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With a new government, Germany’s private eye surgeons faced with cuts
Last year, private outpatient ophthalmic surgeons won big victories in reimbursements, but new leaders have reversed key policies.
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The election of a left-leaning government in Germany is cause for either jubilant celebration or unbridled panic, depending on your political orientation. Liberals and trade unions are thrilled with the voters’ decision last year to elect a Social Democrat government, while the mood of Germany’s generally conservative private practice ophthalmology community is morose at best.
In addition to differences in political ideology, ophthalmologists are unhappy with a law passed last December by the new government that will decrease the national budget for reimbursements to all private physicians by DM700 million and will erase 1998’s hard-fought gains in the way private practice ophthalmic surgeons are paid for their services.
Because cataract operations are the most common surgical procedure in Germany, private ophthalmologists are likely to be hardest hit by cutbacks. Angering them further is the fact that government payments to surgical ophthalmologists in publicly-owned hospitals are slated to remain at current levels, creating a disparity in the value of cataract surgery.
Protecting hospitals
The government claims the new law, which took effect on Jan. 1, is necessary to protect the nation’s hospitals from staff reductions and broader cuts in services, but private practice ophthalmologists see the change as a politically motivated swipe at free enterprise. They argue that private medicine and the rights of physicians who practice outside the national system are being compromised to spare public hospitals the pain of making difficult reductions.
“The hospital sector will be strengthened at the expense of private medicine because our government is more socialistic than it has been in years,” said Klaus Lucke, MD, a vitreoretinal specialist in Bremen. Dr. Lucke is the chairman of the Vereinigung ophthalmologischer Praxiskliniken (VoP), the German association of outpatient ophthalmic surgeons, founded a year ago to serve the needs of eye surgeons threatened by the changes in financing.
Unemployment in Germany is around 10%, and Dr. Lucke argues that the Social Democratic Party (SPD), which last held power in 1982, is very sensitive to public concerns over joblessness. Its leaders would rather see hospital funding remain unchanged than make cuts in hospital budgets that could compromise jobs and contribute to even higher levels of unemployment.
Only a few months before this new law was passed, VoP members had completed negotiations with the Christian Democratic government. Under a deal made with the conservative predecessors to the SPD, ophthalmic surgeons were awarded a number of concessions that were taken away when the SPD came to power. German ophthalmic surgeons are now back to square one in the negotiation process.
Equal pay for equal service
“What we earned through our negotiations under the previous government was a system whereby a cataract operation is worth exactly the same amount of money no matter where it is performed, or who performs it,” Dr. Lucke said. “Hospitals earn much more than the private sector and that’s not fair.” Other states followed Hesse’s lead, and soon reimbursement policies throughout Germany were being revised.
The contracts signed in the summer of 1998 were unique for several reasons. First, they outlined a payment system by which physicians would receive a per-procedure fee, payable directly in deutsche marks. Previously, cataract surgery was reimbursed based on Germany’s health care point system. Each cataract procedure was worth about 9,900 points, but the value of each point varied from state to state, so there was significant disparity in the value of surgery. Under a direct reimbursement plan, the cost of cataract surgery was made universal, and many states moved quickly to adjust their reimbursement policies in keeping with the new law.
Second, the new contracts specified that private practice outpatient surgical ophthalmologists would receive the same reimbursement as their public sector colleagues who treat public patients on an outpatient basis.
Since the mid-1990s, reimbursements for cataract procedures have been cut by as much as 66% in some regions. The new contracts restored the value of cataract surgery to 1990 levels.
The new contracts allowed all patients to seek the care of private physicians. Patients would pay for the cost of surgery out of pocket, then would present the bill to their insurance company, which would reimburse them for most of the costs.
Worth the risk
The Hesse contract paved the way for other states to design similarly egalitarian programs with local surgeons. Bavaria soon followed Hesse’s lead and revamped its reimbursement procedures, placing private and public ophthalmologists on equal footing.
“Last year’s job action was very successful because it gave rise to all of the contracts,” Dr. Lucke explained.
Physicians who participated in Operation Phoenix contend it was a risky venture that could easily have backfired. During Operation Phoenix, physicians artificially lengthened their waiting lists for public patients in an attempt to show them that under private care, patients would receive treatment sooner.
“It made patients aware of the fact that there was a possibility that as a private patient they would be treated better, or at least quicker,” Dr. Lucke explained.
Operation Phoenix worked so well because it did more than just make patients aware that better treatment might be available if they were to pay privately for health care. It caused grave concern among Germany’s state-run insurance companies who were uncomfortable with the fact that some of their patients might think that people who receive public care are not treated as well as those that receive private care.
“Suddenly, after years of resistance to change, the insurance companies were suddenly interested in entering into contracts with the private surgeons,” Dr. Lucke said.
New contracts were signed, and for the first time private surgical ophthalmologists were given the opportunity to treat public patients for the same reimbursements that their public hospital colleagues earned.
Then came the elections.
Reversal of fortune
It is said that all good things must come to an end, but few German ophthalmologists expected it to be so soon. The euphoria that came with the new contracts lasted only a few months. Before the ink on the new state contracts was dry, German voters put the SPD in power and most physicians realized that the post-Phoenix boom would be short-lived.
By December, newly installed officials in the Ministry of Health voted to nullify the new contracts by reducing the amount of money made available for per-procedure reimbursements to private outpatient physicians.
Dr. Lucke said the health ministry’s new policies, which place greater emphasis on the role of the public hospital versus that of the private physician — and funding them accordingly — would begin to transform Germany’s health care system into one that more resembles England’s National Health Service.
“The new government believes that they can save a lot of money by strengthening the role of the public sector,” Dr. Lucke said. “The new government will downplay the role of the specialist because after all,” he added in a timbre dripping with sarcasm, “what has worked so well in Great Britain must be good for Germany.”
Phoenix redux?
Though disheartened by losing so quickly what it worked so hard to get, the VoP leadership and its 150 members are back in negotiations with the new health ministry. The VoP, which has earned the endorsement of the 7,000-member Berufsverband der Augenärzte Deutschlands (BVA), the professional organization of German ophthalmologists, is again asking for direct payment in deutsche marks for surgical ophthalmic procedures in all states for all ambulatory surgeons regardless of where or for whom they work.
The VoP proposal, which at press time was still being discussed, would do three things. First, it would enable Germany’s public hospitals to establish their own private outpatient clinics. Public hospitals could manage these private centers and use the proceeds to fund other operations. Second, the VoP wants the public sector to purchase some surgical services from the private sector, and last, negotiators ask that funding, which was increased after Phoenix and then cut again in December, be restored.
Currently, ophthalmologists are reimbursed about DM1,500 (US$975) per cataract procedure. Leaders of the VoP would not disclose the amount they are requesting in the ongoing round of negotiations, but sources close to the organization say they want about 60% more per case. A 60% increase would bring payments back to the early 1990s levels, which had been the goal of Operation Phoenix.
If the VoP’s efforts do not succeed, payment levels will remain as they are, and profit margins are likely to erode as physicians’ cost for surgery increases, as it tends to do annually.
“I honestly believe that we will be given less per procedure,” said Michael C. Knorz, MD, a private practice cataract and refractive surgeon in Mannheim and visiting associate professor of ophthalmology at the Baylor College of Medicine, Houston, U.S.A. “Some ophthalmic surgeons may decide that it is no longer possible to offer cataract services at their private clinics and will send their patients to the hospitals.”
Preliminary talks with health ministers suggest the government may be willing to show some flexibility. At a meeting on Jan. 20 between officials from the ministry and the VoP, the government seemed willing to make certain concessions, and VoP leaders left the meeting feeling upbeat. The ministry may choose to endorse the VoP recommendations, but it would still be up to the state-run insurance agencies to decide whether they would adopt the plan and change reimbursement policies.
Creating lines
Such a decision by private surgeons would likely increase waiting lists that, for the most part, have been eliminated in Germany. Without private physicians treating public patients, some people could be forced to wait — possibly for months — for cataract surgery.
The potential for the VoP to create cataract surgery waiting lists may be its trump card in negotiations with government insurance agencies. Government leaders are likely to take this threat seriously because they are fearful that voters would become angered over the fact that they have to wait months for a routine surgical procedure. Anger might prompt them to reconsider whether the SPD is right for Germany, and that is a risk that government leadership is unwilling to take.
On the other hand, if the VoP’s efforts prove successful in the latest round of negotiations and the government decides to purchase some surgical services from the private sector, there will be an increase in both volume and reimbursements for private physicians.
Dr. Knorz explained that two more things would happen if the VoP succeeds. First, hospitals would lose some volume, and second, low volume ophthalmologic surgeons would be excluded from the new deal.
The VoP’s proposed model said that surgeons would have to perform at least 300 cases per year to be entitled to treat some of the public sector patients at the increased rate. High volume, the VoP argues, would ensure higher quality surgery.
“Currently, the ophthalmologic surgeons act as one body and this will separate them,” he said. “That is why there is some concern in the ophthalmic community as to whether this is really the right way to go. Because hospitals would be free to open their own ambulatory centers outside their existing ophthalmology departments, they would be free to compete with us. Therefore this proposal is attractive to them as well.”
Report Card: Germany
Population 81.1 million Number of ophthalmologists 6,900 Percentage of ophthalmologists who perform cataract surgery 20% Annual number of cataract surgeries performed 250,000 Average cataract reimbursement DM1,500* Number of new ophthalmologists annually 300–400 *US$975
| German Ophthalmology Societies | |||
|---|---|---|---|
| Deutsche Ophthalmologische Gesellschaft (DOG) Prof. Dr. H. Busse (President) | Berufsverband der Augenärzte Deutschlands e.V. (BVA) Postfach 300155 | Deutschsprachige Gesellschaft für Intraokularlinsen-Implantation und Refraktive Chirurgie (DGII) Prof. Dr. Chr. Ohrloff (President) | |
For Your Information:
- Klaus Lucke, MD, can be reached at the Tagesklinik Universitätsallee, Universitätsallee 3, D-28359, Bremen, Germany; +(49) 421-2012-80; fax: +(49) 421-2012-851; e-mail: TKU_Bremen@compuserve.com; Web site: www.retina.to. Dr. Lucke did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Michael C. Knorz, MD, can be reached at the Klinikum Mannheim, 68135 Mannheim, Germany; +(49) 621-383-3410; fax: +(49) 621-383-3803; e-mail: knorz@eyes.de. Dr. Knorz has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.