Reimbursement for New Examination and Treatment Methods of Outpatients: Comparison of Statutory Health and Private Medical Insurance

• Published in: Gesundheitswesen (Bundesverband der Ärzte des Öffentlichen Gesundheitsdienstes (Germany)) Vol. 85; no. 5; p. 462
• Main Authors: Walendzik, Anke, Abels, Carina, Wasem, Jürgen
• Format: Journal Article
• Language: German
• Published: Germany 01-05-2023
• Subjects: Ambulatory Care; Benchmarking; Germany; Humans; Insurance, Health; Outpatients; Germany
• ISSN: 1439-4421
• DOI: 10.1055/a-1749-5591

The aim of the study was to compare the timeliness of reimbursement for new examination and treatment methods in outpatient care in the social (SHI) and private insurance system (PHI) in Germany.
For the reimbursement in the SHI system, the decisions and further documentation of the Joint Federal Committee and the evaluation committee could be used. For the reimbursement in the PHI system, for example, the resolutions of the Central Consultation Committee for Fee Schedule Questions and those of the Fee Schedule Committee, but also evaluations of the North Rhine Medical Association and a working group of the German Association of PHI were used. Included were medical methods finally assessed for use in outpatient medical care by the Joint Federal Committee between 2010 and 2019.
A total of 17 individual resolutions, two series of resolutions consisting of several individual resolutions, and regulations concerning companion diagnostics were included. The time intervals between the start of the procedure and the introduction of the new method into the SHI system varied widely (14 to 216 months). At the same time, the study showed that for the majority of the methods, reimbursement in PHI was possible earlier than in SHI. Furthermore, five methods showed a potential limitation of reimbursement in PHI dependent on individual insurance contracts, but in two cases also reimbursement by PHI for services later assessed as without benefit by SHI.
Medical procedures based on the included new methods in most cases were reimbursed in the PHI earlier than in the SHI system. However, this also implies a risk of reimbursing services that are subsequently assessed by the Joint Federal Committee as having no medical benefit. If the joint federal committee assessment is used as a benchmark, this could lead to a reduction in the cost-effectiveness of care and, in individual cases, to patient harm due to overuse or misuse of care. Thus, there is a conflict between early access to new examination and treatment methods (especially in the case of very long Joint Federal Committee procedures) and (cost) effectiveness and assurance of the quality of care.