As of: February 6, 2024, 7:23 p.m
By: Amy Walker
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In rehabilitation care, there is resistance to the way health insurance companies select the treating clinics.
Patients should have more choice.
Berlin – When Gerhard H. comes to the Bad Lippspringe rehabilitation clinic, things were supposed to start looking up from now on.
The Martinusquelle Clinic, to which the 68-year-old was taken, specializes in rehabilitation for respiratory and cardiovascular diseases.
During the course of his rehabilitation, he receives a message from his health insurance company.
There is no cooperation agreement with this rehabilitation facility; the patient has to pay the costs themselves or go to another clinic.
The health insurance company would pay for rehabilitation in a facility in Bad Pyrmont, around 50 kilometers away.
For Gerhard H., neither of the two options is an option: he neither wants to go to rehab in Bad Pyrmont nor can he cover the costs for the Martinusquelle.
So he chooses the third, objectively worst option: he stops his rehabilitation altogether.
This process is an extreme example of something that happens all the time in the field of rehabilitation.
This is shown by numerous evidence: For the research, letters from health insurance companies to their patients were viewed, clinic managers, the central supervisory authority of the health insurance companies and a lawyer specializing in medical law were spoken to.
Everything always revolved around one question: Why aren't patients like H. allowed to choose who treats them?
Health insurance companies must avoid increases in contributions
The statutory health insurance companies always justify their actions in cases like Gerhard H.'s by saying that they are mandated to choose the most economical option.
So according to the motto: The cheapest clinic is automatically the best.
This is true to a certain point - and is understandable at first glance.
After all, the health insurance companies have to bear high costs: in 2022, according to the National Association of Statutory Health Insurance Funds, the statutory health insurance companies spent 274.2 billion euros on medical services.
Only 3.8 billion or 1.39 percent of this goes to rehabilitation and preventive services.
Nevertheless, from an economic point of view, it is logical that the health insurance companies (have to) try to keep costs under control.
If expenses increase, then the health insurance companies ultimately have to increase their contributions so that the bill is correct at the end of the year.
And that should be avoided as much as possible.
But the imperative of cost-effectiveness should not determine everything in healthcare.
In 2015, the legislature also strengthened patients' rights when choosing a rehabilitation facility. Since then, Section 40, Paragraph 3, Sentence 1 of the Social Security Code V states: "The health insurance company determines according to the medical requirements of the individual case,
taking into account the wishes and right to choose Beneficiaries
in accordance with Section 8 of the Ninth Book, type, duration, scope, start and implementation of the benefits in accordance with paragraphs 1 and 2 as well as the rehabilitation facility at its best discretion.
Regarding the right to wish and choose, the law states: “When deciding on the benefits and when carrying out the participation benefits, the legitimate wishes of those entitled to benefits are met.
The personal life situation, age, gender, family as well as the religious and ideological needs of those entitled to benefits are also taken into account.”
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In H.'s case, the health insurance company could have made a different decision - perhaps even had to.
“The problem is, the law is very vague.
So it is not exactly defined what is meant by 'legitimate wishes'."
This is what lawyer Laura Mayer, who specializes in health law, says in an interview with
Ippen.Media
.
“In my opinion, it is not permissible to have a standardized procedure.
“It must always be examined on a case-by-case basis.”
Health insurance companies agree on special conditions - and put the clinics out of business
According to their legal opinion, it is not okay for a clinic to be categorically rejected by the health insurance company without taking the patient's wishes into account.
But that's exactly what happens - as here in the Gerhard H. case - again and again.
And this not only has consequences for patients, but for the entire healthcare system.
Because behind the rejection of a single clinic is an entire system whose sole aim is to reduce rehabilitation costs.
A certified rehabilitation facility must always conclude a care contract with the statutory health insurance companies.
This is agreed in each federal state between the clinic and the state associations of statutory health insurance companies.
Both parties agree on what services the facility will provide.
The cost of these services will be agreed in a separate remuneration agreement.
Some of these remuneration agreements are concluded jointly with all health insurance companies, but sometimes they are also concluded with individual health insurance companies.
This agreement is renegotiated at regular intervals to take into account, for example, staff wage increases.
The pension insurance is approving more and more outpatient rehabilitation services.
© Christin Klose/dpa-tmn/dpa
In reality, some health insurance companies also conclude special agreements with individual institutions.
Different conditions will then be agreed upon.
“This can be a discount on the daily rate, or additional services can be agreed, for example a free transport service,” explains Bastian Liebsch, board member of the Dr Becker Clinic Group in Cologne.
The clinic expects this to give it preferential occupancy from the health insurance company.
“The loser is the patient who doesn't even know that he can choose between all clinics with a care contract.” And even if he knows this, his wishes are often rejected, as in the case of Gerhard H.
This is worrying because the health insurance companies can put pressure on the facilities through such special contracts.
These contracts are not public, so the rehabs don't know who or what they have to compete against.
This creates price pressure that has a negative impact on health care in general.
“This structured underfinancing can lead to investments being delayed for far too long and ultimately performance suffering,” explains Liebsch.
Regularly increasing employee salaries or replacing and hiring additional staff as well as fulfilling additional obligations will also become difficult if you are deprived of breath like this.
His clinic group therefore no longer agrees on such special contracts.
Resistance from the clinics: Something has to change
The rehabilitation clinics have tolerated this situation for a long time, albeit reluctantly.
But now that more and more institutions are doing poorly economically and there is a threat of a wave of bankruptcies in the healthcare sector, that should change.
There is resistance to the health insurance companies' approach.
Bastian Liebsch is part of the North Rhine-Westphalia State Working Group for Medical Rehabilitation, a kind of rehabilitation association that wants to network and fight together against this practice - also legally.
They have already achieved initial successes: in North Rhine-Westphalia they have achieved that the AOK there has to add when handing out the lists of its “cooperation clinics” that patients also have the right to wish and choose and can choose a completely different facility.
“The implementation of inpatient follow-up rehabilitation at the expense of AOK NordWest is generally possible in all certified facilities,” can now be read in the small print.
The list of AOK cooperation clinics is available to
Ippen.Media
.
The group has also filed a regulatory complaint against three health insurance companies in cases where the affected patient's right to choose was intentionally circumvented.
Ippen.Media
also has these complaints
.
But that doesn't get to the root of the problem.
From the perspective of lawyer Laura Mayer, this lies in the legally vague wording of the law on the patient's right to choose and to what extent this is above the requirement of economic efficiency.
“Ultimately, the patient always has to defend himself legally.
“In case of doubt, you have to assert your right to wish and choose.”
But she also emphasizes: “I don’t know if I want to denounce the law itself.
If something is regulated in too small a way, problems arise,” she says.
Clinic manager Bastian Liebsch sees it differently.
For him, the matter is clear: the treating doctor should decide together with the patient which facility is best suited for his or her case.
“Just like it is the case in the hospital.
The health insurance company pays the bill and checks the case afterwards via the medical service.
“Nobody would ever be transported many kilometers past other hospitals just because there is a cheaper hospital 50 kilometers further away.”
But for that to happen, the law would have to be changed.