What medicine would a doctor not take?

Performance audit: "No doctor is punished for his expensive patients"

The fear of possible drug regression prevents many resident doctors from enjoying their jobs. Less than one percent are affected each year. Nevertheless: An end to price responsibility is long overdue.

Dr. med. Wilhelm Ehleben paid. From 2002 to 2006 the general practitioner from Dortmund had to pay 65,000 euros for having prescribed too much physiotherapy for his patients. With his prescription numbers, he was twice as high as the average of his specialist group. The testing committees did not recognize any practical features. “That almost ruined me,” says Ehleben. He blames the information policy of the Association of Statutory Health Insurance Physicians (KV) for the misery. Because if he had known his prescription numbers early on, he might have been able to take countermeasures. "I felt I was given insufficient and not particularly competent advice," explains Ehleben. In the meantime, he is in the green area with his medication regulations. There has never been a problem with drug prescriptions. "However," adds Ehleben, "the continuing pressure of recourse means that you can no longer care for your patients optimally, which should be our real task."

Recourse scares off the offspring

Every resident doctor has cases like that of the Dortmund family doctor in the back of his mind when he prescribes drugs or remedies. The official statistics suggest that the perceived threat is greater than the real one. In the KV Westfalen-Lippe responsible for Ehleben, for example, due to changed testing agreements between KV and health insurance companies, the number of testing procedures at around 7,700 doctors who prescribe medicinal products has continuously decreased: from 570 testing procedures in 2005 to 118 in 2007. The The number of recourse fell from 334 to 47. A similar development can be seen in the benchmark tests for pharmaceuticals. In 2005, 696 of the approximately 8,800 prescribers had to undergo a test procedure; in 2008 there were 69. The number of recourse fell from 266 to 26.

A survey by the National Association of Statutory Health Insurance Physicians (KBV) shows that KV Westfalen-Lippe is not a notable exception. According to this, on average less than one percent of doctors are affected by recourse. A benchmark procedure was initiated in 2007 for 2.7 percent. The average amount of the established recourse, which is not yet legally binding, was 28,400 euros. The highest demand was 151,200 euros. The communication of such - existence-threatening - sums should be the reason why, in a KBV survey of 12,000 medical students last year, almost 50 percent named “threatened recourse claims” as a factor that speaks against a branch.

KV Westfalen-Lippe took this survey result as an opportunity to take countermeasures. "The risk of drug recourse is overestimated", it said in a press release of the KV from October 2010. Its first chairman, Dr. med. Wolfgang-Axel Dryden also affirmed to the Deutsches Ärzteblatt: "No colleague who adequately cares for his patients has to be afraid of exams." There are still doctors who fear that treating particularly expensive patients will ruin themselves, these patients Pass them on to colleagues so as not to exceed their target size. “It's unfounded,” says Dryden. "No doctor comes into an exam just because he is treating a cystic fibrosis patient appropriately, for example." His therapy is a practice specialty, the costs are automatically calculated from the benchmark. The procedure does not only apply to rare diseases. Diabetes mellitus requiring insulin is also classified as a specialty of the practice, which also causes high costs. "No doctor can recourse to us because he treats a particularly large number of diabetics who require insulin," assures Dryden, who himself worked as a family doctor for a long time. "However, he can run into problems if he only ever prescribes the most expensive insulins."

Leading substances: guideline for profitability

In Westphalia-Lippe, as in other KVs, they rely on information and advice. The doctors there receive a monthly trend report on their drug prescriptions. This provides information about the practice-specific benchmark volume, the degree of utilization and the prescription data of the practice. "In addition to the pure water level report, we also give the doctor structural information," explains the head of the Prescription Management division, Dr. rer. nat. Matthias Flume. "This is based on the system of lead substance quotas, which we introduced as the first KV in 2006." The aim of this concept is to recommend therapy standards within certain groups of active ingredients. "We try to give the doctor cooking recipes so that he can, for example, initiate lipid-lowering therapy, usually with simvastatin, unless something speaks against it on an individual basis," says Flume. From the trend report, the doctor can then see how high the proportion of simvastatin prescriptions is in relation to the specified quota and in comparison to the specialist group. Also included is a "hit list" that shows the doctor the cost and amount of the most frequently prescribed medication.

In the opinion of KV chairman Dryden, the concept of lead substances has proven itself as a preventive measure against exceeding benchmarks: "Those who stick to the recommended quotas can be as good as certain that they will not even get into the profitability audit." found many imitators among the KVs. Since 2008, the KBV has also recommended lead substances for all of Germany in the framework agreement on the supply of pharmaceuticals.

“The important thing is: the benchmark is not a budget,” stresses pharmacotherapy consultant Flume. “It is primarily an orientation value for what the patient needs on average for the specialist group.” If the doctor cares for a patient with an enzyme deficiency disease whose treatment costs 80,000 euros, the patient is entitled to this treatment. It is not primarily a matter of the doctor adhering to his reference volume, but rather of providing the patient with adequate care - "not completely from the delicatessen, but appropriate". In Flume's experience, doctors in particular are at risk of recourse, who do not have a special patient structure, but who usually prescribe the most expensive in the area of ​​standard therapies: “The recommendations are different, the specialist group does it differently. There is actually a risk that you will be left with the difference. "

The efficiency of the ordinances is checked by the examination offices, independent institutions that are financed by KVs and funds. “We compile the statistics and then deal with the practices that exceed their benchmarks,” explains the head of the examination center in Westphalia-Lippe, Markus Gräber. According to the law, doctors who - after deducting all practice peculiarities - exceed their target volume by 15 to 25 percent, seek advice. If the excess is more than 25 percent, recourse will be established. Gräber advises those affected to contact the examination office in any case when an examination procedure is opened: “We have repeatedly made the experience that many doctors, because it is uncomfortable, first wait and do not justify their prescription behavior. But that is ultimately at the expense of the doctor. "

It makes sense to take advantage of both the KV's advisory services and, in the event of a recourse claim, to lodge an objection, to justify this precisely and to attend the personal hearing before the complaints committee in order to highlight and supplement important arguments. "That can be the decisive factor in a decision in favor of the doctor," says Gräber. (see also "3 questions for...")

Doctors are liable for something they cannot influence

Nonetheless, the main problem, says KV chairman Dryden, is that doctors are liable for something they cannot influence: drug prices. Since pharmaceutical manufacturers and health insurers have been able to conclude discount agreements, pricing has been completely non-transparent. "That is why we support the request of the KBV board of directors to release the doctors from responsibility for profitability," explains Dryden. KBV board member Dr. med. It was only in mid-April that Carl-Heinz Müller, together with the President of the ABDA - Federal Association of German Pharmacists' Associations, Heinz-Günter Wolf, again advertised a concept according to which doctors in future will only be responsible for the indication, the selection of active ingredient, strength, amount and dosage form while the pharmacists choose the product.

However, the legislature has not taken up this requirement either in the drug market reorganization law (see box) or in the cornerstones of the planned supply law. There it only says that no recourse should be established for a review period - usually one year - if no consultation took place in the year before. That leaves the conclusion of family doctor Wilhelm Ehleben: "Imminent recourse should not deter a doctor from going to a branch."

Heike Korzilius

@The possible end of the recourse is the subject of the "Resident Day" on May 13th in Berlin; www.tag-der-niederlassungen.de.

This has been in effect since January 1st

When she took office, the Christian-liberal government coalition announced that it would dismantle overregulation in the pharmaceutical market. With the drug market reorganization law (AMNOG), which came into force on January 1st, the bonus-malus regulation and the second opinion procedure for particularly expensive or high-risk drugs are no longer applicable. The performance audit, however, was retained. Doctors still have to reckon with recourse if they do not comply with the economic efficiency requirement according to Section 12 of the Social Security Code V. What is new is that in future, the examination offices will also be able to take into account the regulations that doctors issue in the context of general practitioner and specialist doctor contracts as well as integrated care when performing benchmark tests. The contractual partners can commission the examination center to carry out an examination and bear the costs.

The AMNOG also enables associations of statutory health insurance physicians (KVen) and health insurance companies to replace benchmark tests by checking the selection and quantity of active ingredients. The responsibility for drug costs and the development of morbidity would then be transferred to the health insurance companies. So that they can take regional particularities into account in terms of care, the health insurance companies are also given the option of deferring or waiving recourse.

Doctors who exceed their target volume by more than 25 percent for the first time pay a recourse amount of no more than 25,000 euros in the first two years of exceedance. This is intended to give doctors who are new to settling or taking on new care tasks more time to adjust to the specific requirements of an economical way of prescribing. fos

3 questions to. . .

Dr. jur. Oliver Pramann, specialist lawyer for medical law

How does a recourse procedure work?

Pramann: First of all, the examination office informs the doctor that recourse has been calculated. He can then present particularities of practice that, in his opinion, require more regulations and differentiate his own practice from those of the specialist group. If the examining body nevertheless establishes recourse, the doctor can lodge an objection to the complaints committee. There he has one more opportunity to comment. If the recourse remains, the doctor can bring an action before the social court. However, the court only checks whether the proceedings were lawful. It is therefore important to put all arguments on the table before the complaints committee.

What should affected doctors pay attention to?

Pramann: It is important to meet the deadlines for statements, objections or lawsuits. Most doctors do not pay attention to when the notice of recourse was sent to them. But if you miss the deadline - one month - you have little opportunity to contest the decision. In addition, the specifics of practice should be presented very precisely and general explanations should be avoided. The associations of statutory health insurance physicians can provide valuable help here, because they have all the prescription data at hand. In any case, you should cooperate with the review bodies and also attend the oral hearings. Experience shows that this is often crowned with success. It is wrong to let everything go because you think it will not do anything.

When does the doctor have to pay?

Pramann: Formally, as soon as the examination office has established the recourse. The objection before the complaints committee has suspensive effect, the action before the social court does not. In the latter case, however, one can try to obtain an “order of the suspensive effect of the action” in court. If the recourse is due, the complaints committee informs the KV, which offsets the amount with the ongoing fee payments. Depending on the amount, the doctor has the option of applying for a deferral or agreeing to pay in installments. Because recourse payments can endanger the existence of the company.