Even after 15 years of Disease Management Programs (DMPs), the wealth of data collected in the approximately 10,000 DMPs approved by the Federal Insurance Office (BVA) – and which is indeed available to your federal agency – can only be analyzed in a rudimentary way and therefore, as you explained at an event for company health insurance funds (BKKs) in Frankfurt on the 15th anniversary of the introduction of DMPs, "cannot be optimally used for healthcare research." Yet, as you further stated, we simply cannot afford to leave this "unique treasure trove of data" unused. What are the arguments for and against?
The "data treasure" you mentioned is not available to the BVA! The legislature transferred responsibility for evaluation to the Federal Joint Committee, which redefined it in 2014. Since then, the BVA no longer receives individual evaluation reports from the health insurance funds.

What are the consequences?
It's important to understand that the focus of evaluation has fundamentally changed. When Disease Management Programs (DMPs) were introduced, the competition between health insurance funds was paramount. The expectation at the time was that the evaluation data would identify "good" and "bad" programs offered by health insurance funds, and ideally, policyholders would then draw their own conclusions. However, it quickly became apparent that such a simple categorization of "good" and "bad" DMPs was not possible: a much more nuanced picture emerged.

So what do we have now?
In 2014, the Federal Joint Committee (G-BA) decided that all data from all health insurance funds should be compiled into a single, comprehensive report, which must be submitted to the G-BA and published. This data is intended to serve the "further development of Disease Management Programs (DMPs)." This means that the G-BA is to consider the findings from the evaluation data when regularly updating the requirements of the DMPs. As a result of this decision, the Federal Insurance Office (BVA) also lost its responsibility to, for example, analyze the "old" data from before 2014. In retrospect, I have my doubts as to whether the BVA was the right entity to analyze this evaluation data anyway. We were and are not adequately equipped, in terms of personnel and resources, for this task. Scientific institutes would be necessary.

Should the data be able to be evaluated transparently?
The unrestricted use of this evaluation data for healthcare research is precluded by Section 137f Paragraph 3 Sentence 3 of the German Social Code, Book V (SGB V). According to this provision, data collected within the framework of Disease Management Programs (DMPs) may only be used within the framework of DMPs. Participants consent to this only when submitting their declaration of participation. Changing this would require an amendment to the law.

However, it can still be useful!
The difficulty of making Disease Management Program (DMP) data usable beyond the scope of the DMP is demonstrated by the experience with the Cancer Screening and Cancer Registry Act, which came into force in 2013. At that time, the intention was to also transfer the data of DMP participants with breast cancer into this cancer registry. However, this would have required a supplementary or additional declaration of participation and consent from the DMP participant. Ultimately, the transfer of this DMP documentation data into the cancer registry failed.

You also mentioned at the aforementioned BKK event that the design of the training programs for disease management program (DMP) participants and the participation rate could be improved. What problems, and especially what potential for improvement, are revealed in your "data treasure"—which is no longer a treasure trove—but have so far remained unaddressed?
Patient education is a fundamental component of the Disease Management Program (DMP) care concept. It aims to activate patients, empowering them to manage their chronic illness effectively. This is a point of general agreement. Nevertheless, participation rates remain unsatisfactory. This data is widely known and published. For example, only 29.2 percent of patients with type 2 diabetes participated in diabetes education, and only 9.3 percent participated in hypertension education – in each case, based on the total number of participants. It's important to note that physicians do not recommend education to a large proportion of DMP participants.

Why is that?
It's not entirely clear. Doctors may consider the training courses unsuitable for their patients, either generally or in specific cases. It's also possible that the patient has made it clear they cannot attend the training – for example, in the afternoon – and therefore the doctor doesn't recommend it in the first place. The training programs may also need to be further differentiated, perhaps depending on the desired level of education. Some training programs are already available in foreign languages, including those that take different cultural backgrounds into account – important, for example, when it comes to nutritional advice. Digitalization will also inevitably impact training programs. Online training courses already exist to some extent, and training apps will follow.

Let's be honest: Is it really acceptable to make chronic care worse than it could be, just because data protection and competition law seem to be valued more than patient safety?
They say "only because... data protection" is more important. We see these so-called "conflicts of objectives" in many policy areas, especially with data protection. Just think of the issue of "internal security." The legislature has to make this balancing of interests, and it has done so for Disease Management Programs (DMPs) by stipulating that DMP data may only be used within the framework of the DMP. And I don't need to tell you that the importance of data protection has steadily increased. There is a particular sensitivity surrounding health data; I need only mention the concept of the "transparent patient." And I don't know if one can go so far as to say that "care for chronically ill patients is worse" because DMP data cannot be used more comprehensively. Use within the DMP system is certainly possible. What we lack is adequate use beyond that!

The host of the event, at which you spoke about 15 years of Disease Management Programs (DMPs) – „both a success story and a challenge for the future“ – was none other than the company health insurance funds, which expressed negative opinions about the results of the first special report on the further development of the morbidity-based risk adjustment scheme (M-RSA). Franz Knieps, board member of the BKK umbrella organization, criticized the fact that „the set of recommendations fails to address the actual competitive distortions between health insurance funds and types of funds,“ as well as the general „path dependency“ of the recommendations and the denial of clear indicators for what he believes to be existing competitive distortions. What is your response?
First of all, I was surprised by the timing of the criticism of the special report by the BKK umbrella organization and the Association of Substitute Health Insurance Funds, as well as by the early praise from the AOK Federal Association. I consider it audacious to evaluate the special report at a time when the full version hasn't even been published. However, given the interests of their member funds – and their expectations of the special report – the somewhat premature reaction of the associations is not entirely surprising.

How do you argue?
The advisory board thoroughly examined the framework within which the risk adjustment scheme (RSA) must function. Contrary to the assumption of the BKK umbrella organization, the advisory board did indeed investigate the perceived distortions of competition between health insurance funds. It concluded that the current over- and under-funding primarily originates outside the RSA, and therefore the RSA cannot be held responsible for every perceived or actual imbalance. In this respect, a closer look at the set of recommendations presented is warranted.

Which ones do you mean specifically?
The advisory board points out, for example, that for a radio-
In the face of competition, the supervisory authorities at the federal and state levels must act uniformly. The Federal Office of Administration (BVA) generally shares this view, and in my opinion, this is already largely implemented. To this end, the BVA, as the supervisory authority, regularly coordinates with its colleagues from the state supervisory authorities to prevent differing supervisory practices wherever possible. I also agree with the Advisory Board, in particular, that competition takes place between all health insurance funds, not between different types of funds. Focusing primarily on individual funds, as the Advisory Board has done, rather than on different types of funds, has little to do with "ignoring clear indicators.".

They are addressing the aforementioned path dependency.
I cannot understand Mr. Knieps' criticism of the "path dependency." Since the RSA is designed as a learning system, its continuous development and evaluation are based on the existing model, which is modified with the implementation of reform proposals. Accordingly, rather than a complete revolution, an evolutionary development of the system is generally to be expected. Furthermore, the Scientific Advisory Board has not yet been able to definitively address some questions, for example, whether the reintroduction of a risk pool is advisable.

Knieps also mentioned in his sweeping criticism that the BVA's Scientific Advisory Board (which was, after all, its mandate) was focusing on "technical indicators for forecast quality and target accuracy" instead of scrutinizing the overall competitive conditions and discussing fundamental alternatives to the risk adjustment scheme. Didn't he perhaps mistake the intended audience of his message – namely the Federal Ministry of Health and federal policymakers?
As you rightly point out, the Scientific Advisory Board was tasked with examining the effects of the risk adjustment scheme (Morbi-RSA) and empirically assessing the consequences of relevant changes to the procedure. A fundamental evaluation of the competitive landscape in the healthcare sector was not actually expected. Nevertheless, the advisory board did address the competitive landscape in those areas directly affected by the risk adjustment scheme and issued corresponding recommendations.

For example?
Risk equalization is necessary in any competitive health insurance system that features mandatory coverage and risk-independent premiums. Without risk equalization, competing health insurance funds have an incentive to focus on attracting "good risks"—that is, policyholders who, to put it simply, cost the health insurance fund less.
to concentrate on the risks they generate in revenue. However, from a normative macroeconomic perspective, such competition, dominated by risk selection, only incurs costs without making a positive contribution to healthcare and thus to the benefit of the insured and patients. The Scientific Advisory Board also emphasizes that avoiding risk selection is the central goal of the risk adjustment scheme. The RSA is intended to provide the basis for competition among health insurance funds by preventing them from "cherry-picking" new customers or pushing "bad" risks—for example, through restrictive benefit provision—into the arms of competitors. The criticized key performance indicators demonstrate how precisely the RSA allocations are targeted. The more precisely targeted,
the lower the average over- and under-
Coverage for insured persons. This, in turn, reduces the risk selection incentives for health insurance funds. Therefore, it is entirely appropriate that the advisory board considers reform options based on this.
The parameters were evaluated. But to clarify: The advisory board's empirical analyses are not limited to the aspect of risk selection, but always also include an examination of the health insurance funds' coverage situation. The potential impact of changes to the risk adjustment scheme on the health insurance landscape was thus taken into account.
Although it's not your job, could you imagine any fundamental alternatives to RSA?
As long as the statutory health insurance system (GKV) involves competition between health insurance funds, coupled with the right to choose one, mandatory contracting for health insurance funds, and a uniform, non-risk-adjusted contribution rate, we need a compensation mechanism between these funds. Otherwise, there is a risk of accepting developments that are undesirable from a societal perspective. For example, competition for "cheap" policyholders would undermine the principle of solidarity, as health insurance funds might, for instance, "lure away" chronically ill policyholders by omitting certain services. As long as policyholders pay their contributions regardless of their health status, a risk adjustment mechanism between health insurance funds to simulate risk-equivalent premiums is absolutely necessary.

The technical indicators for forecast quality and accuracy, which Knieps criticizes so much, can further improve the forecast quality of the Morbi-RSA model, measured using the insured-specific criteria R2 and CPM, as the evaluation of the seven annual adjustments carried out so far has already shown. But how accurate can the forecast quality of the M-RSA actually become? And where do we stand today?
The risk structure compensation (RSA) is continuously being developed further by the Federal Office of Administration (BVA). My office is advised in this process by the Scientific Advisory Board. The R² value has now reached between 22.71 TP3T and 25.81 TP3T, which is an outstanding result by international standards. The special report shows that the predictive accuracy of the morbidity-based RSA could be improved even further, for example, by better considering multimorbidity within the system. We have therefore not yet reached the end of its development. Rather, we must ensure that the morbidity-based RSA continues to be improved, not least to respond to changing circumstances and thus maintain the achieved predictive quality.

„The avoidance of risk selection is the central function of the morbidity-based risk adjustment scheme (M-RSA),“ writes the Scientific Advisory Board in the foreword to the first (of two) special reports on the further development of the M-RSA, explaining that „avoiding risk selection is a necessary, but not yet sufficient condition,“ since the task of creating fair opportunities in the competition among health insurance funds requires a corresponding competitive framework. The Advisory Board further states that „competition (in the healthcare sector) is not an end in itself,“ but should „instrumentally serve to improve health outcomes, i.e., to increase life expectancy,“ yet „so far, it has only been insufficiently successful“ in stimulating competition to improve the quality of care; rather, competition for the lowest possible or no (supplementary) contributions has dominated. What can the Federal Insurance Office (BVA) do here?
The BVA cannot explicitly compete on the quality of care.
Stimulating competition between health insurance funds is not our task, neither as a supervisory authority nor as the risk adjustment agency. However, we can make an important contribution to ensuring that all health insurance funds operate under the same framework. Regarding your question about the extent to which we can use the morbidity-based risk adjustment data to promote quality competition: The risk adjustment data primarily consists of health-related data of those insured under the statutory health insurance scheme and is therefore sensitive and requires protection. When using this data, we must always consider its intended purpose, which is to implement and further develop the risk adjustment scheme.

Where does this leave healthcare research?
While health services research is not the primary purpose, I believe that the available data should also be used for this purpose. To this end, my office provides the data to the German Institute for Medical Documentation and Information (DIMDI) in accordance with the Data Transparency Ordinance. The DIMDI is tasked with adapting the data to enable longitudinal analyses.

But with what time delay?
DIMDI has evaluated the experiences of the first two years in an evaluation report, examining, among other things, the time lag between the reporting year and data availability. These findings have been incorporated into the revision of the Data Transparency Ordinance. Currently, the Federal Office of Administration (BVA) only submits data reports after the correction of an annual tax reconciliation has been completed. This time limitation will be eliminated in the future, significantly improving the timeliness of the data provided.

What are your thoughts on the topic of regionalization?
Various studies show that healthcare expenditures vary regionally even with identical risk characteristics. This raises the question for both healthcare research and the risk adjustment scheme (RSA) of which factors are responsible for these differences and what regional distributions result from them. These questions are the subject of a further expert report commissioned by the Scientific Advisory Board, which is currently being prepared by the staff of the Federal Insurance Office (BVA). No definitive answers are yet emerging. On the one hand, redistributing funds from low-cost to high-cost regions could entrench undesirable regional disparities in healthcare provision. On the other hand, if health insurance funds have no control over differing cost levels, unequal competitive conditions will arise. The precise details of the implementation are therefore crucial, which is why I do not wish to anticipate the expert report. However, I am firmly opposed to the regionalization of contribution rates, as this would, in my view, entail a disproportionately high administrative, auditing, and implementation burden.

At the level of health insurance types, the advisory board's special report shows that the AOKs (on average) and the Federal Miners' Insurance Fund have improved their risk structure since 2009 compared to other types of health insurance funds; that is, their relative disease burden has decreased. Meanwhile, the risk structure of company health insurance funds, guild health insurance funds, and substitute health insurance funds (on average) has deteriorated relatively; that is, their relative disease burden has increased. Is this due to the M-RSA (Multi-Risk Structure Compensation Scheme)?
The equalization of the morbidity burden is a result of competition among health insurance funds in conjunction with the insured's right to choose their fund. The converging risk structures of the health insurance funds can certainly be seen as a positive sign for the effectiveness of the risk adjustment scheme, since a health insurance fund's morbidity no longer significantly influences the (supplementary) contribution rate and thus its attractiveness to new members. Furthermore, my office will, of course, examine each individual health insurance fund to determine whether any anomalies arise from these findings of the advisory board, which we will then investigate thoroughly and comprehensively.

The Federal Office of Administration (BVA), acting on behalf of the Federal Government, oversees the institutions and bodies of the statutory health, long-term care, pension, and accident insurance schemes whose jurisdiction extends across more than three federal states. Would you advocate for its jurisdiction to be extended by policymakers to include all health insurance funds, ensuring uniform oversight across all federal states?
Sole supervisory authority for the Federal Insurance Office (BVA) would guarantee uniform oversight of all statutory health insurance funds. However, this is hardly politically feasible and therefore likely unrealistic. Changing the current division of supervisory responsibility between the federal and state governments would require an amendment to the Basic Law (Germany's constitution). The necessary two-thirds majority in both the Bundestag (Federal Parliament) and Bundesrat (Federal Council) for such an amendment appears politically unattainable, particularly in the Bundesrat.

At least from the perspective of the Scientific Advisory Board – also stated in the special report – it is "essential that the federal and state supervisory authorities act uniformly in implementing the new regulations created by the HHVG." What would be the expected advantages, and what would be the potential disadvantages?
With the new regulations introduced by the HHVG (Healthcare Strengthening Act), the legislator aims to prevent manipulation of the risk adjustment scheme. To achieve this goal and avoid distortions of competition between health insurance funds, it is essential that all supervisory authorities work together and ensure, through uniform and rigorous oversight, that there is no manipulation of physicians' diagnosis coding.

Mr. Plate, thank you for the interview.

The interview was conducted by MVF editor-in-chief Peter Stegmaier.