>> The GKV-Spitzenverband's guideline on measures to protect insured persons' social data from unauthorized access pursuant to Section 217f Paragraph 4b of the Social Code (SGB V) (GKV-SV Guideline on Contact with Insured Persons) dated December 14, 2018, precisely defines what is meant by "contact between health insurance companies and their insured persons": an exchange of information between health insurance companies and beneficiaries, in which representatives of the health insurance companies communicate with beneficiaries in person, by telephone, by mail, or electronically. Section 284 of the SGB V, "Social Data at Health Insurance Companies," precisely regulates which social data health insurers may collect and store for which purposes. This ranges from establishing the insurance relationship and membership, including the data required to initiate an insurance relationship (Section 1), to implementing offers pursuant to Section 68b (Section 19).
However, point 13 also mentions “the preparation and implementation of model projects, the implementation of care management in accordance with Section 11, Paragraph 4, and the implementation of contracts for general practitioner-centered care, special forms of care, and the outpatient provision of highly specialized services.”
However, there is no mention of the fact that the health insurance funds would be permitted under current law to use their billing data to draw conclusions about high-risk situations, for example, and to contact the respective insured person in order to clarify the situation and prevent possible further damage.
The question is whether health insurance funds can (or even must?) inform their insured persons if they become aware of potential high-risk probabilities. Such an obligation could arise from the comprehensive mandate of health insurance funds to promote health. Section 1 of the German Social Code (SGB V) defines the task of health insurance funds as "maintaining, restoring, or improving the health of the insured persons, as well as informing, advising, and promoting a healthy lifestyle" (1).
However, this is countered by the principle of social data protection law that health insurance companies are not permitted to take note of sensitive medical data, let alone store, evaluate, or use it for any purpose. Thus, such communication, which certainly cannot be conducted just once but must follow a sustainable strategy tailored to the respective target groups, could certainly be viewed as a duty on the part of the health insurance companies. However, it should be noted that stratification, which would currently be entirely possible with health insurance data, can only be based on a risk probability. Consequently, it is possible that communication based on such data could also reach many insured persons who are not actually affected, which could lead to unnecessary uncertainty and even fear.
However, one could also postulate that non-communication would be an act of failure to provide assistance if health insurance funds (can or even could) gain knowledge – even if only on the basis of probabilities – of individual risk situations.
That would certainly make sense. However, this would only be possible if a care offering were available at the same time to support informed insured persons through such a communication strategy. However, since the current calculations by the WIdO (German Association of Health Insurance Providers) indicate that the COVID-19 risk groups comprise almost 22 million people in Germany (see pages 18 ff.), the sheer volume of coverage alone is likely to be a deterrent.
It would be conceivable, if legally permitted, to view such a communication strategy not solely as the responsibility of the health insurance funds. A complementary physician-related collective or selective contract solution would be possible. The advantage of this would be that the (family) doctor could assess the individual burden of illness, thus enabling capacity-based management.
However, this would have the disadvantage that such an approach would not be ubiquitous, but would simply follow the normal doctor's visit schedule.
Perhaps it would be possible to combine a health insurance-based approach with a doctor-centered approach model?
But first, this question must be clarified legally: Against this background, can and may health insurance companies stratify defined risk groups, for example for the coronavirus, de-anonymize the data – if necessary – and then actively contact the insured persons thus identified in order to inform them about their individual risk situation?
The legal basis for this is described on pages 30-32 by the renowned lawyer Prof. Dr. iur. Dr. med. Alexander PF Ehlers and his colleague Philipp Rösner.
from:
MVF editor-in-chief Peter Stegmaier

Literature:

1: https://bit.ly/3bJrmmX