Value based Healthcare: Putting patients at the center of medicine. Interview with Sophie Ernst (TU Berlin)

Die deutsche Originalfassung des Interviews gibt es hier zu lesen: https://medizin-von-morgen.de/2021/03/value-based-healthcare-wie-ruecken-wir-den-patienten-in-den-mittelpunkt-der-medizin-interview-mit-sophie-ernst-tu-berlin/

About today’s guest: Sophie Ernst

Sophie Ernst graduated from the Westphalian Wilhelm University of Muenster and Université Paris Descartes and is currently researching in the area of Healthcare Management at the Technical University of Berlin. Her work is mostly concerned with projects in the field of Patient-Centered Care, Quality Measures, and Quality Transparency in Healthcare. Previously, she was a part of the research team Chair for Innovation and Value in Health der Université Paris Descartes. During her time in Paris, her particular research dealt with the topic of “Value-Based Healthcare”, which we discuss in this interview.

Simon: Hello Sophie, I’m excited to interview you on such an interesting topic! But first of all, I would like to know something about your career and how you got to where you are now? And how did your interest in “Patient-Centered Care” develop?

Hello Simon, I’m pleased that I became an opportunity to share my experience and some insights on this topic with you and your readers.

I myself came to this topic in a number of detours. The main motivation that led me to take a step aside from the standard process of becoming a physician was my growing discontent with current patient care: I was working as a nurse’s assistant during medical school, doing mostly night shifts. After all the clinical traineeships that I’ve accomplished, I could just see the issues within the healthcare clearer, but barely any solutions to them.

During my Erasmus exchange semester I was finally able to live a Metropol-Life: I used this opportunity to participate in several conferences and take all the knowledge from this exchange program that I could. That’s how I discovered the “Chair for Innovation and Value in Health” program of the Université Paris Descartes. Because of my interest in the main topics of this program, I applied to one of the few places there. For one whole semester the participants of this program had the chance to talk to researchers, politicians, representatives from industry, and insurance, as well as to discuss some real cases and learn from them. That way I was able to understand the working mechanism of the insurance systems, their stakeholders, and interests. That is also how I came across the “Value-Based Healthcare”. At the end of the program, one of my professors at that time offered me to become a part of a research team for a project, that was organized by EIT Health. Our main goal was to create a framework for the administration of VBHC in Europe based on case studies. And so I did almost 60 interviews with experts from various fields, I traveled to Berlin, Rotterdam, Basel, Copenhagen to take a look at the projects in real and was able to present the first results at the Copenhagen Summer University. Through the interviews and trips, I got to know some exciting personalities and was able to make initial contacts for my further research projects. Through one of the interviews, I also got to know the research group at the Technical University of Berlin, in which I have been working for a year now. After completing the project at the Université Paris Descartes and an intensive seminar at Harvard Business School on Value-Based Healthcare, I applied to the TU Berlin. Since the beginning of the last year, I’ve been working there primarily on the topic of patient-reported outcomes, which are a crucial aspect of value-based healthcare.

Simon: What does Value-Based Healthcare mean and what are the advantages of this approach?

The term “Value-based Health Care” (often abbreviated to VBHC) describes a reorientation and reorganization in the health care system in which care is more geared towards patients.

The focus lies on the measurable patient benefit. Sustainability is also important: the quality of the result is compared with the costs that are expended over a complete treatment cycle to achieve the result. This means that (unlike currently in most health systems) both the quality of the results using patient-reported and clinician-reported outcome measures and costs are measured more comprehensively and considered together. Quality measurement within the VBHC goes beyond the acquisition of structure data and process data. As you see, the focus lies on the part of care quality, which is more difficult to measure, but which is most important for patients: the effect of illness and therapy on their life quality and functionality.

This is also one of the advantages of the approach of the VBHC: A continuous recording of the quality of the results and the comparison of these results triggers a learning process.

Simon: Let’s talk about Patient-reported outcome measures (PROM), which represent a parameter for measuring the success of the treatment. How is the measurement done?

PROMs are a very essential element of VBHC. PROMs are instruments for recording and evaluating the state of health, the ability to cope with tasks in everyday life and health-related quality of life from the patients’ point of view. In contrast to clinician-reported outcome measures, they are reported by the patients themselves; there is no interpretation by healthcare professionals during the survey itself. Together with clinician-reported outcome measures (CROMs), they provide a more holistic picture of treatment quality, because when it comes to the experience of their state of health, patients can and should be viewed as „experts“.

PROMs are recorded using validated questions that are answered directly by patients. There are disease-specific and generic PROMs. There are already a large number of standardized questionnaires for various diseases or areas of indication.

This is where digital health comes into play: The recording of PROMs via digital solutions enables a diverse use of PROMs, because the data can be collected more quickly, merged with other data, partially automatically evaluated and, for example, also used for symptom monitoring.

Simon: Is there an exemplary group of patients who would benefit from VBHC the most?

There are several groups who can benefit from a health care transformation within the meaning of VBHC. For example this applies in particular to patients with complex or chronic diseases. For these groups, more coordinated, patient-centered health care is important and beneficial. Even patients who undergo elective interventions, in which treatment results vary greatly between different hospitals, could make better decisions for their health through quality measurement and quality transparency or their family physicians could base their recommendations on a hospital on evidence.

The use of PROMs specifically for patients with cancer has also been explored by researchers such as Ethan Bash. Here could be determined even positive effects on long-term survival – possibly through better symptom monitoring.

Studies reposted positive effects of PROMs on communication between doctors and patients and on joint decision-making.

Simon: What are the advantages for hospitals, health insurance companies and the entire health system through the implementation of VBHC? Are there already success stories of hospitals that used the VBHC principle?

It may sound almost utopian, but in theory all stakeholders can benefit from a stronger focus on this principle. There are already the first success stories from hospitals or hospital networks and with the Martini-Klinik there is even a much-cited example from Germany that can be used to illustrate this.

The Martini-Klinik, a private clinic with close relationship to the University Medical Center Hamburg-Eppendorf, specializes in the diagnosis and treatment of prostate cancer. It covers everything from diagnosis to therapy “under one roof” and, thanks to this form of organization, already enables more patient-centered treatment. In a Germany-wide comparison, the Martini-Klinik achieves outstanding results in terms of continence and potency preserving outcomes that are extremely important for the patients. In addition to other factors, the consistent outcome measurement and the continuous development based on it are the key to this success.

The clinic is managed by a team of doctors who complement each other in their skills and areas of expertise, and when making decisions, they try to involve the opinions of different specializations. Outcomes are also used by the surgeons as a quality control for their own operational performance and are regularly compared in the team. This peer-to-peer comparison creates a form of “coopetition” – a mixture of competition and cooperation. Team members try to outperform one another, but achieve optimal results by learning from one another.

Today, just 15 years after it was founded, the Martini-Klinik is the largest prostate cancer center in the world. There are patients who come from other countries to be treated at the Martini-Klinik. This clinic is one of the few in Germany that publishes aggregated outcome data including PROMs directly on its website. The clinic has negotiated contracts for integrated care with the five largest German health insurance companies, in which the Martini-Klinik committed itself to complying with fixed quality targets. These contracts also made it possible for the Martini-Klinik to treat patients with statutory health insurance.

This example shows: Service providers who get involved in the measurement of their results, initiate a learning process based on this and make targeted changes through public reporting, could win more trust and patients for themselves or conclude selective contracts based on quality with health insurance companies.

The health insurance companies can also benefit from the high quality of treatment and better health of their insured. Prevention, optimal treatment and good disease management can contribute to more years of life with a better health and help to reduce the need for expensive acute care and inpatient stays.

To sum up, to enable more patients and other stakeholders in the health care system to benefit from the approach, the system needs to be realigned and redesigned. So far, examples of successful implementation of VBHC in Europe can be found at the level of the service provider. We have also analyzed and portrayed some of them in the EIT Health publication.

Simon: Does digitalization in medicine, for example telemedical applications, play a role to relation to value-based healthcare?

VBHC is clearly also a data-driven health care system: data on the course of treatment and its results, but also on costs, are collected. Combined with all the other data that hospitals and health insurance companies collect (increasingly also that patients themselves generate), this could provide interesting insights. VBHC also implies a learning health system in which knowledge gained from data leads to actions, which in turn are evaluated using data and lead to new actions.

Digitization can also make a major contribution to patient-centered health care: Digital technologies bring medicine to where patients are, information gaps can be closed more effectively and processes can be accelerated.

In all of this, it is important that the applications are actually designed to meet users’ needs and also protect their privacy.

Simon: How do you see the general development towards digital medicine?

The COVID-19 pandemic certainly had a catalytic effect on developments in the field of digital medicine. Acceptance and users’ demand and offers have increased significantly.

The Digital Care Act (DVG) passed by the German parliament at the end of 2019 meant a boost for digital transformation, both in Germany and internationally. An important part of the DVG is the introduction of reimbursement for Digital Health Applications (DiGA). After the application has been checked, it can be added to a central register of health apps. The apps that are listed there can be prescribed by doctors and physiotherapists and reimbursed by all statutory health insurances in Germany, which together cover almost 73 million people.

The law thus creates a basis for testing the introduction and dissemination of Digital Health Applications (DiGA), gaining experience and promoting incremental improvements.

Overall, I am pleased to see that things are going in the right direction in many ways. From my point of view as a doctor, however, the development is currently still heavily driven by industry. I would like to see even more involvement of patients and medical professionals here, from design to implementation. The “end-user” perspective could help identify further problems, contribute to targeted solutions, gain more trust and ensure that important aspects remain protected.

Simon: Thank you for the interview!