The collective agreement regulations for statutory health insurance were supplemented in 2019 to include second opinion procedures. If an insured person is planning to have an operation on the palatine or pharyngeal tonsils (tonsillectomy, tonsillotomy), a hysterectomy, a joint endoscopy of the shoulder (shoulder arthroscopy), an implantation of a knee endoprosthesis, an amputation for diabetic foot syndrome or an operation on the spine , then in addition to the doctor who gave the indication (first opinion), you can also ask a second doctor for medical advice (§ 27b SGB V; Federal Joint Committee 2022). In issue 03/2022 of the “Monitor Healthcare Research” it was already possible to analyze billing data and catchment areas for selected indications in the Hesse health insurance area. The presumed influences and incentives on service provision and utilization were identified (Hartweg/Suk 2022). But in addition to these collective agreement offers, many health insurance companies have now also established their own second opinion procedures. These second opinion procedures are the focus of this article.

A central aim of statutory health insurance, in the interest of the insured community, is to guarantee contribution rate stability. This goal can be achieved in various ways. Generally, it is difficult to improve the revenue base of the solidarity-based system, as such measures would be immediately transparent to the largest stakeholder group, the contributors. Therefore, it seems more common to focus on the expenditure side and ensure the economical use of funds, particularly in the area of benefit payments. To (partially) manage the steadily increasing benefit expenditures in the healthcare system, a second opinion procedure has been established, particularly for surgical procedures. This procedure aims to ensure that all relevant medical information is available to patients prior to treatment.
Since 2015, patients with statutory health insurance have therefore been entitled to such additional medical consultation services. These are part of the collective agreement and relate to procedures on the palatine or pharyngeal tonsils (tonsillectomies, tonsillotomies), hysterectomies, shoulder arthroscopy, knee replacement surgery, amputations for diabetic foot syndrome, and spinal surgery (§ 27b SGB V; Joint Federal Committee 2022).
Health insurance companies in competition
As public corporations, health insurance funds are subject to a legal obligation to contract, which means nothing other than that health insurance funds must grant those subject to compulsory insurance and those entitled to insurance admission to the solidarity community if the legal requirements are met.
(Section 175 Paragraph 1 of the German Social Code, Book V). Since 1996, the competitive landscape for health insurance funds has intensified significantly. Since then, all insured individuals have had comprehensive freedom to choose their health insurance provider, meaning they can freely select their fund (Breyer/Buchholz 2021). Previously, there were restrictions relating to specific occupational groups or regions, but these have largely been eliminated. With the introduction of the Health Fund in 2009, this competition became even more differentiated (Busse/Schreyögg/Stargardt 2017). As a result, health insurance funds lost much of their previous financial autonomy and have since been financed by allocations distributed by the Health Fund. Although these allocations are composed of various components, only average amounts sufficient to cover costs are disbursed. In principle, all health insurance funds are required to levy a uniform contribution rate from their members. However, in cases where the funds allocated by the fund are insufficient, this rate is supplemented by a health insurance fund-specific additional contribution rate (Mülheims/Hummel/Peters-Lange/Toepler/Schuhmann 2015). Differences between these additional contribution rates can significantly influence members' desire to switch health insurance funds, making the additional contribution rate a crucial competitive factor (GKV-Spitzenverband 2022).
Focus on benefit expenditure
In this competitive environment, health insurance funds manage their resources to operate as efficiently as possible with allocations that, while risk-adjusted, correspond at most to the average benefit expenditures of the insured members of the overall system. If individual health insurance funds succeed in keeping their total, actual benefit expenditures at the level of the allocated averages, supplementary contributions can be avoided. This gives benefit expenditures and their management particular importance. The total benefit expenditures (TA [total]) of a health insurance fund comprise the individual benefit expenditures for each insured member under consideration. To express the benefit expenditures for the entire number of insured members, the running variable "i" is introduced here. The upper limit is denoted by "n" (i.e., the sum of all insured members of a health insurance fund).1
In principle, all benefit expenditures consist of the quantity component (MKi) individually requested by the insured and a price component (PK) independent of the respective insured: LA = MKi * PK. The quantity component MK(i) is understood as the number of supply, treatment, and/or therapy units to be billed, while the price component determines the reimbursement for the respective services and is generally the same for all insured. For certain services, a structural component (SKi) may also be considered.2
Let's assume that two different care alternatives (A and B) are available. Then, the substitution possibilities would only need to be considered between these two alternatives, A and B. Accordingly, only services of alternative A could be demanded, with the consequence that alternative B would then no longer be needed or demanded. Therefore, the values of the structural components for alternatives A and B will lie between 0 and 1 (or, expressed as percentages, between 0% and 100%) to express this substitution relationship. The sum of both alternatives is thus typically 1 (or 100%), so that SK[A]i + SK[B]i = 1. The SK[A]i of the expected service expenditure can therefore be calculated as SK[A]i = 1 - SK[B]i. Here, the structural component must be related to the individual.3
More abstractly, the total service expenditure (LA [ges.]) of a statutory health insurance fund can essentially be reduced to two (similar) components. The first component of service expenditure consists of the non-taxable (n'stb) service components. Non-taxable total service expenditure (LA [n'stb.]) includes services where the health insurance fund is only informed of the insured's provision of services at a point in time when it is no longer possible to influence the specific service utilization.4 The second component, on the other hand, consists of service expenditure with taxable (stb) service components (LA [stb.]).5 In the following, the previously defined variables A and B will be replaced by these abbreviations: "A" for "n'stb LA" and "B" for "stb LA".
The following assumes a scenario in which the two care alternatives can be substituted within the framework of non-controllable and controllable benefit expenditures.6 For the ratio of non-controllable to controllable benefit expenditures, the following also applies to the two structural components of total benefit expenditures LA (total): values between 0 and 1 (or between 0% and 100%), and the sum is 1.7
This results in the following picture:
Subsequently, an expansion to include the administrative costs of benefit expenditures (administrative costs, abbreviated: AA) is planned.8 Furthermore, attention should be paid to any potential efficiency reserves (WR) that may need to be realized.9 Efficiency reserves are more likely to be discussed on the side of controllable benefit expenditures, since in such a setting, insured-side claims can be more effectively managed by the payers.
The model will be further expanded below, as administrative effort can arise in different organizational settings.10 For example, administrative effort can result from internal efforts (own) or from the engagement of external service providers and/or other external bodies (external).
The economic efficiency reserves for the controllable output can arise from gains in efficiency within the framework of replaced quantity components (MC, e.g., avoided consumption, more economical use of existing resources, possibly circular economy, etc.), from economic efficiency reserves within the framework of adjusted price components (PC, discounts, special conditions, etc.).
(e.g., tions) or within the framework of substitutive structural components (SK, generic drug supply, substitution of a service with, for example, a ward-replacing character, etc.). If only a portion of the efficiency reserves (in the form of MK, PK, or SK) can be realized, the values 1 (i.e., MK = 1, PK = 1, or SK = 1) should be set for the unrealizable parts of the mathematical expression. The complete picture with all introduced variables is thus ultimately as follows:
Second opinion procedure as a response to
avoidance of benefit expenditures
Based on these fundamental considerations regarding the total service expenditures typically incurred by a health insurance fund, it can be established that health insurance funds attempt to generate controllable expenditures from non-controllable service expenditures. Should the frequently voiced assumptions prove true that in Germany, various healthcare sectors (particularly surgical disciplines) are experiencing premature and/or excessive treatments, this could offer avenues for healthcare management. A second medical opinion could thus enable the identification of treatment plans from a subset of services that are generally non-controllable, either as medically inappropriate or as potentially not yet medically indicated (i.e., at too early a point for the planned medical intervention). In this way, non-controllable services could become controllable by influencing both the quantity component (MK [stb.]) and the structural component (SK [stb.]) through the second opinion. In both cases, potential for efficiency gains (WR) can be realized. However, realizing such reserves requires accepting administrative costs (Hartweg 2007). These can arise either within the health insurance organization itself (AA [stb. eig.]) or through the use of external service providers (AA [stb. frd.]).
Study of the twelve largest health insurance companies in Hesse
The statutory health insurance providers have established their own second opinion procedures, which go beyond the GBA (Federal Joint Committee) guidelines on second opinions, and actively promote these to their insured members. In May 2022, the information provided by the health insurance funds was evaluated. For this purpose, their websites were searched for the terms "second opinion" or "second opinion procedure," and the statutory and discretionary benefits available to insured members were analyzed. A complete survey was not conducted if a comprehensive delimitation of the research topic could be achieved solely by referring to large Hessian health insurance funds (with their market shares).
Table 1 shows the ranking of the largest health insurance funds in the region based on rounded numbers of insured persons and the resulting market shares calculated from the KM6 financial levy data for the Hessian Medical Service for the 2021 fiscal year, with a total number of insured persons of slightly more than 5,458,000. Including the 12 largest health insurance funds provides almost 87.4 percent market coverage for the analysis.
Comparative competitive analysis of second opinion services
To better shed light on the advisory services offered by health insurance funds, which vary considerably in scope and are established in addition to the second opinion guidelines, their websites were analyzed. The statutory and discretionary services identified in this way were recorded in tabular form and categorized. One of the two categories comprised advisory services for illnesses with a comparatively high prevalence. These include consultations related to the care of cardiology, back/spine conditions, joint replacement, shoulder problems, rheumatology, and oncology. The second category included advisory services for therapies with a comparatively lower prevalence. These include urological diseases, ENT diseases, dental and denture care, and intensive care services. It is noteworthy that some of the aforementioned health insurance funds limit themselves, at least in name, to offering only advisory services.
to define services closely related to the collectively agreed services of the second opinion guideline. Other health insurance funds, however, pursue a significantly broader strategy and (in some cases) go beyond this basic standard determined by the Federal Joint Committee, thereby establishing a whole range of additional advisory services.11
Which areas of consultation beyond the second opinion guidelines are offered to insured individuals is decided individually by each health insurance fund. The reasons for this may be multifaceted. For example, health insurance funds will likely assess the potential for cost savings arising from the consultation process, both in terms of the quantity and structure of benefit expenditures, quite differently. Furthermore, the respective administrative effort for the corresponding consultation processes will certainly lead to varying expenditure levels, so that the impact on the controllability of benefit expenditures could also be discussed differently from one health insurance fund to another. Overall, this results in a rather diverse range of second opinion services that must be considered.
Recourse to experts and other external organizations
According to their online profiles, relatively few health insurance companies utilize their own organizational structure for this purpose. This would require the organizational integration of the associated advisory services into the workflows and processes of the health insurance company's operations. However, this does not preclude the existence of individual health insurance company collaborations with selected experts, sometimes within hospital structures but also within specialist medical practices. It is noteworthy that a majority of the health insurance companies surveyed in Hesse have opted to commission specialized service providers. Many of the advisory processes have been outsourced, as can be seen on the respective health insurance companies' websites.
According to its own statements, Cologne-based "BetterDoc" GmbH supports insured individuals in case of illness by directing patients to the right treatment with the right doctor (BetterDoc 2022). The Berlin-based company "Medexo," also a limited liability company, provides a second opinion from a renowned specialist and promises reassurance before a planned operation (Medexo 2022). Integrative Managed Care GmbH ("IMC"), based in Limburg (Lahn), provides a second medical opinion before scheduled or anticipated back or joint replacement surgeries (hip, knee, shoulder). The provider utilizes highly qualified pain management centers for this purpose (IMC 2022). "MediKompass" GmbH is a provider specializing in dental care. When insured individuals receive a treatment and cost plan for dental (prosthetic) treatment, they can have it reviewed by a second dentist, as explained by the Frankfurt/Main-based company (MediKompass 2022). HMO AG, based in Oberhaching, specializes in cancer and heart care. HMO's experts assess the respective cancer diagnosis or collaborate with cardiologists for second opinions (HMO 2022). MD Medicus GmbH, from Ludwigshafen, describes its comprehensive, insured-related consultation service for second opinions as "health assistance" (MD Medicus 2022). Mojo GmbH, based in Leverkusen, operates the website "2te-zahnarztmeinung.de" and presents itself as an auction portal. Health insurance companies attribute to this portal the potential of providing a second dental opinion (2te-zahnarztmeinung.de 2022).
The table of advisory services offered by the twelve largest health insurance companies in Hesse can be viewed as an attachment in the online version.
Conclusions
Overall, the range of available second opinion services can be described as heterogeneous. This criterion is based on a direct comparison of health insurance funds. Health insurance funds with more consultation services improved their ranking and subsequently landed at the top of the four-quadrant diagram (AOK, TK, KKH; Fig. 1). Consultation services for healthcare areas with a comparatively high prevalence were rated somewhat more favorably in the ranking than those with a comparatively low prevalence. Health insurance funds that did not perform as well in this dimension consequently offered a smaller number of consultation services (hkk).
Only two health insurance funds (BARMER and Knappschaft) do not rely on external service providers for their second opinion/consultation services as extensively as other health insurance funds (KKH, IKK Südwest, Mobil KK, etc.) have (according to their websites). These two health insurance funds are therefore assigned to quadrant III. In contrast, 10 of the 12 health insurance funds examined rely heavily on the services of externally commissioned providers and are thus assigned to quadrant I or quadrant IV. However, it cannot be concluded that commissioning a service provider (or foregoing it) leads to a broader (smaller) range of services. The underlying strategies are not clearly discernible.
The study also shows that the respective advisory services offered by health insurance funds are apparently not dependent on size (cf. AOK vs. KKH) or on business area (AOK vs. TK). The number of advisory areas mentioned varies considerably even among the largest health insurance funds in Hesse. Therefore, it cannot be said that larger (or smaller) health insurance funds tend to offer more (or fewer) second opinion procedures than smaller (or larger) ones. Likewise, it cannot be stated that health insurance funds organized nationwide (statewide) offer a greater (lesser) range of advisory services compared to those organized statewide (nationwide). Considering the heterogeneity of these results, it can be summarized that the compensatory interactions between presumed efficiency reserves and the associated administrative costs are addressed with highly differentiated strategies. Furthermore, the respective health insurance funds will tailor their advisory services to their own needs, i.e., to their individual insured population structure, in order to achieve the broadest possible healthcare benefits. Nevertheless, the competitive activities of health insurance funds also provide clues to possible future adjustments to the second opinion guideline. For example, expanded areas of care are defined here, which could also be of interest for collectively agreed guideline-based care.