German eye surgeons face tumult of health reform

ESCRS EuroTimes

German eye surgeons have lost large numbers of patients during the first full year of Germany 's new health reforms and are now bracing for a sweeping revamp of the reimbursement system this spring.

Kaweh Schayan-Araghi , MD , co-chairman of the German Eye Surgeons Society, reports that his specialty has lost patients due to two aspects of reforms that began on 1 January 2004 .

First, adult patients must pay a new € 10 fee in each quarter that they see a doctor and, second, many patients are joining a new gatekeeper program that requires a referral from a GP to see a specialist.

“We don't have exact numbers yet, but a lot of eye surgery centers report about 10 percent to 15 percent fewer operations than in 2003,” Dr. Schayan-Araghi reports .

In comparison, all German doctors, including GPs, saw their patient volume fall 7 percent and 10 percent for the first and second quarters respectively, government figures show.

Dr. Schayan-Araghi said about 20 percent of eye surgeons' patient volume isn't affected by reform, either because these patients pay out of pocket or because they are covered by private health insurance, but that amount is not enough to shield them from the reforms.

Volume outside of reform is “certainly a little bigger for eye surgeons than for, say, heart surgeons,” he said, ”but only a few eye surgeons derive a significant amount of income from this.”

Now eye surgeons as well as all other German physicians are preparing for the 1 April introduction of a new reimbursement system, EBM2000 Plus. The new system organises procedures into groups based on the amount of time they take to do and then pays them the same base amount for each procedure in the group, according to Dr. Schayan-Araghi.

The system is the doctor version of Germany 's new diagnosis related groups (DRGs) system for hospitals, which is based on the Australian DRG system and was introduced last year.

Dr. Schayan-Araghi said his specialty group pushed hard to make sure the EBM2000 is as fair as possible, but he said it is hard to predict exactly how the new system will affect eye surgeons.

Reforms were needed

The German statutory health insurance system, called the Gesetzliche Krankenversicherung, or GKV, had been logging deficits for years. Everyone had agreed that it was in need of a major overhaul but for years the actual reform plan was hotly debated.

A year after the beginning of reform, known as the GKV Modernisation Law, the German government is proclaiming it a success. The health ministry reports almost €10 billion in savings, partly due to fewer people seeing the doctor, and an end to the chronic health budget deficits.

The savings allowed for a slight reduction in premiums, from 14.3 percent to 14.2 percent of gross pay, but this fell short of the government's goal of 13.6 percent.

The government says it will introduce adjustments to the system and fully phase in the DRG system by 2007.

Doctors fee causes patient drop-off

Physicians groups have signaled widespread unhappiness with the reforms, especially the € 10 fee.

The fee is thought to have contributed to the marked fall-off in patient visits to eye surgeons and other specialists. It is collected every time the patient sees a new doctor, so if a patient sees a GP and then a specialist, he pays twice.

The fee was supposed to stop unnecessary visits, but critics say it may also be preventing the economically disadvantaged from seeking necessary care. For example, the critics report that a low-income area of Berlin saw a 16.8 percent decline in visits in the first quarter of 2004, well above the city average of 8.6 percent.

Although the fee goes to the statutory health funds, or Krankenkassen, doctors are expected to collect it. Researchers at Cologne Technical College put the cost of collecting the fee at € 315 to € 1,810 per quarter.

Most patients are paying the fee, sometimes after the health funds undertake collection procedures. German authorities reported that only 0.3 percent of all visits were still unpaid as of December 2004.

Gatekeeper system reduces visits to specialists

Unlike the new fee, the new gatekeeper system is voluntary, but it also seems to be playing a major role in reduced patient flow to specialists, physicians groups said.

Each health fund can set up a gatekeeper program and offer incentives to patients to enter it. One common incentive is to waive the doctor's fee when the GP refers the patient to a specialist.

The system has proven to be popular in some regions. For example, the health fund in the German region of Saxony-Anhalt reports that more than 200,000 members have chosen gatekeepers.

But t he German Society of Ophthalmologists argues that the referral process could markedly slow down patient access to specialists, which can mean life or death for fast-paced ophthalmic diseases such as macular degeneration.

“Patients with this condition must be examined by an ophthalmologist without delay,” the society said in a release, adding: “Patients have to keep in mind that under the gatekeeper system they give up their self-determination and their decision to go to a specialist.”

Dr. Schayan-Araghi says the gatekeeper system has scored one success – it has boosted the number of referrals from GPs to specialists. “GPs regard the referral as a service to their patients,” he says.

But he adds that the overall number of patients going to ophthalmologists has actually declined. He identifies a number of reasons for this decline. Due to the fees, fewer patients are asking for routine eye exams. Also, gatekeeping GPs are more likely to treat eye problems rather than refer them.

Even though the GPs do not receive a financial incentive for not making a referral, “now they think they have the responsibility to be good at everything,” Dr. Schayan-Araghi says.

He added that non-surgical ophthalmologists, who make up 85 percent of the specialty, have probably lost more patients under the reforms than have their surgical colleagues. Non-surgical ophthalmologists deal with eyeglasses, which lost coverage under the 2004 reforms. These physicians saw a flood of patients in late 2003 seeking eyeglasses before the law changed, then a drop in visits afterward by as much as 25% compared with the year before, he said.

New reimbursement system

Now eye surgeons and other German doctors are getting ready for the new EBM reimbursement system, which will radically change the way they are paid.

Instead of coding for each procedure – such as for glaucoma surgery or phako surgery – the eye surgeons will code for three basic groups of reimbursement, organized according to the length of time each procedure normally takes, Dr. Schayan-Araghi said . The three groups are extraocular surgery, intraocular surgery and laser surgery. He added that payment within each group rises somewhat for every 15 minutes of extra operation time.

In addition, Dr. Schayan-Araghi said his eye surgeons group successfully lobbied to put phako emulsification into a separate group that receives a higher rate. He said only measuring the length of time of the operation, as was done to set charges for other operations, did not take into account other significant costs.

“Use of products, sterility issues, etc., convinced the insurance agency that just the time of the surgery itself does not reflect the actual effort,” he said. 

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