Three questions – three answers: Dr. Stefan Knupfer, Board of Directors at AOK Plus

The 2b AHEAD expert network in dialogue. Health experts regularly raise relevant questions on the future of health. Other experts from our network comment on this – and in turn ask new questions that will go to new experts. In this way, an inspiring dialogue grows and we will continue to expand it.

Focus today: Dr. Stefan Knupfer from AOK Plus

The expert questions today go to Dr. Stefan Knupfer, Deputy Chairman of the Board of AOK Plus for Saxony and Thuringia, based in Dresden. In 2006, Dr. Knupfer was appointed as an authorised representative of the Management Board. With the merger to form AOK PLUS, he assumed the role of Managing Director of the Market Division. Since 2011, he has worked as Managing Director of the Finance/Controlling unit and authorized representative of the Executive Board.

The future of the principle of solidarity in an ageing society

Peter Ohnemus, DacadooPeter Ohnemus, founder and CEO of Dacadoo: How can the principle of solidarity be financed in a world where we live to be 85 years old on average and where 30% of the German population will soon be 65+? 

 

Dr. Stefan Knupfer, AOK Plus

Dr. Stefan Knupfer, Deputy Chairman of AOK Plus: The logic underlying the solidarity principle to this day is based on the assumption that an ageing society must also be a sicker society. I think this approach is obsolete.

Isn’t it rather the case that older people stay healthy longer and age healthier? Isn’t it also the case that ageing people today have better and cheaper therapies available than a few years ago?

The main burden of health expenditure in a person’s life lies in the last three years of life and is significantly higher for chronically ill people than for those who are not chronically ill. So is it not much more sensible to focus on the prevention of chronic diseases at this point? I think that the digital transformation offers numerous opportunities here, the potential of which is currently far from being sufficiently exploited.

The fact is that both medical progress and, in particular, digitalization are progressing at a rapid pace. This is accompanied by numerous opportunities that have not yet been exploited, or only insufficiently exploited, to make health care more efficient and different, without losing sight of the well-being of the individual in an ageing society.

In addition, the social and economic system in Germany is currently essentially based on private property, whereby a redistribution principle or the approach of a Sharing Economy has so far had little effect. As a result of demographic change and increasing tendencies towards individualisation, the solidarity principle of statutory health insurance schemes is getting into difficulties. In the future, this will pave the political way for a citizens’ insurance to provide basic services or a new financing of the solidarity principle through tax subsidies, e.g. from a financial transaction tax.

In the future, distributive justice will have to play a greater role. Health will become a public good. Particular challenges lie in the equitable distribution of health resources and in equitable access to health prevention and care for all people, regardless of their origin or income. Rationalisation through digitisation alone will not be enough to compensate for cost pressures from medical progress and demographic change, making the question of alternative system logic unavoidable.

In a sharing economy based on distributive justice, everyone has equal access to medical-technical innovations. Trends such as increasing “medical tourism” in the sense of cross-border use of medical services and the increasing willingness to share data also necessitate a fundamental rethink. In my view, Big Data can be a new “currency” and replace obsolete causality arguments. In times of digital transformation, an idea of solidarity extended by the data division dimension will continue to express the will of people to stand up for each other in the future.

Experimental medicine for terminally ill patients

Liz Parrish, BiovivaLiz Parrish, Gründerin und CEO von Bioviva: Do you believe that terminally ill patients should have access to experimental medicine? Please explain.

 

 

Dr. Stefan Knupfer, AOK PlusDr. Stefan Knupfer, stellvertrender Vorsitzender der AOK Plus: In my opinion, experimental medicine represents the basis of all therapeutic interventions, as it lays the foundation for further clinical trials with proof-of-principles experiments.

Experimental medicine makes it possible to understand human diseases, so as their origin, their pathogenesis and their effects on the organism in general and to develop new effictive therapies of various kinds from this understanding. Experimental medicine usually means basic research – of course with the aim to improve practical therapeutic action at the bedside.

However, until the findings of experimental medicine are actually available at the bedside, often a lot of time passes – time that a terminally ill person may no longer have. Such a terminally ill human being, fully aware of and fully aware of his situation, and freely to choosing to do so should, in my view, have access to experimental medicine – that is, to medical interventions that are not yet fully ecidence-based for health care.

The key point, however, is that terminally ill people are often no longer able to make such a decision of full consciousness and full willpower themselves. Here I see an ethical fundamental question of our society that urgently needs an open discourse: how do we deal with the advanced medical options we now have to artificially keep people alive? May trusted people speak for terminally ill relatives, ie act in their (presumed) will when it comes to choosing experimental medicine as a last resort or even providing a terminally ill relative for further basic research?

So far, there is no social consensus, no “modus operandi”, which is carried by all people. In this respect, a generalized answer to the question of access to experimental medicine for terminally ill people, which can only be answered individually, is currently not possible.

The doctor as “health pastor”

Frieder Hänisch, Limbach GruppeFrieder Hänisch, Business Development, Limbach Gruppe: Is the essential role of the physician in the future still the “health pastor”, who brings about the therapy decision and has a competence advantage over technical services (e.g. ADA-App), or is he only needed as a legal entity for liability issues in the health care system?

Dr. Stefan Knupfer, AOK PlusDr. Stefan Knupfer, stellvertrender Vorsitzender der AOK Plus: To start with, a counter question: Is the doctor really a “health pastor” today? Is he not rather a quite rational “health status surveyor” and a therapist of often only symptoms, but not of systemic and dynamic states – because illness and health are not static entities?

The so-called “talking medicine”, which places high demands on the social skills of the physician, has in recent decades actually stepped more and more into the background of medical activity. However, I believe that this trend will again develop in the direction of a return to what we call “pastoral” competences. Social competences, a high degree of empathy and the ability to advise and perhaps even coach other people will play a decisive role in the role of the physician in the future.

Similarly, physicians will be required to have a much greater understanding of digital applications in the future, because they will support the work of physicians on patients to a much greater extent in the future. The role of the physician will be between the physician as “Life Scientist” and the physician as “Mental Scientist”.

The information asymmetry between doctor and patient is decreasing more and more, which means that mature and well-informed patients will expect the best possible offers from a doctor for their respective health situation in the future.

Three questions – three answers: Frieder Hänisch, Limbach Gruppe

The 2b AHEAD expert network in dialogue. Health experts regularly raise relevant questions on the future of health. Other experts from our network comment on this – and in turn ask new questions that will go to new experts. In this way, an inspiring dialogue grows and we will continue to expand it.

Focus today: Frieder Hänisch from the Limbach Gruppe

The expert questions today go to Frieder Hänisch, Project Manager Business Development at the Limbach Gruppe based in Heidelberg.  The Limbach Gruppe was founded as an association of independent laboratories and is the largest owner-managed laboratory group in Germany.

Asymmetry of knowledge

Peter Ohnemus, DacadooPeter Ohnemus, founder and CEO of Dacadoo: DNA testing is becoming more powerful and cheaper. How will we manage this asymmetry between customers and health insurers in the future? The customer can know everything about his clinical picture and the health insurance companies simply have to pay “blindly”?

Frieder Hänisch, LimbachgruppeFrieder Hänisch, Business Development, Limbach Gruppe: There are two scenarios in which genome sequencing is used in a way that can be experienced by the individual: Diagnostic sequencing based on a case of illness or sequencing on behalf of a customer for self-payers.

In the case of a disease, genome sequencing is indicated in a selection of disease patterns for therapy decisions. In Companion Diagnostic, the most effective drug is selected on the basis of the individual genome. Prominent examples are oncological diseases such as breast cancer. Here, medicine has learned that the drugs originally developed are ineffective in some patients because the mechanism of action of the drug cannot interact with the cell receptors. In 2017, however, there were only 14 disease entities for which such a procedure can be used meaningfully.

In my view, there is no asymmetry in this scenario. Both the patient and the health insurance company have a high degree of interest in the fast, target-oriented and thus also most cost-effective therapy.

In the case of a healthy payer, the knowledge of the genome information has to be considered from both sides: A) the information is available to the health insurance company but not to the contributor, and in the opposite case B) the genomic information is available to the contributor but not to the health insurance company.

A) The health insurance company corresponds to an insurance company in its business model. It therefore always has an interest in knowing individual disease risks and their probabilities of occurrence in order to control the business model via the contribution rates. In extreme cases, this means measuring premiums on the basis of the individual genome. As long as society does not block it by ethical norms and legislation, the procedure described is likely to be followed in the future.

It should be mentioned restrictively that the genome only permits statements about the probability of occurrence for a selection of diseases. In my view, knowledge about the Internet browser history of a health insurance fund member is much more meaningful for the formation of risk models than genetic information.

B) The current commercial offers for genome sequencing such as “23andMe” (genome sequencing service for 99 USD, as of November 2018) or MyHeritage present themselves more as lifestyle products for enthusiasts and genealogists. In essence, there is another question at the forefront: Does a psychological factor come into play when private genome analysis provides a probability of illness for serious illnesses that can only occur in the middle phase of life? Huntington’s disease, for example, does not break out until around the age of 40. Knowing a predisposition can lead to an enormous increase in psychological stress. The right of knowledge contrasts with the right to conscious ignorance.

I would not speak of a “blind payment” by the health insurance companies. A payment is made in case of illness, not in case of the probability of a future illness. Furthermore, on average 80% of the individual health costs are incurred at the end of life due to intensive medical care (about the last two years of life). From this fact out I consider the information advantage of an individual by knowledge of its hereditary information negligible for the health system.

Personalization vs. data protection

Arkadiusz Miernik, Universität FreiburgArkadius Miernik, Professor at the University of Freiburg: How will the further development of data-based, personalised treatment approaches be possible if data protection requirements become increasingly strict?

 

Frieder Hänisch, LimbachgruppeFrieder Hänisch, Business Development, Limbach Group: Thank you very much for this very up-to-date and important question. It is also a complex question.

Even today, without personalized treatment approaches, pharmaceutical research faces the great challenge of identifying the ideal patient population and including it in the later phases of clinical trials. Since the statistical effect strength of the new treatment approach must exceed that of the treatment previously used, the choice of study group per se is becoming increasingly difficult. The fundamental hurdle is therefore the study design and only much later data protection.

Data protection becomes relevant if the largest possible data pools are to be created over a longer period of time and then evaluated. In other words, all studies that use a big data approach. On the scientific side, I’m a little sceptical about the use of Big Data. More data does not necessarily mean better data. For me, the most important question here is the minimum data set that is required to answer the question.

I see the use of new technologies such as blockchain technology as a promising solution. It offers the possibility of a validated and complete documentation of the used data (smart contracts). This technology makes it possible, for example, to link the personal data of study participants with a token. Each use of the data in the sense of an analysis should generate a traceable transaction. The data owner thus has the option of controlling the use of his data and retaining decision-making authority similar to copyright. A little further thought can also result in new payment models for the use of personal health data. The study participant deposits the data anonymously and, in the event of a request for use from a study, can release the transaction, if necessary even for a usage fee.

Unfortunately, as far as I know there is no implementation of this technology yet, so this thought experiment has yet to prove itself in reality.

Interaction of the physical and the mental

Florina Speth, 2b AHEADFlorina Speth, Senior Researcher, 2b AHEAD ThinkTank: The interplay of our mental and physical state is often still ignored in the Western medical world. How will this develop in the future?

 

Frieder Hänisch, LimbachgruppeFrieder Hänisch, Business Development, Limbach Gruppe: In contrast to physical diseases, which are described and understood very well in molecular terms, mental diseases are predominantly phenotypically characterized. Similar symptoms are interpreted as similar diseases. Since the symptoms and intervals of the disease phases are very broad in the area of mental diseases, this basic assumption may lead to a misleading classification of disease patterns. It would be better to classify according to the molecular profile. As an analogy, the reclassification of bacteria based on findings from genome analysis should be mentioned here.

Furthermore, the diagnosis of mental diseases is essentially dependent on standardized questionnaires, in which the patients’ self-awareness contributes to the diagnosis and is also based on the psychologist’s subjective experience. Although biomarkers for diagnosis are in research, they have not yet gained market acceptance.

However, the further development of this field of science is clearly recognizable and the standard work on the classification of mental diseases “Diagnostic and Statistical Guide to Mental Disorders” (DSM-V) increasingly refers to the basic molecular events.

Neurodegenerative diseases – such as Alzheimer’s dementia – are diseases of old age. Life expectancy worldwide rose from 50 years in 1960 to over 65 years in 2010. This increase by 15 years has unmasked these clinical pictures. They have always been there, but their symptoms were hardly relevant because other diseases had already led to death.

These orthodox medical examples show a developing understanding for the mental impairments also in the western world. With reference to your initial question, I cannot name any good reasons in Western medicine for this strong physical focus. In Asia this connection of body and soul is, in my opinion, also based on the religious world view. In Japan every object is attributed a soul, which is a completely different basic understanding than our western division into organic/animated and inorganic substances.

 

The healthy pace: Alexa vs. card

Two messages that @medinfode pointed out this week: Alexa learns diagnostics and the German Handelsblatt reports a breakthrough in electronic patient records. In their random juxtaposition, they form a lesson about the importance of speed: the healthy pace makes the healthcare of the future.

Doctor Alexa

Message one: Amazon is working on Alexa recognizing possible diseases by the human voice. I have already reported on similar approaches in connection with Beyond Verbal. And Amazon is already in the spotlight here in the blog as one of the key players in healthcare. As early as 2017, Amazon applied for the corresponding patent on the algorithm. Now this has been granted. In a nutshell: It is well known that Alexa constantly listens to what happens in the environment of the smart loudspeakers. With this development step at stake, Amazon is moving on to scanning the voices of the environment for diseases: Coughs and sniffles, but apparently also depressions. We futurologists have long predicted this: emotion becomes a natural part of data collection and analysis.

The benefits for Amazon are obvious. Anyone who knows the physical sensation of a person can address him personally at a decisive point. If you hear coughing, you can play out personalized advertising. And what’s more, they can also suggest orders and sell healing products. And, by the way, this creates an almost perfect usecase for models with ultra-short delivery times. DocMorris is currently advertising its online services nationwide with the slogan “Those who should stay in bed should not have to go to the pharmacy”. This logic is already outdated here: If you have the right smart speaker, you don’t even have to go to your online pharmacy.

Doctor with card

The other success message – and yes, it is a success message: The most important players in self-administration in the health care system of Germany have agreed on a policy paper that should provide us with a first form of the electronic health card for everyday use by 2021. This is a) more than has been achieved in the past 15 years. But that’s b) just exactly what it is: a paper. We have agreed on what the doctor´s associations should process and what the Gematik should process.

The key data sound promising: the patient retains sovereignty over the data. We at 2b AHEAD predicted in a large study as early as 2015 that this is where the future lies. Uniform standards should ensure broad application. And at least the Federal Minister of Health can already be quoted with the statement that the card is after all only one of potentially many access routes. The network structure in the background is decisive. And the health insurances publicly agree: A deviation is no longer possible without loss of face. On the other hand, who hasn’t actually lost face in the years since 2004? No one has been disturbed yet.

The healthy pace

And here is the connection: The one factor that is repeatedly underestimated in prognoses on artificial intelligence is its learning speed. Once in the world, the growth of performance continues to accelerate. Prerequisite: A sufficient amount of data is generated in the system. The fact that this is the case is unlikely to be seriously debated with Alexas’ market penetration. The forecast is characterized by a healthy pace. Some people program network standards, while others use algorithms to evaluate large amounts of data. Some are imposing sanctions on doctors to purchase suitable reading devices, others are having algorithms evaluate large amounts of data. Some hope for Gematik’s first successfully completed project, others have algorithms evaluate large amounts of data.

Who wins? Exactly.

Demographic change and healthcare: Good News

Demographic change and healthcare: The core business of health insurance in the future will no longer just be healing the sick. Health insurers will support healthy people – from the prevention of diseases to increasing well-being and life expectancy. This is the result of a current trend study by 2b AHEAD ThinkTank. Demographic change has a direct impact here.

Trend study health insurance

The healthcare sector will undergo unprecedented change by 2030. With digitalization, the possibilities of medical research, diagnostics, therapy, rehabilitation and prevention are growing at exponential speed. These effects are nowhere more evident than among the fastest-growing groups in our society:

  • The old who don’t feel old even when they retire,
  • the still older, who in many cases can still lead an active and active life, and
  • the very old, still rare today, soon an everyday occurrence.
The good news

The majority of today’s forecasts and future studies address demographic change as a problem and a threat. Of course, it will present us with social and economic challenges of an unprecedented scale. But for both individuals and our communities, demographic change represents the greatest conceivable progress: the considerable extension of one’s own life in activity and self-determination. Demographic change may be expensive news, but above all it is good news.

People born in this decade realistically reach an age of over 100 years. It is the interaction of four influential drivers that brings the dream of longer life within reach. The first condition is the freely available gene analysis. The second development concerns the breeding of individual copies of internal organs, which may be optimised compared to the previous version. The third prerequisite is a comprehensive understanding of the aging processes of humans. The fourth element is the synchronization of the human psyche with the virtual world. A breakthrough in research in all four fields is likely in the coming years.

For the sake of completeness: There is a well-founded opposite position to this, especially taken up here in the blog. It is represented among others by the medical ethicist Ezekiel J. Emanuel. He fears extension as a phase of helplessness and diminishing dignity.

The increase of well-being

A decisive change in dealing with human health is the disappearance of the binary assumption that a patient is either healthy or ill. This categorical distinction has always been a fiction anyway. Nobody’s just sick or just healthy. Instead – assuming the corresponding amount of data and its continuous collection – the individual well-being can be measured and located on a scale. This is changing the goal of medical action. While yesterday the focus was on repair and damage prevention, tomorrow it will be on gradually improving one’s own well-being. What can I do to feel a little better tomorrow – and who will support me? The enlightened healthcare customers of the future are very consciously and with the support of digital assistance systems selecting the most competent physician for their situation, the appropriate insurance and the trustworthy data manager from their individual healthcare network. At the same time, they will no longer accept that the interaction of several service providers is associated with increased effort for them.

In the near future, evidence-based, personalised recommendations for targeted prevention will replace the always identical bonus booklets of health insurance companies and lump-sum and overall undirected health-promoting measures.

Test Case Robotics in Nursing

This can be clearly seen in the emergence of robotics in care. Robotics became a widely accepted matter of course in the course of the 1920s. This has long been the case in the field of dementia care. The fact that a robot has the patience to listen to the same question, the same story, the same excitement over and over again as it did the first time makes this development even easier.

However, the development will not be limited to animated stuffed animals. This is shown in the example of medication. Where nursing staff still have to work by hand today, the procedure is time-consuming and prone to errors. The next step is automated dispensing of medication to the patient at home: individual implementation of the medication plan by a pill robot. In the next step, robots learn to analyse the state of health of humans. By blood sample, air analysis, nutrition tracking, later by observing the skin temperature, the movement patterns and by voice analysis. The dosage of the active ingredient is calculated in real time.

In the next expansion stage, the medication robot is able to print the individually appropriate active ingredients onto a carrier directly before ingestion. Is this a relief for the nursing service? With great certainty. Does this development, and thus indirectly the demographic change, have the potential to improve the well-being of the individual patient? With a very high probability. These are the simple questions. But whose knowledge is the robot`s work based on? As soon as he has access to networked medical knowledge, his professional competence will always be higher than that of the individual doctor. For the time being, the family doctor is still needed to issue prescriptions, which also makes up for a reason to exist professionally. His profession will change permanently, a thesis that Markus Bönig of Vitabook has just confirmed here. The medicines or active ingredients do not have to be purchased in the pharmacy around the corner anyway. This opens up completely new business areas for new players.

Smart Home

An additional driver of this development is the currently exponentially growing networking of buildings, starting with Ambient Assistant Living. The smart home of the person in need of care is the first and most competent care robot. This means that completely new players are suddenly active in the health industry: Network operators, property managers, building contractors, manufacturers of electronics and sensor technology. This, too, is an indirect consequence of demographic change.

Health insurers as the health promoters of the future must start much earlier in the process, which means that they will occupy a much more active and positive position in the perception of health customers. The one-size-fits-it-all-principle has had its day. In future, health promoters will not react only when health customers are ill, but will continuously monitor their current state of health and act before the onset of a foreseeable illness. This too: That’s good news.