German ophthalmologists optimistic despite budget woes

Private ophthalmologists are adamant about eliminating government interference and negotiating with insurance companies on an individual basis.

Global Notebook NUREMBERG — Ophthalmologists convening here at the annual Kongress der Deutschen Ophthalmochirurgen (DOC) are hopeful about their economic prospects, although the government continues to trim health care budgets. The current German government, a coalition of Social Democrats and a left-wing ecological party known as the Green Party, has instituted tight budgets for medical services and medication costs. Payments for ophthalmic surgical procedures continue to decrease as the cost for the necessary supplies and materials escalates. Many ophthalmologists are forced to work for small, insufficient salaries that pay only for necessities.

Government budgets are allocated differently in different regions of Germany. In some areas, the numbers of treatments and surgeries that are reimbursable are fixed, and further services are not reimbursed. In other regions, the number of treatments is unlimited but reimbursement for each individual procedure decreases as the physician treats more patients. The government does not consider the real cost of procedures to physicians in calculating the payments for ophthalmological procedures. Cataract surgery, for instance, for which ophthalmologists estimate a fair payment be at least DM2,000, is reimbursed at much lower rates.

Because cataract surgery is the most common surgical procedure in Germany, private ophthalmologists are being hardest hit by cutbacks. But ophthalmologists in the hospital sector are also feeling the brunt of the budget restraints, which have reduced salaries and, in some cases, the number of hospital beds.

Cataract surgery

The methods of reimbursement for medical services mentioned above “especially affect ophthalmologists in private practice, ambulant treatment and ambulant surgeries,” said Alf Reuscher, MD, a member of the executive committee of the DOC. “Therefore, many surgeons reduced the number of operations and don’t use high quality and more expensive medications like viscoelastics. That means for myself that I receive the same honorarium irrespective of performing 1,000 or 1,300 cataract operations.” Dr. Reuscher spoke to Ocular Surgery News International Edition here at the DOC’s annual meeting.

Brandenburg Gate During the past 10 years, payment for cataract surgery has decreased by approximately 40%, Dr. Reuscher said, while costs for staff, rent, materials and related supplies have increased. The current fee system for doctors values each medical service with a different number of credit points. Ten years ago one credit point had the value of 0.10 DM. Today, depending on the region, one credit point has the value of between 0.05 DM and 0.08 DM, he said. In fee negotiations with the government, the Berufsverband der Augenärzte Deutschlands (BVA, the union of all German ophthalmologists, with a membership of more than 7,000) consistently tries to win payment with fixed amounts of deutschemarks for each procedure.

Today, cataract surgery payments range from 450 DM to 1,000 DM. However, according to Dr. Reuscher, cost calculations have shown a minimum fair price to be at least 2,000 DM. Still, until policies change, German ophthalmologists must accept these small fees that fail to cover their costs.

According to Dr. Reuscher, due to the growing competition in the private sector, waiting lists for cataract surgery are short, especially since still half of the surgeries are performed in hospitals.

Many ophthalmic surgical procedures that are commonly done on an outpatient basis in other parts of the world continue to be done on an inpatient basis in Germany to an amazing extent, he said.

About 50% of cataract surgeries in Germany are done as inpatient procedures, with a required hospital stay of 3 to 7 days. Virtually 100% of vitreoretinal procedures require a hospital stay of 7 to 14 days, he said.

Efforts to fix fees

Two ophthalmological societies, the BVA and the Vereinigung ophthalmologischer Praxiskliniken (VoP, the German association of outpatient ophthalmic surgeons), of which Dr. Reuscher is also a leading member, together developed a model project for payment of ambulatory cataract surgery. This project plans to increase the payments for ambulatory surgeons through savings from the clinical sector, according to Dr. Reuscher. The plan requests fixed fees for each surgery, regardless of the number of procedures performed. Likewise, it sets a separate budget for operations, which are not deducted from the budget for the ophthalmologists.

According to Dr. Reuscher, in Nordrhein-Westfalen, the largest region of Germany, a contract to test this model project has been agreed upon with one health insurance company.

Hospitals affected

Like private practitioners, hospital-based surgeons also deal with a budgeting process that affects operations. The German government runs a vast majority of the hospitals and wants to save money in their administration. The government has reduced the number of beds in some hospitals, while other hospitals have been forced to close down entire ophthalmic departments — thus also decreasing the total number of ophthalmologists and training positions available. But in other instances, the government has been reluctant to give up political clout and power by reducing inpatient beds.

photograph The VoP is doing quite well, however, where privately owned ambulatory surgery centers are concerned, in its negotiations with insurance companies. The VoP was founded several years ago to serve the needs of private practice eye surgeons threatened by the changes in health care financing. Germany is becoming tight-fisted where health matters are concerned, according to Klaus Lucke, MD, a vitreoretinal specialist in Bremen and president of the VoP.

“We are going to be the winners in the long run,” Dr. Lucke told Ocular Surgery News International Edition at the DOC meeting. “And as others join us, the government will not be able to keep up the level of care and expense associated with inpatient structures. We will have to move towards efficient [outpatient] structures, which we can provide.”

Hospital-based doctors are quite welcome to join the VoP, he added. The hospital sector is attempting to resist change. However, many hospital sector doctors foresee where things are headed in the future and are looking increasingly in the direction of the VoP.

Dr. Lucke is head of one of the two outpatient surgery centers in Bremen. Approximately 1,100 vitreoretinal procedures are performed in Dr. Lucke’s ambulatory center in Bremen each year on an outpatient basis in an effort to confirm the success and acceptance of a more modern outpatient approach to vitreoretinal surgery. Financially, however, Dr. Lucke’s center does not have the capacity to meet the current demand.

Insurance

The biggest innovation in German politics since the beginning of the year, according to Dr. Lucke, is that health care providers are now allowed to negotiate directly with insurance companies, including government insurance companies, on an individual basis and without intermediary involvement from institutions such as the Kassenärzliche Vereinigung. The Kassenärzliche Vereinigung has been the mediator between private doctors and the government, but is losing some of its former power and influence with the current movement toward individual contracts, Dr. Lucke said.

Ophthalmology is one of the specialties well on its way in this process, he said. Currently, the VoP has three agreements in the pipeline with insurance companies regarding cataract surgery, which the VoP hopes will create a landslide towards individual contracts between health care providers and government-run insurance companies.

According to Dr. Lucke, the VoP has decided to go highly professional, develop management structures and plans to negotiate with the industry.

“I think the German outpatient surgeons are organizing themselves in a very professional way, and they will have to be reckoned with in the future,” Dr. Lucke said. “We have more than 250 members at the moment, with probably 90% of them being outpatient surgeons. That tendency is rising.”

Dr. Lucke is aware that in order to sell the idea of outpatient surgery to insurance companies, high-volume care must be delivered, meaning that low-volume surgeons will have to band together to form high-volume practices or high-volume institutions.

“I don’t think we will be very successful if we have a large number of institutions doing 3 cataracts per week,” Dr. Lucke said. “We are trying to entice our members to join forces and form larger units so that they can deliver care at a more professional level.”

	Report Card: Germany
	Population	82 million
	Gross domestic product (GDP) 1996	US$1.7 trillion
	GDP per capita	US$20,400
	Percentage of population 65 years and older	16%
	Annual number of cataract surgeries performed	250,000
	Average cataract reimbursement	DM1,500
	Number of ophthalmologists	about 7000
	Number of new ophthalmologists annually	300 to 400
	Source: Deutschen Ophthalmochirurgen and The Wall Street Journal

For Your Information:

Klaus Lucke, MD, can be reached at the Tagesklinik Universitätsalle, Universitätsalle 3, D-28359, Bremen, Germany; +(49) 421-2012-80; fax: +(49) 421-2012-851;

Alf Reuscher, MD, can be reached at Berufsverband der Augenärzte Deutschlands, Neckarstr. 71, 73728, Esslingen, Germany; +(49) 711-351773-0; fax: +(49) 711-350506.