It's not just about a waste of money, but about the arbitrariness of the statutory health insurance companies!

16.08.2012 16:51

The Federal Insurance Office denounces the waste in statutory health insurance companies. The individual examples listed are hair-raising. But they are just the tip of the iceberg.

As an independent representation of the interests of insured persons and patients in the healthcare system, the DGVP is repeatedly confronted with the arbitrary spending policy of the statutory health insurance (GKV).

The President of the DGVP, Wolfram-Arnim Candidus, criticizes: “The insured are the payers in the GKV. At the same time, they are obviously being increasingly and arbitrarily excluded from the health and nursing care insurance benefits to which they are entitled. Of course, this is rarely done transparently and comprehensibly – we have to talk about covert rationing.”

For hospital stays, flat rates per case are the decisive criterion for billing - and not whether there is still a need for treatment and care. Many a sick stay is shortened due to the influence of the statutory health insurance on the clinic doctors and clinic management. The clinic that decides in favor of the patient and continues treatment is then criticized - if necessary, payment for the services provided is reduced or refused. “This not only creates excessive bureaucracy when it comes to billing control, but the health insurance companies also fuel mistrust towards hospital employees and institutions,” complains Candidus.

Another typical example: medical prescriptions are questioned by the health insurance company. This is an infringement on the doctor's prescribing authority. If patients have the strength to fight stubbornly, they may still receive the services. This is questionable in terms of content. In addition, further visits to the doctor are necessary. “The GKV always argues that German patients go to the doctor too often. But the GKV probably doesn’t see its own complicity in this,” Candidus continued.

“The dependency of the medical service is also critical. He is on the GKV payroll, receives his orders from there and checks medical prescriptions at considerable cost. Since the GKV has to and wants to budget, the goal of not granting benefits through the health or nursing care insurance company cannot be denied. The medical service was originally intended to ensure a high quality of care for patients. Nowadays he mostly only acts as a controller of services and costs. If employees of the medical service not only intervene in the doctor's prescription, but also control the care and patient behavior themselves, that goes definitely too far.

But savings measures must also be re-examined from the perspective of waste: through supply contracts with manufacturers and retailers and tenders at European level, the GKV only purchases certain products and makes them available to patients in a selected manner. Reimbursement for the medication or aid originally prescribed by the doctor is often not given. The GKV is less interested in whether the contractually selected product has exactly the same effect or exactly the same benefit for the patient. There are no independently prepared studies on this, as these are probably not wanted or required by the GKV. The result is incorrect medication. The replacement of aids is becoming increasingly necessary, for example for incontinence products. The patient then has to endure this.

In nursing, billing is created and checked to the minute. If there are objections to the fund's decision, the nursing services will be placed under the supervision of a quality representative. “These are thumbscrews – and the patient then suffers from it,” criticizes the DGVP President.

Candidus adds: “Another example of the power of the statutory health insurance is the threat of recourse against doctors if they have provided services that go beyond the volume of a service budget. For this reason, there are millions of cross-referrals made annually by outpatient physicians to avoid exceeding their budgets. However, this does not limit the quality of life of patients, but also causes unnecessary costs and delays in treatment and care.”

“All of this has to be discussed, it’s not just about wasting money, which is certainly there,” says Candidus on the Federal Insurance Office’s activity report, “but one crow doesn’t peck out another’s eye.”

In the interest of patient care, the DGVP wants continuous monitoring of GKV behavior and dedicated transparency for all citizens. This is the only way to stop the arbitrariness and unspeakable power of statutory health insurance companies. To this end, citizens should not only be called to the social elections as an alibi function, but should also take on the role of monitoring the statutory health insurance funds through independent citizen representatives.