Importance and contributions to better care through Health Management Services – HMS

With the changing framework of the German healthcare system, particularly the introduction of the Health Fund and the morbidity-based risk structure compensation (M-RSA), the quality of care for their insured members is becoming more of a focus for health insurers than ever before. One option is the Industry Sponsored Nurse Services (ISN), which have been used in the UK for almost 25 years at various levels of the National Health Service.

Many of the UK's outpatient and inpatient care trusts have long been accustomed to the qualified staff of the ISN (Individual Social Nurse) teams. The role and tasks of these non-physician professionals vary considerably, depending on the relevant care setting and indication. Their responsibilities include, among other things: auditing and reviewing prescriptions, optimizing treatment progress, disease and case management services, patient and family education, adherence support, high-tech homecare services, and ensuring compliance with guidelines and care protocols. ISN programs are an essential component of the health management services portfolio. The spectrum of HMS modules ranges from simple and ad hoc to complex and continuous. A more detailed definition of HMS and its content modules will be explained later.
The list in the preceding section demonstrates that these are not merely "nice to have" services, but rather "need to have" services. To be able to provide the medical services listed above independently and as autonomously as possible, nurses working in ISN programs must possess sound medical and nursing training, relevant professional experience, and extensive contact with patients and their families. Simultaneously, standard medical practice and applicable medical regulations must provide an adequate framework for ISN programs. Both of these conditions have long been met in England.
With the changes in the framework of the German healthcare system, particularly the introduction of the Health Fund and the morbidity-based risk structure compensation scheme (M-RSA), the quality of care for their insured members is now a greater focus for health insurers in Germany than ever before. In the future, the quality of care, rather than the price (i.e., the contribution rate), will be the primary criterion when choosing a health insurance provider.
Every health insurance manager is intimately familiar with the compensation amounts from the new M-RSA (Multi-Risk Structure Compensation Scheme) as well as the surcharges for the 106 hierarchical morbidity groups (HMGs). With these financial resources per illness, they must in the future provide high-quality care that reflects the current state and progress of medical science.
The previously standard allocation for enrolled participants in Disease Management Programs (DMPs) will be replaced in the future, under the conditions of the Model Risk Structure Compensation (M-RSA), by a flat rate of €170 per patient, year, and program. This is significantly less than before, but with approximately 5,000,000 enrolled DMP participants, roughly €1 billion is available for health management services – within the statutory health insurance system alone. These new financial allocations will create a demand for numerous health management services on the part of health insurers. Therefore, those who are able to offer health insurers high-quality services for the diseases listed in the 106 German Disease Management Programs (DMPs) or within the existing DMP programs can expect to be considered, especially if these services are cost-effective.
The complete takeover of the management of a defined disease by a single healthcare provider or a consortium of service providers is also conceivable, provided it is cost-efficient while simultaneously offering the required quality of care. Health management services (HMS) can play a central or peripheral role in this, depending on the indication. However, efficient care will hardly be achievable without effective HMS modules.
Last but not least, traditional disease management providers and medical assistants see these new conditions as an opportunity to gain a foothold with payers through new business models. Contract Sales Organizations (CSOs), which primarily focus on acquiring physicians and pharmacies for pharmaceutical companies, also see an opportunity, due to their international presence and experience with various health management services, to transfer these activities from other countries (UK and Scandinavia) to the German healthcare system.
However, several instances of health insurance companies providing medical services via so-called medical call centers last year caused irritation and unease among healthcare providers and their associations. The health management services offered by pharmaceutical companies, the so-called "nurse teams," which have been available for several months, have also exacerbated uncertainty about the purpose and benefits of these services for the healthcare system.
The aim of this article is therefore to clarify the terminology, to elaborate on the objectives, instruments, framework conditions, and technological dimensions of healthcare management services (HMS), and to identify potential areas of application. Subsequently, several sections will be dedicated to the strategic and operational development of specific HMS services, as well as a preliminary cost-benefit analysis. Finally, a scenario for the market development of HMS services within the German healthcare system will be outlined.

Framework conditions for HMS offers
Fundamentally, a suitable framework is needed to establish HMS services effectively and economically in clinical and outpatient care. Only the most important framework parameters will be outlined here.
Medical law
This area presents many challenges and pitfalls for healthcare services; unlike in the UK or the US, medical support staff (medical assistants, nurses, or nursing assistants) are only permitted to perform very few medical activities autonomously, i.e., without the instruction and supervision of a physician. In the future, "collaborative decision-making" will be required not only in inpatient but also in outpatient settings—that is, a task-oriented allocation of responsibilities—in order to meet complex care needs. The dangerous ambiguity surrounding the boundaries of responsibility (multiple accountability) fosters a defensive and cautious attitude among the professions involved.
The physicians' monopoly on treatment is being fundamentally challenged by many healthcare management (HMS) programs. Accordingly, there was considerable resistance from the medical profession when the first projects were implemented in 2008. This fact must be adequately addressed during the planning phase of HMS programs through early communication and the involvement of various professional groups. The more extensive the medical interventions are intended to be by specialized medical assistants, nurses, or nursing staff within the framework of HMS programs, the more thoroughly a comprehensive review of the legal framework governing physicians is recommended, and the early consent of the involved specialist groups must be secured.
financing
For example, the technology-intensive home care of patients sometimes requires the involvement of up to five different social security providers, each operating according to its own logic and invariably only financing partial services. Conversely, in hospitals, all medically necessary care services for this patient group are financed from a single source – despite budgetary constraints – and still largely without problems. A simple model for financing home care services, for example, has become established among the payers, and this model also applies to their willingness to finance home care services. Because these are often rather isolated and product-related services, statutory health insurance payers argue that the reimbursement for the product also covers all "add-on" or "surround" services, which are often useful home care services. So far, home care providers, for instance, have not been able to sufficiently assert the value of their additional services in their arguments to the payers. On the other hand, DMP service providers are reimbursed for the expenses of their programs without problems by both statutory health insurance funds and private health insurance companies, and this involves four-figure euro amounts per patient per year.
Homecare, pharmaceutical, and medical device providers face the challenging task of justifying their services beyond product delivery to health insurers. Insurers currently view product-related services as covered by product reimbursement and do not consider services unrelated to the product as a specific or new area for reimbursement. This attitude will only fundamentally change when convincing evidence demonstrates the benefits of homecare services for insurers. Therefore, it remains the responsibility of service providers to secure appropriate billing codes, service packages, and reimbursement items in the German Fee Schedule for Physicians (GOÄ) or the Uniform Assessment Standard (EBM), or to identify corresponding analogous codes. At a minimum, they should attempt to establish initial evidence through pilot projects or participation in the new integrated care models according to Section 95 of the German Social Code, Book V (MVZ), contracts for special outpatient (specialist) care according to Section 73c of the German Social Code, Book V, and/or Sections 140 et seq. (Integrated Care).
data protection
Data protection initially presents a further obstacle to HMS initiatives in Germany. To fulfill their communication, coordination, and educational tasks within the framework of HMS services, homecare managers, case managers, or nursing staff require authorization from the patient. This authorization, which must be granted in writing, also applies, for example, to therapy training and the mandate to procure and ensure the continuous supply of necessary homecare products from the patient's chosen suppliers (pharmacy, medical supply store, industrial homecare provider, etc.). A written agreement with both the patient and their primary care physician, which takes data protection into account, is absolutely essential. This agreement must include an assurance that the homecare case manager will handle the patient's personal data confidentially and solely for the intended purpose. The same applies to most HMS services. At the same time, this agreement regulates the transfer of data to third parties that contribute to the treatment (specialist medical practice, hospital, outpatient nursing service, pharmacy, medical device supplier).
Availability and acceptance of qualified staff
Innovations, both at the product and process levels, are increasingly leading to specialized, knowledge-based service offerings. To meet the growing demands of technology-intensive and medically oriented home care, homecare, and outpatient services, nursing and healthcare support professionals in other countries often possess specialized qualifications at an advanced practice level, such as IV nurses, critical care nurses, or clinical nurse specialists. Intensive care and infusion therapy have developed into specialized areas of nursing in many countries and have even spawned their own professional societies. There is no comparable system in Germany to date. The pronounced physician dominance of the German healthcare system and the associated fact that physicians, even when dealing with highly qualified professionals with university degrees, tend to prioritize subordination over cooperation, present a significant barrier to the successful implementation of healthcare management programs.
Initial studies in healthcare research indicate a lack of needs-based care. In particular, there is a shortage of specialized services for pre- and post-acute, as well as technology-intensive, home-based nursing and care. In the future, there will be a demand for clinically trained nursing experts who, due to their specific qualifications, are able to provide patients with sophisticated treatment methods in the home setting, even during critical phases of illness (the "hospital at home" concept), and to ensure the safety and quality of treatment and care. Formalized training and continuing education programs for case management now exist in Germany, for example. But where are disease managers or medically qualified call center agents actually trained?

What are Health Management Services?
As will be shown later, the term "Health Management Services" encompasses a wide variety of medical, educational, psychological, and data-analytical services. These services can be dominated by specific technologies or characterized by labor-intensive components. Even the translation of the term "Health Management Services" remains general and doesn't really help. However, a common core element of all HMS services is a specific knowledge component. Essentially, HMS services are specialized, knowledge-based services within healthcare.
Regardless of the actual product services within the care process, the accompanying healthcare management services (HMS) often involve educational, coordination, or integration services, which are essential for achieving a positive overall medical outcome. Only through this coordination and integration of services and products can good long-term results be achieved for patients. Furthermore, an integrated and patient-centered HMS approach aims to activate the patient's self-help potential as well as the social resources of their family and social environment.
In general, HMS offerings provide five core functions:
- the information,
- the control,
- the educational,
- the logistics and
- the monitoring function.

Portfolio of HMS instruments and programs
While in the past the focus was on providing close physical support, social care, and domestic assistance to the elderly, today, and even more so in the future, there is an increasing demand for the sophisticated care and treatment of acutely and seriously ill patients, as well as the many elderly and chronically ill, in the home setting. This politically driven shift towards outpatient care requires structural and procedural adjustments to prevent a decline in the quality of care. Differentiation processes in home healthcare can be initiated by office-based physicians, outpatient nursing services, or industrial service providers such as home care companies or home healthcare providers. Outpatient care refers to the process of shifting social and healthcare services from the inpatient to the outpatient sector, thus generally prioritizing outpatient care.
In principle, the insured population of any health insurance provider can be classified as shown in the following figure. To put it somewhat succinctly: there are many healthy individuals, many acutely ill individuals, a large group of chronically ill individuals, and relatively few very seriously ill individuals. Different goals arise for each cluster. The aim is to keep healthy individuals healthy for as long as possible, to cure acutely ill individuals as quickly as possible while avoiding complications, to provide appropriate care for chronically ill individuals throughout the course of their incurable illness, and to prevent disease progression and/or typical costly complications. Finally, for the most seriously ill, the goal is to prevent the worst through coordinated, intensive medical intervention.
In relation to the current health status of the different patient clusters, specific care and health management (HMS) services have consequently developed. Health policy has also taken this into account, for example, through the introduction of several disease management programs (DMPs) since 2002. Each patient cluster has different priorities, which are further adapted by the specific disease in question. The spectrum of HMS services ranges from health coaching or screening programs for those who are still healthy to multi-disease management programs for patients with multiple comorbidities and to major case management or palliative care for seriously ill patients. Therefore, there is no single HMS service, but rather a continuum of programs, tools, and activities. Furthermore, the correct selection of the most suitable and cost-effective HMS program is largely determined by the indication and the relevant care setting (home care, outpatient, day-care, inpatient, nursing care). Some illnesses also require offering a whole bundle or a temporal sequence of HMS services that accompany the course of the illness and thus the patient.
When grouping the long list of health management services, one can proceed according to different criteria and perspectives. In the following illustration, for example, the green box contains information- and data-analytical, as well as low-cost, personalized health management services. The red box includes all services that strengthen therapy adherence and programs that modify behavior or the patient's attitude toward their illness—in other words, coping behavior. These programs sometimes use technical aids as well as psychodynamic components for program implementation. The black box contains labor-intensive health management services. These interventions are complex and time-consuming, but when professionally designed, they are also very effective. The last, dark blue box contains two specific services focused on drug therapy. These two programs alone would each warrant their own separate article.

In principle, most HMS offerings are based on medical knowledge, data analytics, clinical algorithms, and increasingly, specific software. Notwithstanding the HMS clustering presented here, other perspectives can also be chosen.
Technology versus labor-intensive HMS services

Crucial for acceptance and implementation is differentiating between technology-driven and labor-intensive health management (HMS) services. The service chain begins with automated reminder services, such as SMS to improve compliance or remind people of upcoming appointments, and culminates in a full-time personal health coach, a service increasingly enjoyed by celebrities. Many other modules of the HMS continuum lie in between, which are neither technology-heavy nor primarily labor-intensive. Figure 3 below illustrates an initial possible clustering from this perspective.

Development of the process chain for HMS services according to indications and specific disease progressions.
When considering which diseases, care settings, or patient groups HMS services should be developed for, it has proven beneficial to become thoroughly familiar with the course, complications, and accompanying circumstances of a disease.
Depending on the disease, a distinction is made between acute, chronic, relapsing, progressive, and many other specialized courses. Only a precise understanding of the disease course allows for the identification of the most effective intervention points. Let's take rheumatoid arthritis as an example. Approximately 20% of patients experience a mild course of the disease, meaning they do not develop significant complications and the disease progression is slow. Another 60-70% of patients undergo a chronic progressive course and develop the typical complications over time. A small group of patients, slightly more than 10% of all affected individuals, experience a rapidly progressive course that quickly leads to serious complications, disability, and early retirement.
For every indication, there is no single typical disease course, but rather a certain diversity of possible courses. This fact should be taken into account through an initial risk assessment and the resulting risk stratification. The intensity and type of health management services should then be assigned according to this classification. The right module, at the right time, for the right patient is the key to success for effective and efficient health management programs.
In principle, Health Management Services (HMS) can be implemented on an ad hoc basis (e.g., a one-time screening campaign), sequentially and periodically (e.g., a reminder service for upcoming doctor's appointments or a weekly patient education program), or continuously (a Disease Management Program (DMP) or Biomedical Management Program (BMP) running for a year or several months). This classification allows conclusions to be drawn about the benefits of HMS offerings. Ad hoc services only provide focal optimization. Sequential and periodic services, on the other hand, enable partial optimization, and only predominantly continuous HMS programs have the potential for full optimization of the care pathway and thus for better health outcomes for patients.
If one does not wish to deal with entire disease progressions, one can also partially optimize defined phases or intervention options through HMS services. In the home care sector, this includes, for example, nutritional, infusion, and pressure ulcer therapy, or in prevention, health coaching or behavior modification through smoking cessation programs.
Once a thorough medical analysis has provided sufficient certainty about which HMS module to develop, the next step is to intensively examine the associated process chain.
The traditional treatment process begins with diagnosis and ends very quickly with a prescription. For the majority of patients, statutory health insurance reimbursement no longer covers more than this. However, as treating physicians are well aware, this approach is neither truly effective nor sustainable. Many other components of the treatment chain are either left unaddressed or only offered half-heartedly. This is precisely where HMS services come in. Only a comprehensive treatment chain, tailored to the severity of the illness, will lead to positive medical outcomes. HMS completes the treatment chain!

Practical example: Osteoporosis
Osteoporosis provides a good example of the application of health management services at different stages of the disease progression. It is a significant healthcare condition affecting approximately 7,000,000 people. The disease is chronic and progressive, and its associated complications (fractures) lead to high follow-up costs. In the early years, the progression of the disease is barely noticeable to the patient. Only with the occurrence of the first fracture – without any significant preceding trauma – does the diagnosis of osteoporosis become tangible for the patient.
Since the onset is gradual, targeted screening for risk groups would be advisable initially. Once an accurate diagnosis has been made via X-ray and bone density measurement, the problem lies in the low patient compliance associated with osteoporosis, due to the disease progression being barely perceptible to the patient. Early educational programs and patient support groups are essential to raise awareness of the condition among those affected. The standard prescription of bisphosphonates often requires adherence to complex dosing schedules. These range from one injection per year to quarterly administration, weekly doses, and even daily doses. The need for effective compliance programs is evident in these cases. In addition to pharmacological treatment, osteoporosis should ideally be addressed with a multimodal approach if lasting improvement is to be achieved. This approach includes targeted nutritional counseling, exercise and coordination training focused on osteoporosis-related issues, and, for patients who still smoke, consistent smoking cessation. This focuses primarily on changing personal lifestyles through targeted Disease Management Program (DMP) initiatives. The involvement of healthcare professionals such as nurses, medical assistants, nursing staff, physiotherapists, and nutritionists is possible and effective at various levels. In principle, osteoporosis—much more effectively than, for example, official DMP indications like breast cancer—can be treated with an integrated disease management program. If, despite good treatment or due to poor compliance, the dreaded fractures occur, consistent case management is recommended in the case of a hip fracture to prevent the need for long-term care or worse. The necessary coordination of the treatment chain, from the general practitioner to the orthopedist and, if required, the osteologist, can be ensured through effective data management, an electronic health record, or specialized medical software. Figure 5 schematically illustrates the different modules of the treatment chain, their respective responsibilities, and their interactions.

Cost-benefit considerations
Many seemingly useful health management (HMS) services aren't actually worth it when you do the math. The lowest cost for a single intervention is a call center call (around €7), an SMS reminder (around €3), or a medical email service like "Infozept" (around €2). Screening campaigns, risk assessment programs, and motivational interviewing fall in the middle range, costing roughly €50 to €300 each. More ongoing HMS services, such as disease management programs (DMPs) or personal health coaches, typically cost more than €1,000 per year per patient.
For simplicity, one can also speak of "low-cost" and "high-cost" HMS modules. To truly intervene effectively in the course of a disease, a single HMS module is rarely sufficient. As a rule, several modules must be combined to achieve better outcomes and sustainability.
Which modules of the Health Management System (HMS) spectrum are necessary, appropriate, sufficient, and also economical for which disease and severity level? Opinions still diverge on this point. Unfortunately, much of what we encounter in healthcare practice today under the HMS label is not truly sustainable and lacks sound medical reasoning. However, this is often unavoidable at the beginning of a development. On the other hand, there are also well-known and highly regarded HMS activities, such as the community nurse project AGNES.
In general, it can be observed at present that the majority of HMS initiatives offered are rather limited in duration. At the same time, the number of HMS offerings that can be deployed periodically or sequentially is growing. Highly effective, continuous HMS programs are still clearly in the minority. However, under the conditions of the M-RSA (Managed Risk Adjustment), they will be the future. Furthermore, only a few service providers in Germany are currently capable of implementing the full spectrum of HMS offerings or complete, integrated, and vertically integrated HMS programs.
In principle, health management services (HMS) can be financed in various ways. These include statutory and private health insurance providers, as well as long-term care insurance. The pharmaceutical and medical technology industries can also finance HMS services that complement their products. Finally, there are also a number of HMS modules where co-financing by patients would be conceivable. Perhaps, in the future, HMS services will also be financed through supplemental insurance. This presents a new business model opportunity for private health insurers.
In principle, health insurers will base their willingness to finance health management (HMS) services on their effectiveness. The clearer the data and scientific evidence, the greater the willingness to provide partial or even full funding. However, if the modules are useful but not particularly effective, such as training patients to self-inject medications (insulin or antibodies), the insurer will not co-finance them but rather classify them as part of the product's standard benefits.
Regardless of this approach of financing HMS initiatives based on performance and outcome, there will also be health insurers and industrial providers who use HMS offerings for marketing purposes. This is by no means objectionable, but should be clearly distinguished from more medically focused HMS offerings. In principle, a reallocation of marketing resources to HMS offerings is a welcome development and could relieve the burden on statutory health insurance in many areas.

Conclusion
The policy-driven shift towards outpatient care, the concentration of hospitals on their core services, the risk of hospital-acquired infections (MRSA, methicillin-resistant Staphylococcus aureus), the desire of cancer and pain patients to be treated at home, the numerous advances in medical technology, and the clear economic advantages of outpatient care over inpatient care models will lead to rapid and sustained growth in the outpatient high-tech care sector. Innovative pharmaceuticals, new medical technology products, and a whole range of qualified health management services will play a key role in this growth.
Currently, so-called "halfway technologies" still dominate the market. These do not halt the actual disease process, or only do so to a limited extent. However, they can: prevent worsening of symptoms, help control or alleviate symptoms, or replace lost bodily functions. In the future, causal technologies will gradually become available for the high-tech outpatient care approach. The innovative strength and research efforts of the pharmaceutical and medical technology industries will lead to a continuous transfer of technology. Many of these innovations will extend lives and bring further benefits to patients. However, these innovations will not be available at affordable prices for the majority of patients.

Scenario for the HMS market in Germany for 2012
The development of the Health Management System (HMS) market is driven by various forces. Firstly, there are the existing Disease Management Program (DMP) providers and medical assistants already working for health insurers. Simultaneously, new providers are exploring the HMS market, including contract sales organizations and medical software companies. Both see good opportunities for establishing a lasting presence. In 2008, we observed the first major initiatives, financed by health insurers and the pharmaceutical industry. All activities of the past year involved rather isolated offerings and lacked disease-specific, holistic, and integrated approaches. In the future, the HMS market will evolve into providers of individual modules, providers focused on "episodes of care," and ultimately, fully integrated HMS providers capable of offering the full spectrum of HMS services. According to cautious expert estimates, the health management system (HMS) market will grow from approximately €40 million today to quickly more than €100 million and could reach over €250 million in 2012. If the €170 lump sums available in the statutory health insurance system for the approximately 5 million disease management program (DMP) patients are also reallocated to meaningful HMS activities, the HMS market could develop into a truly significant healthcare market in Germany.