Adjustment of doctor and practice-related standard service volume

The consequence of selective contracts according to Sections 73b, 73c and 140d SGB V is an adjustment of the need for treatment. However, no regulation could be found for the year 2009 in either the evaluation committee or the extended evaluation committee regarding the effects of this adjustment of the treatment requirement on the doctor and practice-specific standard service volume. And the decision for 2010 only came about after several rounds of meetings in the extended evaluation committee, i.e. with the participation of the neutral chairman. The resolution therefore also bears the hallmarks of a compromise, as the representatives of the National Association of Statutory Health Insurance Physicians (KBV) and the National Association of Statutory Health Insurance Funds were unable to reach an agreement on their own.

>> The regulations for adjusting the need for treatment as well as for adjusting the doctor and practice-specific standard service volume (RLV) generally apply to all contracts in accordance with Sections 73b, 73c and 140d SGB V. Nevertheless, this complex of topics is currently being discussed exclusively against the background of the contracts for family doctor-centered Supply (HZV) is discussed because these contracts naturally have the largest volume. However, in the legal text, Section 73b Paragraph 7 SGB V, only an adjustment of the need for treatment is expressly required - an adjustment of the doctor and practice-specific standard service volume is not mentioned anywhere. Against this background, there is no indication in the legal text that the evaluation committee or the extended evaluation committee would have to decide on the question of adjusting the RLV.
This raises the question of whether the (Extended) Evaluation Committee can actually be the responsible authority to decide on this issue. The evaluation committee is made up of three representatives each from the KBV and the GKV umbrella association. Particularly for the HZV, which is currently primarily affected by these decisions, the involvement of the KBV and the simultaneous exclusion of the selective contract partners from the decision-making process is unacceptable. High-ranking representatives of the KBV are constantly calling for the abolition of Section 73b SGB V in its current form. At the same time, elected representatives of the German General Practitioners Association should be excluded from positions within the KVen / KBV. In this context, a statement is being made that one cannot sit on the supervisory boards of competing (car) manufacturers at the same time. But if the legal text of § 73 b SGB V expressly privileges a mandated community over the KVs, how can it be logically justified that this community, in contrast to the KBV, representative of the KV system, has no say in such a central question as the cleanup of the RLV should have? To stay with the car manufacturers: How is competition supposed to work if a manufacturer also acts as a “TÜV” and decides which measures the competitor has to take or accept before approval? The mere fact that the KV system has benefited from tax exemptions for decades due to its corporate status means that competition with other organizations is strongly distorted in favor of the KVs.
The question of whether and, if so, by which procedures the RLV is adjusted has a significant impact on the HZV. Assuming that the RLVs need to be adjusted at all, a fair solution would mean that the doctor participating in the HZV would not have more deducted from his RLV than he would have received for the care of the patients enrolled with him under the collective agreement would. It is sometimes shocking to see the narrow-mindedness with which representatives of the KBV/KV side argue in the opposite direction. To the extent that this is at all comprehensible to outsiders, there is a main disagreement as to whether the RLV should only be adjusted for those doctors who take part in a selective contract or whether this should apply to the entire specialist group.
The argument is then usually as follows (to make it clear that the regulations do not only apply to the HZV and therefore to general practitioners, an example with ENT doctors is chosen):
• It cannot be the case that ENT doctor A receives a lower RLV just because ENT doctor B takes part in a selective contract.

In addition to a false understanding of fair remuneration, this also shows a design error in the RLV: A doctor's income from work under the collective agreement should depend exclusively on what services he provides within the framework of the collective agreement.
Why should ENT doctor A and ENT doctor B receive a different fee for the same service in the collective agreement? In any case, the fact that ENT doctor B takes part in a selective contract does not justify different remuneration in the collective agreement - assuming the same performance. But perhaps it is only a matter of time before someone comes up with the idea of calculating the RLV depending on the number of private patients, IGeL benefits and other “non-collective income types”.
The design error of the RLV, namely the reference to the previous year's quarterly case numbers, becomes clear if you expand the example a little: Suppose there are ten ENT doctors in a town and the residents of the town are roughly evenly distributed across these ten practices. If all residents of the town decided to take part in a selective contract, which stipulates that, if necessary, an ENT doctor participating in this contract is consulted, but only nine of the ten ENT doctors take part in this contract, then the question arises the question of why or why the ENT doctor who does not take part is assigned an RLV at all. For those patients who participate in the contract but still use it, they receive extra-budgetary remuneration outside of the RLV. Although this example is not realistic in the short term, it shows that the real problem is not the cleanup of the RLV, but is rooted in the RLV construction.
Regardless of this aforementioned fundamental problem of the RLV, the decision of the extended evaluation committee of December 16, 2009 to clean up the RLV can be presented in three simple steps based on the current state of knowledge:
The starting point is the RLV, which is calculated on the basis of an unadjusted total remuneration (and is therefore too high). The RLV is calculated, also simplified, as the product of the individual previous year's quarterly case number and the specialist group case value.
As a first step, the number of cases of doctors participating in the selective contract will be reduced. On the one hand, the cases caused by the patients who are now registered with this same doctor in the previous quarter are counted, and on the other hand, cases of patients who were seen by this doctor in the previous quarter but have now been registered with another doctor (keyword: “patient migration”) . This procedure is fundamentally correct because it is very much based on the calculation of the RLV. What is incomprehensible is the fact that patient movements are only recorded within the doctors participating in the selective contract. For three doctors A, B and C, of whom A and B participate in a selective contract, patient migration between A and B would be taken into account, but patient migration from C to A or B would not be taken into account. This example shows the logical inconsistency of the specifications (see the example above with the ten ENT doctors), with the result that the number of cases, i.e. an individually assignable quantity, falls to a lesser extent than would be possible and thus a higher one in the next step The amount must be reduced “across the board across the entire specialist group”.
In the second step, the specialist group case value is reduced - by a maximum of 2.5 %. In contrast to the first step, this affects all doctors in the respective specialist group. However, the limit of 2.5 % is just as incomprehensible as the limitation in the first step to the doctors participating in the selective contract when reducing the number of cases.
Whether the goal (of the KBV) of minimizing the effects of an RLV adjustment for doctors not participating in the selective contract was achieved is a question of perspective. On the one hand, the regulation means that for non-participants “only” the case value can decrease by a maximum of 2.5%, but on the other hand, this reduction applies to everyone, i.e. both to the non-participant for whom there was no patient migration, as well as to the one in which, for example, 100 cases could theoretically have been reduced in the first step.
In the event that there is still a shortfall after these two steps, this will then be distributed in a third step via a “case-related residual adjustment amount” only among the (RLV of) doctors participating in the selective contract. A reliable forecast as to whether this third step will be applied in 2010 - as the resolutions to adjust the treatment needs and the RLV only apply to this period - cannot currently be made.
In summary, it can be said that the adjustment of the RLV takes place alternately between the doctors participating in the selective contract, the entire specialist group and, if necessary, again within the participants. To put it bluntly, this can also be described as a “ping-pong process” in which, at crucial points, only compromises were possible instead of logically comprehensible solutions.
Nevertheless, the resolution represents at least significant progress compared to 2009. Last year, the KBV prevented a decision from being made by leaving the meeting and then filed a lawsuit against the resolution for formal reasons (because they were not present). This behavior is evidence of the KBV's conflict of interest, which inevitably arises when deciding on an adjustment of the total remuneration and RLV. With this decision, the German Association of General Practitioners is primarily hoping that - parallel to the arbitration proceedings that have already started and have been partially completed - the necessary coordination with the respective KVs will also take place promptly everywhere.
Given the aforementioned lack of legal obligation to adjust the RLV, another, simpler solution that is more in line with the wording of the law can be advocated: Instead of adjusting the RLV, i.e. a subsequent correction, it should be calculated correctly from the start. This would work if the RLV were not calculated on the basis of the unadjusted treatment needs, but rather on the basis of the payments actually made by the health insurance companies to the respective KV for the collectively contracted care of their insured persons. This should by no means be misunderstood as a “plea for the RLV”, but if one has to accept the RLV as a framework, then this approach would be preferable. As a result, only the deadlines for allocating the RLV would have to be changed so that the insured can, for example, apply to participate in the HZV up to two weeks before the start of the new quarter. The law currently requires the RLV to be allocated no later than four weeks before the start of the period of validity. However, the (final) allocation of the RLV did not take place in all KV districts at least four weeks before the start of the quarter in 2009, nor would anything fundamental change if the RLV were allocated on time at the start of the quarter. This would still be in time to have a “controlling effect”, if one wants to grant this instrument one at all. What controlling effect should, for example, be assumed from an RLV case value of 31.28 euros, as is currently the case for general practitioners in North Rhine, if the insured flat rates alone according to EBM numbers 03110 - 03112, based on a reference point value of 3.5 cents, are already above that lay? Ultimately, the problem lies less in the cleanup of the RLV than in the construction of the RLV itself. <<