/image alliance, Sina Schuldt
Berlin – proposes solutions to improve and strengthen outpatient care National Association of Statutory Health Insurance Funds. A position paper adopted today by the association’s board of directors states that the aim is to address structural challenges – in particular the shortage of skilled workers, digitalisation, financing and outpatient care – and remedy existing deficits for the benefit of policyholders.
To improve access to outpatient care in doctors’ offices, measures must be combined to digitize appointments and “make appointment times more flexible”, according to the National Association of Statutory Health Insurance Funds. The “preferential scheduling of appointments for privately insured or for private medical services” should be avoided.
With regard to the necessary flexibility in appointment times, the health insurance association is in favor of binding specifications. Based on a legal mandate, the guarantee mandate of the Statutory Health Insurance Doctors’ Associations (KVen) must be specified in such a way that legal medical care through medical practices and medical care centers (MVZ) must be guaranteed in a “significantly extended time window” with more flexible appointment times.
Doctors should also be “better able than they are currently to conclusively treat patients’ health problems.” This could, in particular, reduce additional contact with other service providers that is not medically necessary.
“An essential prerequisite for this is sufficient medical treatment time to care for the insured,” the position paper states. However, the document does not contain any measures to increase the attractiveness of a branch or to expand medical study capacity – health insurance companies want to ensure sufficient medical treatment time through “optimal utilization of existing treatment capabilities”.
Zero payday
Last year, November 15 was Zero Pay Day for budget-bound practices. From this date, statistically speaking, doctors in private practice stopped receiving any money for the majority of treatments for patients with legal health insurance. The date represents an average value. Exactly when budgets run out depends on location and discipline. Services such as early detection exams, vaccinations or outpatient operations, which are paid extra-budgetally, are not affected.
Among other things, the “incentives for remuneration for the reappointment of patients who are not medically necessary” identified by the National Association of Statutory Health Insurance Funds will be reduced.
This would require a more extensive flat fee for medical services and further development of the previous quarterly flat fees to include remuneration for longer periods of treatment. Furthermore, new regular appointments without medical necessity should be avoided – for example, through the “consistent use” of the possibility of multiple medication prescriptions.
For the National Association of Statutory Health Insurance Funds, “direct control of the quantity of medical services for practices” continues to represent an essential element for the targeted use of medical resources. Only with “robust quantity control through the budgeting of medical services” is it possible to “overcome”. – or even avoid incorrect care for policyholders.” “Avoid medically unnecessary services through expansion.”
Health insurance companies also advocate for increased delegation and substitution. On the one hand, this requires the promotion and recognition of the skills of non-medical staff. On the other hand, it is important that the legislator defines the direction for the transfer of medicines to duly qualified professional groups.
With regard to outpatient care, it is stated that this must be combined with the reduction of excess inpatient capacity and opportunities for effective verification of invoices by health insurers. The expansion of outpatient care must be accompanied by continuous monitoring of performance in order to evaluate and further develop current regulations.
Security order adjustment requirement
In the position paper, the National Association of Statutory Health Insurance Funds advocates an “update of the security mandate.” It has become clear that a “clearer definition of which services should be offered and provided by doctors in mandatory healthcare” is necessary.
When evaluating health insurers, it is necessary to specify a specific service framework for contracted doctors depending on their specialty. Failure to comply with these supply orders must be punishable.
The review of purely quantitative compliance with supply mandates, carried out so far by the KV, must be “unified or standardized and complemented by a qualitative aspect”. At the federal level, autonomous government partners should develop guidelines that would then form the basis for review by KVs.
The National Association of Statutory Health Insurance Funds also wants to make adjustments to existing quality assurance measures in outpatient care – these should be “deepened in a focused way”. Existing data on quality of care should be used to establish a “regular referral system”. This system should also be used to inform patients.
More digitalization in care
The position paper states that increased digitalization in the healthcare system opens up new opportunities to improve the quality and accessibility of medical care. Among other things, video consultations should be offered “in principle by all contracted doctors”. Furthermore, there must be contact points where patients can receive short-term care from non-medical staff and supported by video consultations.
Regarding artificial intelligence (AI), health insurance companies are realizing that the use of AI components places great demands on users. Doctors must learn the relevant skills before using AI components – regulations for this must be established “in the short term”.
In order to improve supply management, which health insurers consider necessary, data transmission within the scope of collective agreements should also be developed. Billing data on mandatory healthcare performance is only available five months after the end of the quarter.
“The transmission of billing data must be significantly accelerated so that patients can transparently understand the services provided and health insurance companies can advise their individual policyholders on what other treatment options exist,” the position paper states . Contract doctors should be obliged, based on a legal mandate, to “transmit data on defined services to health insurance companies on the same day”. © aha/aerzteblatt.de