003).
In addition to their participation in the cross-sector care models already mentioned, more and more health insurance companies are developing activities in individual case management, in health advice for their customers and in so-called health coaching. The aim of these measures is, on the one hand, to enable the insured person to take personal responsibility and self-management with regard to health risks that they can influence, and on the other hand to overcome supply deficits at the interfaces described above. All of this is done as a service for those insured by a health insurance company.
Both the design of forms of care such as integrated care and disease management programs as well as the support of insured persons through health advisors and coaches implicitly require a cross-sector approach.

The representation of the supply process
is achieved using key figures

The data available to a health insurance company is now of good quality, so that valid key figures can be created for the individual care sectors. A series of these key figures can be used to illustrate the supply process. In order to avoid misinterpretations and thus mismanagement, the entire supply chain must be considered. For example, a pure reduction in hospital costs and a shortening of the stay in medical rehabilitation could lead to savings in the sectors mentioned, but with a subsequent higher need for care and a higher need for aids, considerable additional costs could arise overall, not to mention a poorer medical outcome and lower patient satisfaction .
The aim is therefore to provide a cross-sector representation of care using key figures. However, in order not to lose sight of effects in individual sectors of care due to control in another sector, the presentation of purely cross-sector key figures is not sufficient. The DAK is therefore developing so-called “control cockpits” that enable both a sectoral and cross-sectoral view of the supply process. (see Fig. 3)
The main feature of these “control cockpits” is that the individual displays contain key figures that represent the respective area, and the overall process view is also displayed. This allows essential effects to be recognized at a glance.
It is initially used for the dimensions of performance and finances, which can be derived directly from the available data.
Developing cross-sector metrics to assess the quality of care is more complex but possible. This affects both the assessment of treatment quality from routine data as well as within cross-sector care models (Eikötter/Greiner, 2008). Quality assurance activities in all sectors and across sectors make it appear possible to meaningfully incorporate the dimensions of quality and patient satisfaction into such a “control cockpit” in the future.

Based on a key performance indicator system
control can take place

By using such a tiered key figure system, it is possible to generate information about the design and success of cross-sector care and to discover areas of action for care management as well as to illustrate the success of possible measures. Control measures can be based directly on these findings and effects can be observed promptly. By condensing the key figures collected, the overall process can be assessed, but the staged structure enables in-depth analysis of individual process steps at any time.
A time-accompanying presentation also makes it possible to evaluate effects that are expected in the medium term.
By differentiating the level of detail of the “cockpit”, the key figure system can be used both at the operational control level in direct contact with the insured person and as reporting at the management level.

Conclusion
It is possible to map supply processes using key figures, provided that they reflect sectoral as well as cross-sectoral aspects and are meaningful for the process under consideration. In principle, all participants in the care process can set up such a system of key figures for their respective area of influence.
Health insurance companies also have the advantage of having data from all areas of care. They can use the data available to them to map the entire treatment process and take control of it. The goal here must be to be able to map quality results in a key performance indicator system in addition to the dimensions of performance and finances. <<