Can MEPS doctors diagnose you

Doctors and AOK warn: Changes in the law jeopardize targeted and adequate treatment of patients

(11.12.19) The Alliance of German Medical Associations and the AOK warn that numerous contracts for the better care of patients with serious illnesses are at risk due to planned changes to the legal requirements. With the "Law for a fair GKV-Kassenwettbewerb" (GKV-FKG) contracts between doctors and health insurers, in which certain illness diagnoses are mentioned as a prerequisite for remuneration, are to be declared generally inadmissible in the future. "Despite all the warnings and protests, the problematic regulations are also included in the latest version of the draft law. They drastically affect the design of existing and future supply contracts," says Dr. Werner Baumgärtner, CEO of MEDI GENO Germany and representative of the Alliance of German Doctors' Associations in a joint press conference with the AOK. "There is a risk that particularly innovative supply concepts will simply be made impossible in the future."

The medical associations shared the legislator's concern that there should be no separate remuneration for doctors for the documentation of specific diagnoses without a corresponding benefit reference. With the planned changes, however, the legislature is clearly overshooting the target: "Here, the child is thrown out with the bath water," said Baumgärtner. "If a supply contract with the health insurances is to achieve a targeted and adequate treatment of the patients, we still need the possibility that the diagnoses are described as precisely as possible in these contracts."

The AOK agrees with the doctors' demand: "Remuneration for services that, for medical reasons, are only agreed for patient groups with certain illnesses, should continue to be permissible," says the chairman of the AOK Federal Association, Martin Litsch. If the text of the GKV-FKG is not changed at this point, numerous regional supply contracts that the AOK have developed and successfully implemented with its medical contract partners in recent years are at risk. As examples he cites a care program of the AOK Sachsen-Anhalt for patients with chronic kidney diseases or the specialist program of the AOK Baden-Württemberg. Regional contracts for patients with lung cancer, diabetic foot syndrome or with mental illness are also affected.

"The precise definition of the diagnoses and the necessary medical measures ensures that a fair and cost-based remuneration for the doctors can be agreed," emphasizes Litsch. He protests against the claim that doctors and health insurers use these contracts to jointly systematically manipulate patient diagnoses. "To this day, this claim has never been substantiated or arrested in a court of law. And I absolutely cannot imagine that doctors consciously manipulate diagnoses for a few euros and make their patients sicker on paper than they are," said Litsch. In their statement on the GKV-FKG, the federal states had also called for improvements to the planned regulations. "They were rejected outright in the Federal Government's counter-statement - on the grounds that it was still possible to state a diagnosis in the contracts. That must be clarified in the legal text," demands Litsch.

Baumgärtner points out that, according to the explanatory memorandum to the legal text, further payments for certain illnesses should be possible, provided that they are linked to the chapters or main group structures of the international system for the classification of illnesses (ICD) or to a "general concept of illness". "On closer inspection, however, this apparent defusing is not at all because it does not work," he criticizes and illustrates this with an example: "If you can only write the ICD group diabetes mellitus in a contract for the care of diabetics, then it remains completely It is unclear which type of diabetes is meant, because this group includes both diabetes mellitus type 1 and diabetes mellitus type 2. These are two completely different diseases that have different causes and affect different patient groups, "said Baumgärtner. He warns of a "setback in health care policy" due to the planned changes: "We appeal to the legislature to maintain and further strengthen the necessary innovation potential and scope for evidence-based care and contract design for the benefit of patients."

In a resolution at the beginning of September, the Alliance of German Medical Associations spoke out against a ban on specific treatment diagnoses as a prerequisite for reimbursement of services. The resolution was initiated by the Association of German Internists (BDI), the Association of Specialist Medical Associations (GFB), the Hartmannbund, MEDI GENO Germany, the NAV-Virchow-Bund and the leading association of specialists in Germany (SpiFa). She is also supported by the Federal Association of Resident Cardiologists (BNK), the Professional Association for Orthopedics and Trauma Surgery (BVOU) and the German Association of General Practitioners.

(Joint press release of the Alliance of German Medical Associations and the AOK Federal Association)