>> Prof. Dr. Wolfgang Greiner, one of the 13 scientists appointed to the scientific commission by the Federal Ministry of Health in the summer of 2018, sees the situation somewhat differently. In his summary published in the “Contributions and Analyzes – Health Care Current” (2) of the bifg (Barmer Institute for Health System Research), he mentions a report from France that had a similar task to the KOMV. One of the main French results was that there is no one optimal form of remuneration, but rather a “sensibly put together mix of individual performance remuneration”
The aim should be to provide benefits, flat rates (particularly for the care of chronically ill people) and components of quality-based payments. But that doesn't mean at all that a "standard fee schedule for GOÄ and EBM is off the table," as Gassen predicted.
Rather, Greiner advocates for a uniform remuneration law for outpatient medical services, which not only has “a number of advantages with regard to the requirements of a modern remuneration system”, but also creates “long-term economic synergy effects” since there are no longer two service lists further developed in parallel with calculation systems based on this
would have to be wrapped. This could also be used to bring together knowledge and data and thus improve cost calculation, so that “financial disincentives in treatment decisions are reduced and the quality of care is improved” and “transparency about the performance and practicality in everyday medical practice” is increased.
However, according to Greiner’s comments, a uniform remuneration law “would also be
with considerable challenges”. In view of the different remuneration levels in the statutory health insurance and private medical treatment
would become rich as a result of unification either that
Current medical fee volumes are decreasing or would have to be maintained in order to maintain the same
additional funds
through increases in GKV contributions or a federal subsidy from tax revenues; The compensatory access to self-payers or private health insurance companies, which is already difficult to implement in practice, is constitutionally controversial. And even if an overall consistent level of remuneration in outpatient medical care were ensured, there would be considerable financial shifts. Greiner: “Medical fees would tend to decrease in the city and increase in rural areas. Within the medical profession there would be a redistribution from more technical to more conservative groups of doctors.”
In addition, the question arises about the preservation of statutory health insurance control mechanisms that are not effective in the private medical sector, such as budgeting (of MGV services), regionalization (regional Euro fee schedule) and the individual health insurance fee distribution standards. And last but not least, even with uniform prices, it would be difficult to prevent a secondary market from forming in which patients who are willing to pay buy medical services at higher prices, for example to avoid waiting times. This could counteract many of the advantages of standardizing remuneration. It is also controversial under constitutional and EU law whether a categorical ban on different remuneration could be justified.
The concept of a partial
harmonization
The KOMV report therefore proposes the concept of partial harmonization, which partially takes up the positive aspects of standardizing remuneration law, but takes into account the challenges described and - according to Greiner - "is not associated with any constitutional or EU law concerns". A distinction is made between those components of a fee schedule that should be (further) developed together and components in which the differences between contractual and private medical remuneration are retained. The present proposal differentiates between the definition of medical services (service legend) and the relative cost assessment of services on the one hand - that is, the cost ratios of medical services in comparison to one another expressed in factors - and the prices for these services on the other.
The proposal further stipulates that the common service classification (GLL) should basically cover the entire range of medical treatment services, whereby the service classification should be independent of the downstream question of financing or cost reimbursement (through statutory health insurance, private health insurance or subsidies). Furthermore, in addition to the services currently included in the EBM and the GOÄ, services for outpatient specialist medical care, through socio-pediatric centers or psychiatric institute outpatient clinics, should also be included. Separate regulations could still be made in selective contracts. Greiner: “A common relative cost calculation (GRK) is created based on the GLL.” This should determine the relative evaluations of the services compared to one another based on cost data. As a result of this evaluation, each GLL service is assigned an evaluation factor that indicates the cost ratios in comparison to a standard service to be defined. However, in this step no statement is made about the (absolute) prices of the services; these are determined at a separate level within the respective system (contract/private medical area).
While the performance legend and the relative cost calculation are developed by joint committees for contract and private medical care, the experts believe that prices should continue to be negotiated on this basis in dual negotiation regimes (joint GKV self-administration or PKV/BÄK). According to the report, in addition to the costs, “regional, subject-specific, quantity-related and other – higher-level – aspects” can also be taken into account, in particular “the medical benefits or eligibility of a service or the general level of remuneration”. With this proposal, differences between contractual and private medical remuneration could be controlled and consciously maintained by the negotiating partners (Fig. 2).
In addition, as Greiner writes, there is a need for further action at various points in the outpatient reimbursement system. Among other things, the false incentives that are associated with compensation that is predominantly flat-rate or based primarily on individual services should be counteracted by a “stronger mix of compensation consisting of individual and flat-rate services and by combining them with quality-oriented compensation elements”. In addition, the reference to the quarter as a billing period in the GKV, which can only be explained historically, should be partially avoided. The quarterly view is particularly problematic if the budget is exhausted at the end of the quarter and a service provided is no longer reimbursed in full from a medical perspective." <<

literature
1: https://www.kbv.de/html/1150_44046.php
2: https://www.bifg.de/media/dl/Gesundheitswesen%20aktuell/2020/GWA%202020-Kapitel%20Greiner.pdf;  doi: 10.30433/GWA2020-14