How do I become a profitable doctor
The sicker, the more profitable
And until recently, the rules of the game of the health insurance companies worked completely differently.
If the hunt was in the actually peaceful cash reserve, then the hunt was aimed at the young, healthy and better-earning insured persons. Having as many of them as possible among the insured ensured a high premium income with low expenses. If insured persons could also be addressed, for whom many branches and the one-to-one conversation with the So-Fa responsible for them, the social security clerk responsible, were not so important, it could be operated as a virtual health insurance company with a focus on the network in a lean and cost-effective way.
Small, streamlined company health insurance funds with contribution rates of sometimes less than twelve percent benefited from this. The cash tankers with their large clientele of insured persons with lower incomes and thick medical files were left behind on the route - Barmer, DAK and many local health insurances with contribution rates of sometimes over 15 percent and correspondingly poor cards in the competition were left behind.
All of that will change, and according to health expert Stefan Etgeton from the Federation of German Consumer Organizations, this has advantages for the insured:
"The fact that the health insurances are more strongly urged to differentiate themselves in the service area and less to bind the young and healthy to themselves."
However: The system change in the competition between the health insurance companies is causing unrest. Cash registers complain. Especially those who have been ahead of the competition so far. Dorothee Meusch, the spokeswoman for Techniker Krankenkasse, which will become Germany's largest insurance company after the merger with IKK-Direkt, is upset:
"In the future, the more illness is documented for the individual insured, the more money the health insurance company will receive. The more illness is documented, the more money it will get!"
The losers of yore see each other on the winning road. The general local health insurance companies in particular are feeling the tailwind. The chairman of the AOK Federal Association, Herbert Reichelt, is pleased:
"We have more money available. The Federal Insurance Office has calculated that the AOKs will have around 2.4 billion euros more available."
After deducting the 400 million euros that the local health insurance funds estimate as additional money for doctors' fees, the bottom line is two billion euros that the AOKs can also book for themselves. For themselves? No, for the insured, that sounds better for the chairman of the AOK Federal Association:
"The real winners are the insured and especially the sick insured, because the system ensures that more money now flows to where it is needed to care for sick people."
Dorothee Meusch from Techniker Krankenkasse parries:
"It is not at all bad when health insurances take care of the sick, that is in their name and in their self-image. The health insurances should take care of the sick. But they should not document illnesses that are not there, in order to generate income to obtain from the redistribution! "
And there the reproach is back in the world: health insurances document illnesses that supposedly do not exist. Again, the supposed hunt for the sick is blown. What is happening in the German healthcare system?
The trigger for all the allegations and conflicts in the health insurance world are the changes in statutory health insurance at the beginning of 2009. Since then, a uniform contribution rate has been in place for all 200 health insurance companies. The contributions of the insured persons and their employers first flow into the health fund. From there they are distributed back to the cash registers using a complicated key.
Each health fund receives a flat rate for each insured person. The amount depends on the age and gender of the insured person and on whether he or she suffers from one of 80 previously defined diseases that are expensive to treat. If this is the case, the health fund receives a surcharge for this insured person.
In technical jargon, the term "morbidity-oriented risk structure compensation" is used. The purpose of this procedure, as the responsible department head in the Federal Ministry of Health explains, is to pay particular attention to the clinical pictures of the insured when distributing the money. Franz Knieps:
"These are usually very expensive diseases with high treatment costs. In the past, flat-rate payments were made based on age and gender. This gave the health insurances an advantage, whose insured population was healthier."
The decisive factor for the flow of money is how many insured persons a health insurance company has whose clinical picture applies to one of the 80 defined diseases. It is not simply a question of whether someone has old age diabetes or has a heart condition. The 80 diseases, which according to the definition are supposed to be serious and cost-intensive, are split up into around 3800 individual diagnoses.
These diagnoses are made by doctors and hospitals. And unlike ever before in the statutory health insurance, the resident doctors in particular hold a key in their hand that unlocks the money safe for the individual statutory health insurance companies or opens it only a crack. TK spokeswoman Dorothee Meusch complains with serious consequences:
"Consulting companies are on the go all over the country and want to explain to the health insurance companies how they have to look through their databases in order to come to diagnoses Increase risk structure compensation. "
The new key for the money from the health fund doesn't work that simple. Only if certain criteria are met does the health insurance fund receive a supplement for a sick insured person. The doctor has to make the appropriate diagnosis for an insured person in two quarters. A "one-time stamp" is not enough. In the case of some diseases, specific drug therapies are also required. The health insurers also do not receive a subsidy in the amount of the actually incurred medical costs, but only a statistical average amount. Part of the cost risk for their sick insured remains with the health insurance companies. Nevertheless, says the representative of the Techniker Krankenkasse, Dorothee Meusch:
"In short, it depends on documenting illness, then money will flow!"
Since the beginning of the year, it has therefore been more important than ever how precisely the doctor makes his diagnoses. More precisely: How exactly the doctor documents the diagnosed disease. This is done according to an international code, the International Code of Disease, or ICD for short. With regard to this ICD, one also speaks of "coding" the diagnoses. So far, it has hardly played a role if a doctor recorded an incorrect ICD number in his or her records. Perhaps this distorted some disease statistics. But neither the health insurance company nor the doctor usually suffered a financial disadvantage. With one exception:
In the case of the disease management programs, the treatment programs of the health insurers for the chronically ill, precise documentation was essential beforehand. Because the health insurance fund received a supplement from the existing financial equalization system for insured persons who had enrolled in these programs.
Otherwise, however: which diagnosis stamp the doctors put on their patients could not really matter to anyone involved. Correspondingly, many doctors' surgeries dealt with the diagnoses with his shirt sleeves. A study by the AOK Westfalen-Lippe estimates the proportion of incorrectly documented diagnoses in dialysis patients at around 25 percent.
What used to be a nuisance at best is now costing the tills dearly. And so it comes to the conflicts, so it happens that the tone in the health insurance world has become sharper. For the health insurance expert from the Federal Ministry of Health, for Franz Knieps, not really surprising. It has never been peaceful, he says, when it came to redistributing money with the health insurance companies:
"Since we fought hard for this balance for ten years and we have seen all kinds of smoke candles, I do not want to rule out that such candles will be lit again now."
What is certain, however, is that individual company health insurance funds began to sift through their insurance data last year in order to discover more sick people for whom they could receive supplements from the health fund. And the AOK Niedersachsen had specifically asked doctors to check whether their patients were not suffering from one of the lucrative diseases. "Right-Coding" was the official name for the "correct" coding of diseases. "Up-Coding" - coding higher is actually meant, said critics, higher coding for the purpose of obtaining higher assignments.
The doctors also go to court with the health insurance companies. In a newspaper interview, Andreas Köhler, the chairman of the National Association of Statutory Health Insurance Physicians, accused the health insurance companies of trying to lure doctors. In the meantime, the top representative of the statutory health insurance physicians is more cautious:
“There are such instructions, agreements between health insurers and doctors in selective contracts, whereby it cannot be said with certainty whether the correct coding is being promoted here or whether there is really coding susceptibility. Here, too, it remains to be seen in the tests that are now being carried out what really happened . "
Doctors and the general local health insurance fund in Bavaria were particularly noticeable. The Bavarian Association of General Practitioners, an association of resident physicians in the Free State, prepared a supply contract with the local AOK - a family doctor contract - which provides a bonus of 26 euros for the doctor if he makes a diagnosis to an AOK patient, for which the AOK in turn helps Allocations from the fund can be expected. The chairman of the Bavarian General Practitioner Association, Wolfgang Hoppenthaler, wrote verbatim to his colleagues:
"Every patient that you identify more as an RSA patient earns more fees."
RSA stands for risk structure compensation - the legal basis for compensation payments. Wolfgang Hoppenthaler considers his campaign for the association members, the Bavarian family doctors, to link their economic interests with the clinical pictures of their patients to be completely correct. In the ARD magazine Panorama, he said last month:
"The contract is excellent, the AOK secures the existence of the general practitioners. With the AOK contract we will get about double that."
Associations such as the Bavarian General Practitioner Association are currently enjoying a lot of tailwind. More than before, the health insurers are obliged to look for independent medical associations as contractual partners. And since the doctors now have the keys for the money transfers to the health insurances for their sick insured persons in hand, they also ask for dictation. This is what happened in Bavaria, where general practitioner chief Hoppenthaler freely admits:
"Well, yes, in politics it is always the case that you have to build up a little pressure somewhere, yes. Now we are urgently going to ask the replacement funds and company health insurance funds to come to the negotiating table."
However, this seems to be overstretched. In the morning interview on Deutschlandfunk, the SPD politician Karl Lauterbach was precise:
"What is being discussed here is in principle nothing more than fraud. If you understand it correctly, this is the request to code in the way that your wallet demands, and not in the way that is medically optimal or as it is right, and of course that is no trivial offense. "
And a blatant warning is also given to the cash registers:
"For family doctors in Bavaria as well as for the AOK in Bavaria, the hands that fed them get bitten. So I also warn the health insurances to stop such games, because otherwise we can't keep it up, we have to Change the law, and that will not be to the benefit of the health insurers with many chronically ill people. "
In the meantime, people in the Free State have become cautious. Yesterday, Monday, the AOK Bayern announced that it was defending itself against allegations of wanting to obtain diagnostic documentation with a separate fee that would literally result in "unjustified payments". Bavarian AOK representatives secretly admit that the contract with the Bavarian Association of General Practitioners will probably not become legally binding.
And on the part of the AOK Federal Association, the chairman of the board, Herbert Reichelt, rejects any intentions to manipulate:
"Nowhere is it about diagnoses being manipulated. We as AOK absolutely reject that. We also reject that. That must not happen. What it is about is that the diagnoses made by the doctors are correct can also be found correctly in the coding documents, because the system depends on it being done correctly. "
It is undisputed among experts that a financial compensation that supports health insurance companies with many sick and poorly paid insured persons makes sense. In fact, such a risk structure compensation has also existed since 1994. It was introduced against the background of the free choice of health insurance fund, which has existed since 1996: Since then, workers do not necessarily have to be insured in the AOK, rather they can opt for insurance just like employees decide a cash register. The risk structure compensation is intended to ensure that all health insurers can compete with the same opportunities.
The old risk structure compensation, however, got stuck. The difference in contribution rates between the funds remained enormous. In 2002 the legislature decided on a reform. Experts called for a so-called morbidity orientation of the financial equalization - a calculation of the equalization payments depending on the sickness burden a fund had to shoulder. A goal that even received the blessing of the highest court. In 2005 the Federal Constitutional Court rejected a regulatory review application from three countries and declared the morbidity orientation to be constitutional.
"The legislature pursues legitimate goals because it wants to improve the solidarity balance between healthy and sick people and in particular avoid risk selection at the expense of - chronically - sick people."
Above all, the AOK, but also large substitute funds like the Barmer with many sick people among their insured persons and correspondingly high expenses, pushed for the morbidity orientation. They are now receiving more money for the care of their sick policyholders than they ever had before. This is exactly what politicians wanted, explains Franz Knieps from the Federal Ministry of Health:
"So if you have an insured population that is sicker based on your history, you are in a better position, and vice versa, if you previously had a premium advantage because your insured persons were healthier, you are now in a somewhat worse position."
If so, if the system of referrals for the sick insured works. The strange hunt for sick insured persons does not speak in favor of it. But who is actually the victim in this hunt? Who is the prey? The patient? Can't it matter which diagnosis stamp is emblazoned on his medical record?
What if, instead of a depressed mood, a depression is written down? The latter can trigger allocations from the fund, the former not. How does the new risk structure compensation, along with all susceptibility and risk of manipulation, affect the patient? Franz Knieps from the Federal Ministry of Health admits:
"Yes, you don't know that yet. If the doctor wrote down a wrong diagnosis, it could harm the patient, because the patient then knows this diagnosis. He is wrong in assuming that he is seriously ill or that he will get one Illness that he would not have and that can indeed have fatal consequences, have psychological consequences, but also have very serious somatic consequences if, for example, due to the first incorrect diagnosis, incorrect treatment may be given by another doctor, who is from the Manipulation did not know anything, is initiated. "
But, this is how the official fixes the state of knowledge of the Federal Ministry of Health:
"But once again: we do not have the relevant facts."
At the same time, the Federal Insurance Office, the supervisory authority for the nationwide cash registers, must be prepared. There is a problematic development, said Office President Josef Hecken last Sunday, which should be stopped at short notice. It is said that this can be done in a comparatively simple manner. For example, by refraining from using the most recent quarters for calculating the allocations if there was a sharp increase in lucrative diagnoses for individual health insurance funds in those same quarters.
Meanwhile, it is reassuring that nobody has been seriously harmed in the hunt for the sick. Especially not the sick. On the contrary: if they come to play a greater role for the health insurance companies in the future, that can only be helpful.The hunting scenes now would only be one stage on the way to an actual improvement in the quality of the German health care system - a very superfluous one, however.
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