This article is more than 5 years old. Information may no longer be current.
Germany’s reimbursement system may be diminishing patients’ quality of care
Surgeon says reimbursement rates are not differentiated based on technology or complexity of surgery.
Germany’s health care system provides coverage for all patients, but reimbursement for ophthalmic procedures may lead to a decline in the quality of care patients are receiving, according to one surgeon.
Holger Mietz, MD, is an ophthalmologist at the University of Cologne with a focus on anterior segment and oculoplastic cases. He told Ocular Surgery News that reimbursement is fair for procedures such as cataract extraction with IOL implantation, which is currently about 700 euro. However, reimbursement rates are not differentiated based on technology or skill required for particular cases, he said. More advanced procedures and techniques do not receive greater compensation.
“I believe that cases should be compensated with respect to difficulty. We actually have many of the difficult cases for cataract surgery, glaucoma and retina. Nevertheless, we can only bill fairly standard rates that do not reflect the difficulties,” he said.
Because of this, the number of patients that can be seen by ophthalmologists is limited, which means that nonemergency surgeries may be delayed. Additionally, attempts to control costs and increase profitability have resulted in declining levels of patient care, he said.
Cost-constrained coverage
According to Dr. Mietz, the majority of patients in Germany (approximately 90%) pay into the public health insurance system, which is composed of up to 40 independent health insurance companies. The remaining patients, who usually have greater income levels, receive coverage through private health insurance policies.
Dr. Mietz said the public insurance companies provide roughly the same grade of service. Overall, patients only pay out-of-pocket expenses for cosmetic surgeries such as LASIK. However, because reimbursement rates for necessary procedures such as cataract surgery are fixed regardless of the skill needed, complicated cases cannot be billed differently from routine procedures.
In addition, reimbursement rates have been diminishing as technology has improved, he said. Instead of increasing compensation, health care providers have been forced to become more cost efficient. This has resulted in many surgery centers attempting to cut costs any way possible, including using cheaper, lower quality IOLs, he said.
“It is possible to do it cost efficiently, but you do want to make some money,” he said. “The service for the patient is not as good.”
Mediocre care
Dr. Mietz noted that current reimbursements only cover the actual performance of the operation. For cataract surgery, this includes the surgery itself, use of the operating room and the IOL. Patients have to pay for preoperative IOL power calculations out of pocket. This means surgeons have to spend a lot of their time discussing these additional costs with patients.
“As a doctor who does surgery, I want to treat the patient. I do not want to spend 20% or 30% of my day just talking to the patient about money,” he said.
Because of cost restraints, it can also be difficult to determine whether a patient is content with his or her postoperative vision. Dr. Mietz explained that patients implanted with cheaper IOLs may have a good visual acuity, but they may have problems with their vision resulting from the lower optical quality of the lens. “But there is no one who checks that,” he said.
“You can perform surgery with a moderate effort and have moderate results, and no one is going to care,” he said. “Ten years ago, we said we wanted to provide the best possible patient care basically at whatever it costs. If it is for the patient’s good, we would do it. Now we are starting to see that we are basically going to get moderate results, but that is the best we can do.”
For Your Information:
- Holger Mietz, MD, can be reached at the University of Cologne, Department of Ophthalmology, 50924 Koeln, Germany; +49-221-478-3425; fax: +49-221-478-4347; e-mail: h.mietz@uni-koeln.de.