Why is medical care so extensive


How effectively these new opportunities can be used also depends on how well the healthcare system can keep up with the new developments.

Health is a state of complete physical, mental and social well-being - this is the famous definition of health by the World Health Organization (WHO). More than 70 years after it was formulated, its broad claim remains unchanged. Medical care, on the other hand, seems anything but unchangeable. In books, at congresses, in politics and the media: There is discussion everywhere as to whether the “medicine of the future” should be nothing more than caring for sick people.

Maintaining health instead of chasing illnesses therapeutically, this change in the medical self-image is gaining more and more supporters. Behind this are several major trends that the health care system has not just been confronted with since yesterday, but which have experienced enormous dynamics in recent years, above all the sharp increase in knowledge about molecular and other causes of diseases and digitalization.

Genetic changes are turning cancer medicine inside out

The investments in biomedical research over the last few decades have resulted in a better understanding of what exactly happens at the molecular level when a person becomes sick. What this leads to can best be illustrated with cancer. Cancer specialists are now no longer only interested in the tissue of a patient with lung cancer or salivary gland cancer, but also, or above all, in the genetic analysis of the tumor. It reveals which molecular mechanisms contribute to the respective cancer - and it gives valuable information about which treatments are useful - and which are not.

The importance of genes became evident in September, when a cancer drug was approved for the first time in Europe, completely independent of a specific cancer. Larotrectinib can be used for all kinds of cancer, provided there is a very specific genetic defect, an NTRK fusion. This is the case in most patients with salivary gland cancer, but in lung cancer it affects only a few patients.

Experts assume that such “tumor-agnostic” drug approvals will become more and more common. But is the healthcare system prepared for it? In any case, Germany is far from having comprehensive access to modern gene sequencing. But this is the prerequisite for many of the new therapeutic approaches. The German Society for Hematology and Oncology recently emphasized this. The question of reimbursement is also often unclear. The complicated procedure of benefit assessment and pricing in Germany is not made for innovative and very effective treatments that are approved very quickly.

Recognize earlier, treat earlier?

More knowledge about molecular mechanisms (and other influencing factors) also means that diseases can be detected earlier and earlier - sometimes before they even arise. So far this has only happened in isolated cases. In the case of hereditary breast cancer, for example, prophylactic removal of the breast is recommended in certain constellations. It is more difficult with Alzheimer's disease. With modern imaging and laboratory diagnostics, patients can be recognized here today, long before they become “sick”, that is, the first memory disorders occur. Experts advise against this early diagnosis because there is no preventive treatment.

But what if there are treatments that are effective, but that also have risks? Medical advice will then be very difficult and there will be many situations in which knowledge from clinical studies does not help. It is possible that at some point there will be big data algorithms that can use artificial intelligence and dozens of biomarkers to identify the individual risk of disease very precisely. How such software is then actually used and what clinical research could look like in such very early stages of the disease is completely open.

How and where digital tools can help

The use of artificial intelligence to estimate the individual risk of illness is currently largely a long way off. In other places, however, digitization has long since made completely new supply scenarios possible. The Professional Association of German Dermatologists (BVDD), for example, started a new telemedicine project at the end of September, the OnlineDoctor, which can be accessed via the association's website. Patients can send photos of skin findings there, and the consultation takes place via data line - without a visit to the practice, without a waiting room.

The new thing about the offer is that every resident dermatologist can participate. This has never happened before in Germany, but it did in Scandinavia, Switzerland and France: "Experience from Switzerland shows that patients usually look for a doctor in the area," says BVDD President Klaus Strömer. "This is advantageous if it turns out that the patient should come to the practice better." In any case, the dermatologists are very impressed: "The response is better than in any other project that we have started."

Offers like the OnlineDoctor not only relieve the office hours, they can also help close gaps in supply in underserved, rural regions. The first so-called OhneArztPraxis, which opened in mid-October in Spiegelberg in northern Baden-Württemberg, goes one step further. As the name suggests, there is no doctor in the practice, instead there is a specially trained nurse who can call on doctors if necessary via video conference or online request.

The nurse makes extensive use of digital tools in order to be able to offer a high quality of care. In this way, 12-lead ECGs and examinations of the ear canal can be diagnosed telemedically. And there is a digital stethoscope that helps record heart sounds and forwards them directly if necessary. "We don't want a practice that is only assigned to one doctor, we are thinking of a hub that different specialists can access," says Dr. Tobias Gantner from the company PhilonMed, which runs the practice and employs the nursing staff. In perspective, she could also work independently as a kind of franchisee, says Gantner.

Implementation of digital care in Germany remains difficult

The examples "Telemedicine at dermatologists" and "OhneArztPraxis" show how digitalization could fundamentally change medical care. But they are also good examples of the hurdles that continue to be put in the way of innovative, digital supply projects in Germany. The dermatologists have designed their telemedicine platform as a self-pay offer. A consultation costs 39 euros. The current reimbursement catalogs do not provide for health insurance benefits for exclusively telemedical contact. What is also not yet available are recipes, because they would have to be created electronically during an online consultation - a foreign word in Germany. In several Scandinavian countries, on the other hand, prescriptions are already 100 percent digital: The patient receives his prescription via app and can redeem it wherever he wants. In Sweden in particular, pure online contacts to doctors are used extensively.

Even with the OhneArztPraxis, the financing is unclear. The project is running because there is funding and the district is financially committed. It remains to be seen whether funding from health insurance funds will ultimately succeed. Specialized nurses in their own practice are a new professional group, and the German healthcare system does not welcome newcomers with open arms. The medicine of the future has to fight in the land of the great innovators Robert Koch and Rudolf Virchow.

The big trends

The medical industry is facing a radical change. What are the key drivers of innovation in the areas of prevention, diagnosis and treatment?

■ Prevention and early detection. Scientific research, technical miniaturization and advances in diagnostics mean that more and more diseases can be detected very early - often before the patient has symptoms. This places completely new demands on the treatment and also on clinical studies.

■ Diversification. Diseases that were previously considered uniform are now being divided into numerous subgroups thanks to new scientific knowledge.

■ Personalization. Treatments are no longer “off the peg”, but are tailored more than before to the individual and his or her individual risk profile. This increases the importance of laboratory and device diagnostics, among other things.

■ digitization. Online consultation hours, apps and mobile sensors as well as electronic patient files make medicine more independent of individual institutions, so that new, patient-friendly care concepts are emerging. Artificial intelligence ensures better access to technical expertise and a more constant quality of care.

The most important brakes on innovation

The German health system was conceived under Otto von Bismarck, and sometimes it seems as if it has stopped there. Some examples:

■ Innovation brake on reward. There has been a billing number for video consultation hours in the German health care system for two years, so that outpatient doctors can in principle use them for follow-up contacts. At less than 10 euros, the payment is so unattractive that this type of telemedicine never got off the ground.

■ Infrastructure brake on innovation. Despite almost 15 years of work, the German healthcare system still does not have a digital data highway through which all doctors, hospitals and pharmacists can reach each other. The result: German doctors are world champions in sending faxes and telephoning afterwards.

■ The brake on innovation. When medical services are to be provided by other professional groups, there is regular shouting. Projects that try to do this take years of preparation.

■ The brake on innovation, wrongly understood data protection. As part of the medical informatics initiative funded by the Federal Ministry of Research, health researchers have been trying since spring 2018 to coordinate a patient declaration of consent for electronic patient files with 16 state data protection officers. In vain until today.