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Nürnberg - The German medical system is doing away with a dispassionate middleman and learning from the mistakes of the past. Alf Reuscher MD reported on the changing state of medicine for the German ophthalmologist in private practice today at the 13th annual meeting of the German Ophthalmic Surgeons. An active member of the German Ophthalmologist Professional Association (BVA), Ophthalmic Surgery Division, Dr Reuscher predicted big changes within the next four years. Among the most probable and indeed welcome of his predictions is the end of what he called the cartel-like Kassenärztliche Vereinigung (KV). The KV is the German association responsible for distributing federal health care and insurance monies among the different specialty groups, or the 'middleman'. The KV was established to help ensure outpatient care among private practitioners of all specialties, and negotiate with the state-run insurance companies appointed to carry out the task. The KV has a stranglehold over any physician in private practice who treats state-insured patients, whether the physician is involved in a private office or private clinic. Yet the KV does not represent their interests or needs. This has been frustrating and sometimes devastating for private practice, he explained. The usefulness of the KV as mitigator seems to have worn thin, as patients, physicians, insurers and the Federal treasury point fingers at one another, at a loss to account for or admit to on-going budget deficits. Many believe the system would benefit if physicians and insurers dealt with one another directly. Recently, an unprecedented case in point reflected the state of affairs as it affects ophthalmic surgery. Ophthalmic surgeons in private practice were put in the position of billing their state-insured patients for cataract surgery directly, without the help of the KV as negotiator or the promise of the insurer to cover expenses. This occurred when a major Hessian state insurance firm suddenly ended its contract with the KV, leaving the patients and surgeons puzzling over what to do. State-insured patients - an enormous group comprising most public and private employees - do not pay for cataract surgery out of their pockets. This procedure is covered, and 'neatly' taken care of between the surgeon, the anaesthesiologist, the operation centre, the insurer, and the KV. The patients were suddenly obliged to pay for the surgery (and all other costs), themselves, resulting in an onslaught of complaints and extra paperwork in order to be reimbursed. Dr Reuscher foresees that other insurances will follow suit and dissolve their contracts with the KV as well, suggesting that the 'middleman' may be unnecessary. In the wake of these changes within the German health system, the German Ophthalmologist Professional Association (BVA) is stepping forth to represent ophthalmologists in private practice. They remain the only democratically structured association that is qualified and committed to doing so. Limiting physicians and patients On another front, newly devised disease-management programmes are planned for the new year which will set new specifications regarding the treatments that insurances cover, and detail which physicians are enabled to carry them out. The general practitioner will be charged with a sort of 'gate-keeping' function. Dr Reuscher foresees that these upcoming changes are likely to cut into a patient's choice of treating physician and limit the physician's choice of therapy as well. Although these may only marginally affect ophthalmologists, the planned increase in quality assurance measures are likely to limit the number of treatments an eye doctor is allowed to perform. New budgets and treatment categories top off the list of changes and have specialists again wondering which treatments will be included in their budget and whether the proffered payments will cover the actual expenses of the treatments - a problem German eye surgeons have encountered before. Vitreo-retinal surgery, for example, will not be included in the ophthalmic surgeon's budget at all. Uninsured treatments will most likely necessitate private billing. Patients will have to choose between not having the treatment and paying for it themselves, which may not sit well with them. The ever-changing budgets, point systems, and reimbursement models, as well as the various individual contracts arising between the physicians or clinics and the insurers are causing a break-up in the once unified payment models, and leading to the tendency for some physicians to wish to square off independently. A new categorisation of treatments into Diagnosis-related-groups (DRGs) is planned to simplify the reimbursement plan. Under this new organisational idea, reimbursements paid to specialists for in-patient treatments or surgeries will be individually established, based on a patient's symptoms and diagnosis. In-patient surgeries are to include retinal detachments and some eye emergencies. Keratoplasty and glaucoma surgery will be reimbursed on either an inpatient or outpatient basis, again depending on symptoms and diagnosis. Most of the remaining ophthalmic surgeries are to be performed on an outpatient basis. This will greatly increase the quotient of ambulatory ophthalmic surgeries. Although they seem straightforward enough, DRGs have a major downside. Grouping treatments reduces the number of individual procedures the physician can account for. Ophthalmic surgeons, for example, will be permitted to perform and bill for 14 procedures. However, these were formerly categorised as 32 separate procedures. This basically means that a stationary laser coagulation, which lasts a few minutes, will cost as much (or as little) as stationary retinal surgery, which can last many hours and comprises a number of complicated procedures. All in all, it seems that inpatient surgery is being discouraged. Although, the German constitution claims the right of every citizen to choose an occupation and place of work, and specifies that no one can be forced to do a particular form of work, Dr Reuscher points out that these basic, constitutional rights are only partially true for physicians. German doctors are obliged by another set of laws to treat anything within their area of expertise. In short, even if the reimbursement does not pay for the actual costs of a procedure, the doctor is obliged by law to perform it, and not permitted to recommend the patient to another physician. According to Dr Reuscher, this is only a "limited" freedom, bound and regulated by the national government. In some cases, it also ends up costing the physician. Demographic factors Additionally, demographic factors will drastically influence eye surgery, namely an increasing number of older patients and a decreased number of doctors. An increase in the number of older patients means meeting the needs of the increased incidence of cataract, glaucoma, and macular degeneration cases. The outcome of the decrease in medical school applicants, medical school graduates, and even the numbers of medical graduates who went on to pursue a specialisation will surface in the near future in the form of a huge physician gap, he predicted. This gap will be strongly felt in the ophthalmologic field, particularly in surgery, as only 15% of German eye doctors are currently performing operations. Dr Reuscher maintains that the future need will lead to private eye doctors reconstructing their practices to incorporate surgery, or to enter into associations with operating private practitioners. In fact, the government plans to encourage mixed-specialty practice associations and small clinic formation by offering a 30% break. The BVA is aiming to change the official title given to eye doctors to state: 'Specialist for Ophthalmology and Optometry', as German optometrists, although obviously lacking a comparable, comprehensive medical background, vie with eye doctors for patients. Although an eye doctor with a 12 semester course of study and a five year specialisation may be deemed overqualified by some, Dr Reuscher maintains that it is the job of the ophthalmologist and no other to examine eyes. "The medical profession and its future are subject to the bureaucratic and highly differentiated nature of the state-regulated German Health System. The fundamental changes facing eye doctors today will break up static, out-dated structures, and hopefully improve patient care while offering ophthalmologists new options," he said. |
