What makes medical treatment so much
questions and answers
Two patients, two insurance systems, the same illness - one experiment: 45 minutes followed two patients who were both getting knee prostheses. What is the specific effect of being a health insurance or private patient when you need a doctor's appointment or have an operation? How does rehab work? What are the costs for patients and insurance? Do private patients really only benefit from their health insurance?
1. How is it going in the doctor's office?
Both the public patient and the private patient have major complaints in the knee joint. You go to different orthopedic surgeons. Both doctors advise their patients to have a knee prosthesis.
Meeting: In the experience of many statutory health insurance patients, they have to wait much longer before they get a doctor's appointment. According to a Hamburg study, this is also true. According to this, private patients receive an appointment after an average of 7 days, those with statutory health insurance only after 16 days.
Doctor service: The orthopedic surgeon of the patient with statutory health insurance receives around 22 euros for examinations and patient discussions from their health insurance company - every quarter, regardless of how often the patient comes to the doctor. In this case, he can charge an additional 10 euros to the health insurance company for an X-ray examination in his own practice. Due to her complaints, the patient is already in his practice for the third time, as injections and physiotherapy did not help.
"If you really take these average values, I skipped that, then it's the case that I earn just as much as the practice assistants. I can only increase that in the legal area if I have more case numbers, i.e. more patients in the Quarter. But then of course there is less time per patient. "
Dr. Knut Christoph Allmann, resident orthopedist
For his private patient, the other orthopedist can charge between 10 and 20 euros for the consultation alone, depending on the effort. The fee schedule for doctors specifies the scope of the amounts that can be charged for private patients. Examinations are paid extra - in this case with 21 euros. An X-ray image costs another 38 euros. With the same performance, a doctor can therefore charge more than twice as much for a single visit in our experiment and re-bill each subsequent visit. Since doctors can invoice each treatment individually for private patients, patients run the risk of receiving more treatments than necessary.
The economic success of a practice is therefore not measured by the quality of the treatment, but by the proportion of private patients. "In this respect, it is understandable from the doctors' point of view when they give private patients a special priority," said health scientist Prof. Dr. Gerd Glaeske. "But all in all, it leads to dissatisfaction in the system and the statutory insured to feel behind." For private patients, this may mean that they are "re-ordered too quickly so that they can be billed. That means that private patients are billable objects. That has to be said very clearly".
2. How do the stays in hospital differ?
The two patients from our experiment will be operated on in the same clinic, the Duchess Elisabeth Hospital in Braunschweig. But accommodation, food and the hierarchy level of the operating doctors differ.
Flat rate per case: For all knee prostheses, hospitals receive a general flat rate per case - in English DRG (Diagnosis Related Groups). This means that the hospital receives EUR 7,559 for the use of a knee prosthesis and all accompanying treatments in the clinic for both the statutory insured patient and the private patient. But for private patients, every move made by the head physician is charged separately, every conversation, including ultrasound examinations, every visit and also the operation. This can result in additional costs of more than 2,000 euros for knee prosthesis surgery.
Depending on the contract, between 20 and 50 percent of this amount goes to the chief physician personally. The clinic will keep the rest. The Braunschweig hospital has a high proportion of private patients (20 percent). They bring additional money into the cash register via so-called comfort rooms and treatment by the head physician.
Treatment: In the case of those with statutory health insurance, the clarification interview is not always carried out by the person who also operates. The preliminary discussions in the clinic are similar for private patients, but they enjoy personal care from the doctor of their choice. He has the right to be treated by the chief physician. But he also issues an extra invoice for this.
Every X-ray from the chief radiologist and every additional therapy, such as lymph drainage, can be billed separately for private patients, while it is included in the flat rate of 7,559 euros for patients with health insurance. On the one hand, this can mean that private patients do not receive treatments, but on the other hand it can also lead to false incentives and unnecessary thearpia.
Private patients bring the clinic additional income and are therefore also welcome here. The hospitals are dependent on this additional income from the few private patients. Good medicine alone is not enough. This is also confirmed by Prof. Karl-Dieter Heller, Head of Orthopedics at the Duchess Elisabeth Hospital: "50 percent of the clinics no longer cover costs, although they treat private patients. I am sure that if this extra income is lost, many clinics will have even bigger problems. "
Accommodation: Three-bed rooms are standard in most clinics for those with statutory health insurance. But every cash patient can make himself a private patient, so to speak, if he finds a so-called comfort room with better equipment out of his own pocket. In the clinic from our experiment, it is around 65 euros per day for a "comfort" twin room and 116 euros for a single room in the private ward. However, patients with statutory health insurance do not get treatment by the chief doctor. In addition, all statutory health insurance patients have to pay an own contribution of 10 euros per day in the clinic.
The private patient is always entitled to a "comfort room". Towels, shampoo and shower gel await him there. Other special services that a private patient receives in this hospital include a daily newspaper, free Wi-Fi or a bathrobe and a selection of dishes à la carte. An "optional service manager" takes care of all the special requests of private patients.
Prosthesis: However, private patients do not get any better prostheses than those with statutory health insurance. "There is no difference with the implant," says Prof. Heller. "That would be ethically unjustifiable. The implant is chosen on the basis of the findings. We do not make the choice of the implant dependent on the insurance status in any way." But: knee prostheses make quick money for the clinics. This tempts you to do more than necessary. With 170,000 knee prostheses per year, Germany is one of the European frontrunners.
3. Are there differences in the rehab clinic?
The two patients also come to the same rehab clinic after their operations. For the three-week stay, the health insurance of the legally insured patient pays a flat rate of 105 euros per day. This includes the costs for accommodation, meals and all therapies. Every year the clinic negotiates a fixed price with each insurance company. As in the hospital, the cash patient pays an own contribution of 10 euros to her health insurance for the stay and treatment.
The private health insurers also negotiate a flat rate for patients with the rehabilitation clinics. Private insurance pays 110 euros per day for its customers. That is little more than the costs that are billed for patients with statutory health insurance.
The private patient receives the same therapy as the statutory health insurance patient. The clinic cannot claim additional bills. Rooms and meals are also the same for everyone in the rehab clinic. However, the private patient is examined from time to time by the chief physician. Similar to a resident orthopedic surgeon, he or she can issue an extra invoice for this.
4. How do private patients bill?
For those with statutory health insurance, all medical services are billed according to a very complicated key directly between the health insurances and the doctors. It looks different with private health insurance. Then it is not the health insurance fund, but the patient who is the doctor's contractual partner.
Therefore the patient has to check his doctor's bills himself. The remuneration here is in principle transparent for the patient, unlike with statutory insurance. However, many medical abbreviations remain a mystery for the layperson when a bill for a complex treatment at a specialist doctor or in a clinic.
Nevertheless, the patient has to decide whether the invoice is correct. He must raise objections to the doctor himself. But only a few do that. The accounts are hardly checked professionally. This can have negative consequences. "Whenever you can bill privately, i.e. when patients have a contract with the doctor, there is a risk of oversupply, which means that more is done than necessary," warns health scientist Glaeske.
5. What are the insurance costs for patients?
In the statutory coffers, the income and thus the financial ability determine the contribution. In the private sector, on the other hand, the age and state of health. As a result, the premiums increase with age.
"There are examples of people who started at 300 euros," explains Glaeske. But then the premiums quickly rose to 700 or 800 euros a month. "There are also cases where you have to pay 2,000 euros. That is extremely dramatic for many people. You have to recognize that sometimes a third of the pension goes away for health insurance."
How fair is the dual health system?
Is the cash patient now the loser in the health system with the two types of insurance? In the hospital, the differences between the private wards and the normal wards have become particularly clear for the patients. The patient with the health insurance scheme received the same prosthesis as the private patient, but the latter received several additional benefits and more attention. For this, his fund has also paid more money to doctors and hospitals.
Does the money alone determine what happens to patients? Is that fair? Germany is now the only country in Europe that still has a dual health insurance system. The health scientist Glaeske thinks that it makes sense to have a common basis, into which everyone, including the financially well-off patients, paid: "For social peace it is very important to establish a common social and solidarity health insurance."
The bottom line is that the medical treatment of our two patients hardly differed. Both now have the same prosthesis and the same physiotherapy in rehabilitation. But the private patient received more attention and time in the treatment. The money determines the donation. Because the treatment of the private patient cost a third more in total. Doctors and clinics have earned well. A common competitive market in the health system is long overdue. Because the dual system leads to unjust and superfluous treatment.
This topic in the program:
45 min | 10/30/2017 | 22:00 O'clock
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