Increasing quality through transparency? Use of quality seals in healthcare

As a long-requested regulatory model, more competition should contribute to improving economic efficiency, demand orientation and the quality of care. However, in addition to positive effects, the increased supply variance (due to competitive dynamics) leads to an information imbalance on the demand side, which makes a complete market overview impossible. More and more seals of approval, certificates, awards and ratings are providing guidance to consumers, whose current inflationary escalation is, in turn, leading to uncertainty. For this reason, this omnibus study by the Department of Prevention and Health Promotion at APOLLON University examined the point of view of healthcare decision-makers on the use and effects of quality seals.

>> Five years ago (January 1, 2007 to December 31, 2007), the Internet hits when entering the words “seal of quality and health” in the search engine Google (limited to Germany) amounted to 140,000 hits (seal of quality only: 1,400,000) , the number increased tenfold five years later (January 1, 2011 to December 31, 2011) to 1,470,000 hits (quality seal only: 4,000,000). Regardless of the limited validity and inaccuracy of this research instrument, the topic of quality seals seems to be gaining in importance from a provider and demand perspective. This is understandable, because with increasing market transparency, “tangible” decision-making criteria such as financial benefits, advertising, brand image and quality seals have a strong incentive. The current competitive environment is forcing healthcare players to adopt short-term advantage strategies.
These pose the risk that increasing price competition (or quality seal competition) will develop instead of quality competition (Hujber 2005). This danger is exacerbated by comparison portals, product reviews and third-party recommendations, some of which focus heavily on financial benefits rather than on the quality of the offers. In addition to established reviews from consumer protection organizations (Stiftung Warentest) and consumer magazines (ÖKO-Test), numerous comparison portals have developed especially on the Internet. There are more than 70 different quality seals for statutory health insurance (GKVn) alone (Scherenberg 2011). Either the institution (e.g. best health insurance company, best regional health insurance company, best health insurance company without additional contribution) or its service or products (e.g. TOP prevention, best range of services) are examined. In addition, advantages - mostly financial - for certain target groups (e.g. best health insurance for singles, athletes, active, passive people, career starters, families) or other advantages (e.g. doctor's favorite) are highlighted. Around 40% of the GKVn already point out such awards with corresponding seals of quality on their websites (ibid.).
Reasons for using quality seals
There are several reasons for the expansion of quality seals: On the one hand, it is obvious that consumers trust that they receive an additional evaluation criterion or an independent basis for decision-making over the unmanageable thicket of offers. On the other hand, awards on the provider side, as a certified symbol of excellent performance, represent a marketing strategy profiling opportunity, among other things in the context of public relations work. The online survey in December 2011 by the APOLLON University (on the topic of “Seals of Quality”) as part of the 10th wave (Dostal/Dostal 2012) of the “healthpanel” launched in 2008 confirms this assumption (see Fig. 1): More than a third of the health industry decision-makers surveyed (n=432) (33.8%) who use quality seals see them as established instruments with a signaling effect , especially in the area of prevention (45.5%). A total of 53.7% of those surveyed (GKVn to 50.0%) use quality seals. Participants in the study who do not use quality labels do not share this opinion or deliberately do not use quality labels for reasons of cost or persuasion. The vast majority are therefore convinced that the established quality seals have an important signaling effect and that quality seals therefore represent an adequate aid for orientation. The current inflationary increase in such “orientation aids” weakens the effect and thus runs counter to the original intention. According to the respondents (see Fig. 2), quality seals only contribute a maximum of 2.2% to increasing transparency and acceptance of products. More than a third of those surveyed (39.1%) are even of the opinion that quality seals tend to contribute to uncertainty. It is striking that those surveyed see quality seals as having potential to increase quality competition, particularly in the area of prevention (59.9%), and see quality seals less as a marketing tool.
Obstacles and risks
In order for quality seals to make a contribution to improving quality, a common understanding of quality is necessary. Because quality is not only difficult to grasp, but can never be presented completely objectively. It follows that quality seals are always just an attempt to make parts of reality more communicable to the interested public (Rauschenbach 2005). In addition, the information and evaluation systems consistently lag behind reality, as they can only reflect the current status - often in sub-areas (e.g. service or individual products). Another problem is the need for financing, selling and publishing rankings, which always requires a certain degree of media effectiveness. Spectacular and sales-promoting statements from winners and losers promote media effectiveness and thus, for example, the circulation of corresponding magazines, but can be inappropriate (Lanfermann 1998) or stimulating. User-generated reviews and hit lists (e.g. Ciao, Dooyoo) are also becoming increasingly popular. In addition to independent experts (e.g. Stiftung Warentest), more and more consumers are exchanging their experiences online due to the increasing confusion (Frick/Hauser 2007). Consumer advocates warn against these sometimes flawed and manipulative opinions from laypeople (Consumer Center 2005). In contrast to the Netherlands (“Choose better”, www.kiesbeter.nl), an independent consumer portal for increased transparency and orientation for those insured in the healthcare system does not yet exist for the German health insurance market.
The urgent need for value-neutral advice has already been taken into account with the introduction of Section 65b SGB V (GKV health reform 2000) and the obligation of the GKVn to “promote institutions for consumer and patient advice” (Dierks et al. 2003). In this country, the “Independent Patient Advice Germany gGmbH”, as a model association of the leading associations of health insurance companies, enables free personal advice in 22 regional facilities nationwide (www.upd-online.de). A proliferation of sometimes expensive
Required quality seals can not only lead to renewed confusion, but sometimes to unfair competition. If paid quality seals are accepted by the public, providers with little financial strength have fewer opportunities to distinguish themselves in this way. Criteria that are checked for such quality assessments during interviews include service culture, service reliability, handling of complaints and employee qualifications. Product reviews are sometimes based on self-disclosure. If data is not provided truthfully and does not stand up to a possible audit (e.g. by DISQ, German Institute for Service Quality), the respective health insurance fund will be excluded and the seal of quality will be withdrawn (e.g. from the Hanseatic Health Insurance Fund (HEK) in 2006; DISQ press release , December 4, 2006). Negative assessments and exclusions in turn have an unfavorable effect.
Key weaknesses and
Optimization options
With regard to quality seals, the lack of standardization, comparability, continuity as well as methodological and conceptual inequality can reduce the chance that quality incentives are created and well-intentioned transparency degenerates into a pure marketing tool. All actors (Fig. 3) agree that quality transparency is ensured through the “exclusive evaluation by independent institutions without commercial interest” (86.9%) and the definition of standardized evaluation criteria for commercial and non-commercial institutions (63.9%). can. The statutory health insurance providers (in third place) are more in favor of a legal transparency obligation via quality seals than the guarantee of verifiable “must” criteria (in fourth place). According to the actors, the use of traffic light systems or state seals of approval should be neglected. If results are created by independent institutes and published by a higher-level central body (e.g. umbrella association of statutory health insurance companies, consumer associations), this increases credibility because the highest possible objectivity is assumed. This can reduce the information asymmetry between providers and buyers. Changing criteria could also avoid a situation where there is no concentration on optimizing individual criteria relevant to the public, but rather an optimization of the content of actions. In the sense of “public disclosure”, publication contributes to promoting quality-related behavior, as reputation is directly affected by publication. A legal obligation to be transparent as well as uniform standards for seals, ratings, evaluation portals or greater disclosure of evaluation criteria as well as the transparency of possible commercial interests can also represent a step in the right direction. Quality seals with different levels can lead to the demand side being made aware of the issue of quality and the supply side being motivated to reach the next level.
Limits of quality seals in the area of prevention
In order to increase the quality of preventive measures and to do justice to the value of health for the individual and society, assessments would have to take into account the special features of the healthcare system. If preventive offers are evaluated, it should be taken into account how likely it is to achieve high prevention potential and to what extent (high) risk groups with currently poor health behavior and health status (can) take part in them. Offers that appeal to groups of people who are already active miss the mark and do not make an active contribution to reducing health inequality. This presupposes that the competitive potential generates a mutual improvement. In addition, the “consumers” are co-producers of health, whose use (or participation) is influenced by social and economic resources compared to “classic” products. If it is possible to create incentives that reward those actors who make the greatest contribution to health well-being, the entire health system will benefit in the long term. There is currently still a strong incentive to focus on attractive and high-income target groups, as vulnerable people from low-income backgrounds represent a rather unattractive target group. These competitive framework conditions are not only ethical, but can also be described as questionable from a socio-economic perspective and, viewed overall, are contrary to sustainable development. When it comes to the signaling effect of quality seals, it should be noted that the primary source of information, the Internet and thus also comparison portals - tends to be used less by socially disadvantaged and older people - despite the digital divide being increasingly overcome. Young, well-educated and economically secure classes therefore have an advantage in participation for information technology reasons alone.
Conclusion
In order to make an effective contribution to increasing the quality of the healthcare system, we must respond to the increasing uncertainty due to the variety of products and the proliferation of quality seals. The apparent lack of clarity means that people are currently resorting to “tangible” criteria that are not quality-oriented, or that selection is made “instinctively” based on a sympathy orientation anchored in advertising, instead of performance-oriented decision-making. A departure from the current dominance of representations of financial advantages would trigger a stronger competitive dynamic towards performance and quality competition, which makes a social value contribution. Fair performance and quality competition requires factual and lay-friendly information as well as increased transparency and the ability to pay for the performance contribution through quality-assured and evidence-based offers. In this respect, “individual” and “sometimes graded” quality seals can make a positive contribution to the healthcare system under the premises described, provided that the interested public rewards quality with their demand behavior. <<