Individual health service

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The so-called individual health services in specialist circles in Germany - IGeL for short - are services for which the health insurances in the Federal Republic are not liable or which other service providers are responsible for ensuring, for example the statutory accident or pension insurance. This applies in particular to services which, according to the decision of the Federal Joint Committee , were excluded from the statutory health insurance obligation in accordance with Section 92 of the Social Code Book V because they go beyond the level of adequate, appropriate and economical patient care defined by the legislature (so-called excessive treatment ).

These services can only be provided by contract doctors and private doctors in Germany to patients with statutory insurance as part of private treatment against self-payment, for which a written treatment contract was concluded with the insured person before the start of treatment (Section 18 (8) Federal Medical Insurance Contract ). Billing is based on the fee schedule for doctors (GOÄ).

Some statutory health insurance companies also pay for certain IGeLs, even though they are not part of the statutory health insurance's catalog of services, or they offer these services as part of private supplementary insurance.

classification

The individual health services can be divided into:

  • Services that are not paid for by the statutory health insurances because, in the opinion of the Federal Joint Committee, there is currently insufficient evidence of their benefit. These can be new types of services that are covered in the hospital by the statutory health insurance, but not in the outpatient area. In the hospital, services may be provided at the expense of the statutory health insurance companies, as long as they are not expressly excluded. In outpatient care, services must be checked for their benefit and expressly approved before the statutory health insurances take them over. That is why such services are often offered as IGeL in the doctor's practice.
  • Medical services outside the scope of coverage of statutory health insurances such as B. medical advice on long-distance travel or expert certificates on fitness to fly
  • Services for which there is no proof of benefit, but which also do not lead to any significant damage, so that the ratio of benefit and damage is at least balanced
  • Services desired by patients that have no medical objective, such as B. cosmetic surgery if they are at least justifiable from a medical point of view.

The various IGeL lists are not binding. Other services can also be referred to as IGeL and doctors can offer additional services without naming them IGeL. The services listed in the list of fees for GOÄ are chargeable , as well as the analog services according to § 6 Abs. 2 GOÄ.

The AOK Scientific Institute (WIdO) estimated the volume of services for 2014 at EUR 1.03 billion.

Individual IGeL

The most common IGeL are (as of 2015):

Hedgehog proportion of
Ultrasound examinations 24.8%
Glaucoma early detection 17.6%
Medicines / remedies and aids 11.4%
Blood tests / laboratory services 11.2%
Supplementary cancer screening tests in women 8.2%
PSA value for prostate cancer early detection 4.3%
acupuncture 3.1%
cosmetic services 3.0%
Skin cancer screening 2.8%
Others 13.4%

An online survey that is representative of the population on behalf of the Medical Service of the National Association of Health Insurance Funds. V. (MDS) found at the beginning of 2018 that intraocular pressure measurements for glaucoma early detection and ultrasound of the ovaries and breast for early cancer detection are the three most common IGeL. Every second respondent who had contact with IGeL was offered one of the three IGeL or asked about it. 2,072 publicly insured persons aged between 20 and 69 were surveyed. Of the IGeL carried out, only four percent, i.e. only every 25th IGeL, were asked about by the patients.

Frequency of offered and requested individual health services (IGeL) in Germany in 2018

The determination of the PSA value is only a pure screening examination of an IGeL, but is covered by the health insurances if there is a corresponding clinical suspicion (abnormal palpation of the prostate, symptoms). The IGeL Monitor of the Medical Service of the Health Insurance Funds (MDS) rates the PSA test for prostate cancer early detection as "tending to be negative", since the study situation gives indications of a benefit, but also evidence of harm. Therefore, the harm (from false positives and overdiagnosis) was weighted higher than the benefit.

Vaginal ultrasound

One of the most common IGeL offers at gynecologists is vaginal ultrasound for the early detection of cervical and ovarian cancer. However, this is rated "negative" by the IGeL monitor. According to the study, as many women die of ovarian cancer with an ultrasound examination as without an examination, at the same time women are often unnecessarily worried by false alarms and even healthy ovaries are removed. The current S3 guideline also advises against examinations for the early detection of ovarian cancer.

Early detection of glaucoma

In the eye disease glaucoma (glaucoma), the optic nerve is slowly destroyed, often unnoticed at first, which can ultimately lead to the affected person becoming blind. Various fee-based examinations are offered under the term glaucoma early detection / prevention. In some cases it is only used to describe intraocular pressure measurement, in other cases the pressure measurement is combined with the visual examination of the optic nerve. In some cases, a field of view is also determined. The various examination methods are assessed differently. The sole measurement of intraocular pressure is used for early detection of glaucoma, independent of suspicion. B. rated by the IGeL monitor as "tending to be negative", as is the ophthalmoscope in combination with an intraocular pressure measurement. Very often, patients in ophthalmological practices are asked to sign so-called waiver declarations, i. In other words, they should confirm their no to glaucoma prevention in writing. But they are not obliged to do so.

Skin cancer screening

Women and men aged 35 and over can take advantage of a standardized full-body examination of the skin (skin cancer screening) every two years from specially trained and certified dermatologists and general practitioners (e.g. general practitioners, internists). The health insurance companies pay for the visual (i.e. with the naked eye) inspection of the entire skin. Patients cannot automatically assume that they will be offered free skin cancer screening in every dermatologist's practice. This is shown by a market study by the consumer advice center in North Rhine-Westphalia in 2015. A good fifth of the doctors' practices tested do not offer their patients free skin cancer screening. They either do not make an appointment at all or only offer a fee-based dermatoscopy examination .

psychotherapy

In the field of psychotherapy there is a real undersupply, as only a limited number of therapists are approved for contract psychotherapeutic care. Waiting times of up to six months for a psychotherapy place, which can be billed with the statutory health insurance, are commonplace in almost all federal states. That is why the pressure has increased in recent years to recalculate the demand figures and to create more cash register seats.

Psychotherapists who are not licensed to provide medical care have the opportunity to pursue their work through private liquidation in accordance with the fee schedule for psychological psychotherapists and child and adolescent psychotherapists (GOP). However, these services are not to be referred to as IGeL because they are provided outside the scope of statutory health insurance from the outset.

The psychotherapists who are licensed to provide medical care can, on the other hand, offer the statutory health insured persons individual health services in addition to the statutory health insurance. In particular, these are forms of treatment that are not covered by the psychotherapy guidelines of the Federal Joint Committee .

Dentistry

The concept of IGel services does not exist in dentistry. In the service catalog of the statutory health insurances, those services are shown to which the statutory health insurance patient is entitled ( dental contract services ). All other services can be agreed between the contract dentist and the patient at the patient's request . In some cases, the patient only has to bear the additional costs. The otherwise applicable ban on co-payments in the statutory health insurance has been lifted for these services.

The IGeL-Monitor of the MDS (Medical Service of the Central Association of Health Insurance Funds) rates professional teeth cleaning as a prophylactic measure for tooth decay and periodontitis as "unclear", since so far neither a clear benefit in terms of dental health nor indications of damage have been proven. This is contradicted by the German Dental Association and the German Society of Oral and Maxillofacial Surgery (DGZMK) in a science-based patient information. Most statutory health insurances also did not agree with the statements of the IGeL monitor. For example, the AOK states on its website: “A PZR cannot replace the necessary daily home oral hygiene measures, but it can optimize them by cleaning all long-neglected and / or hard-to-reach areas in the teeth - similar to a 'spring cleaning'. Depending on the intensity of personal dental care and the individual risk of disease, a PZR should be carried out at least 2–4 times a year if it is to perform its preventive and therapeutic task effectively. "

Further studies in this regard ( Improving the Quality of Dentistry , IQuaD) are currently underway , in which 10 English universities are participating.

criticism

The medical benefit of individual health services for patients is controversial.

According to the consumer advice centers , not all IGeL are medically useful. According to the former patient representative of the German federal government, Helga Kühn-Mengel , doctors offer additional measures, the benefits of which are often questionable. The chairwoman of the board of directors of the National Association of Statutory Health Insurance Funds (GKV) criticizes the fact that the IGeL is primarily concerned with the economic interests of doctors and not with the necessary medical services for the sick.

The online portal IGeL-Monitor launched in 2012 by the Medical Service of the Central Association of Health Insurance Funds (MDS) evaluates the benefits and harms of IGeL according to scientific criteria. Of the 50 services assessed so far (as of October 30, 2018), none are rated as positive , three as generally positive , 20 as unclear , 21 as generally negative and four as negative . One rating is being revised, one has been replaced by a new rating. Four other IGeL were not evaluated, only discussed.

The former chairman of the German Society for Internal Medicine, Johannes Köbberling, describes IGeL as a "non-transparent mixture of expendable services" that promotes medicalization and overdiagnosis. The consumer advocate Wolfgang Schuldzinski from the NRW consumer organization called most of such additional offers either “not absolutely necessary”, “simply superfluous” or even “medically questionable”. From the point of view of the consumer advice center, it is particularly annoying when doctors have the consumer's "no" to an IGeL confirmed in writing, allegedly in order to exempt themselves from liability risks. Such forms are legally untenable, indirect sales strategies and associated with considerable pressure for patients. They should not and do not have to be signed by them.

The chairman of the board of directors of the Bavarian Association of Statutory Health Insurance Physicians, Axel Munte , said: “Statutory health insurance cannot guarantee optimal care,” and therefore a supplement with IGeL would make sense.

According to two surveys by the National Association of Statutory Health Insurance Physicians (KBV), in which patients interviewed u. a. stated that they often felt taken by surprise by the doctors, the head of the KBV warned his colleagues to be more cautious about paid treatments. This should not damage the patients' high level of trust in the doctors.

The Internet portal www.igel-aerger.de has been used frequently by angry patients since it was founded one year ago. Around 1,500 reports were received. Many of the complaints come from patients who feel pressure from their doctor to use a paid service.

Free health benefits

Self-payer medicine includes unsystematised wish, additional, supplementary, comfort, or alternative and preventive medicine, which has been conceptually referred to as IGeL since 1968. The Medical Society for Health and Prevention (ÄGGP) has listed these services, which meanwhile include almost 450 SMEs, and is given the “Free Health Services” (FGL) seal of approval. This is intended to create a distinction to the individual health services (IGeL). They complement the services of the statutory health insurance companies. A generally applicable definition and systematization of the SMA and the ÄGGP as an independent body for the control of quality and appropriate remuneration should ensure the necessary transparency. Self-payer medicine sees itself as complementary and additional medicine that enables innovative procedures to be introduced into diagnostics and treatment in individual cases.

literature

  • Consumer advice center NRW: IGeL offers at the doctor. What you need to know about private additional services. 1st edition. 2015, ISBN 978-3-86336-057-3 .
  • Bernd Harder : The big IGeL check. When additional medical services make sense and what they cost. 2nd Edition. Knaur, Munich 2005, ISBN 3-426-64269-7 .
  • Lothar Krimmel, Bernhard Kleinken: MEGO - Medwell List of Fees for Individual Health Services. Edition 2007. ecomed, Landsberg 2006, ISBN 3-609-16247-3 .
  • KBV, BÄK, DNEbM: Pay yourself? A guide to individual health services (IGeL) for patients and doctors. 2nd Edition. November 2012.

Web links

Individual evidence

  1. ↑ Section 3, Paragraph 1 of the Federal Sheath Contract - Doctors from January 1, 2015 ( Memento of the original from December 22, 2014 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. . @1@ 2Template: Webachiv / IABot / www.kvwl.de
  2. ↑ § 12 SGB V: Economic efficiency requirement .
  3. ↑ Bundesmatelvertrag-Ärzte (accessed February 12, 2015).
  4. ↑ The extra investigations bring little (article in Die Zeit )
  5. ↑ German Medical Association: Pay yourself? A guide to individual health services (IGeL) for patients and doctors . 2nd Edition. November 2012, last changed: January 2014. PDF. Retrieved April 8, 2015.
  6. ↑ a b WIdOmonitor: Private additional services in the doctor's office. Issue 1/2015, p. 4, ISSN  1614-8444 , ( online , PDF; 1.2 MB).
  7. ↑ IGeL Report 2018, short report
  8. ↑ IGeL monitor, evaluation of the PSA test for the early detection of prostate cancer
  9. ↑ IGeL monitor, evaluation of the ultrasound of the ovaries for early cancer detection
  10. ↑ cf. krebshilfe.de ( Memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. . @1@ 2Template: Webachiv / IABot / www.krebshilfe.de
  11. ↑ igel-monitor.de
  12. ↑ Market study by the consumer advice center NRW from 2015
  13. ↑ Waiting times in outpatient psychotherapy ( memento of the original from February 1, 2012 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. BPtK background, from June 22, 2011 (PDF file). @1@ 2Template: Webachiv / IABot / www.bptk.de
  14. ↑ Marc Meißner, Sabine Rieser: Interview with Prof. Dr. Rainer Richter, President of the Federal Chamber of Psychotherapists: "The care in the country must get better" . In: Deutsches Ärzteblatt . PP 11. Deutscher Ärzte-Verlag , June 10, 2012, p. 251 ( [1] [accessed February 2, 2015]).
  15. ↑ cf. igel-monitor.de .
  16. ↑ Patient information, professional tooth cleaning , BZÄK, DGZMK. Retrieved April 14, 2015.
  17. ↑ Professional teeth cleaning AOK Baden-Württemberg.
  18. ↑ Jan E Clarkson, Craig R Ramsay et al: IQuaD dental trial; improving the quality of dentistry: a multicentre randomized controlled trial comparing oral hygiene advice and periodontal instrumentation for the prevention and management of periodontal disease in dentate adults attending dental primary care. In: Study protocol IQuaD dental trial. October 26, 2013, accessed April 14, 2015 .
  19. ↑ Joint press release MDS and National Association of Statutory Health Insurance Funds: Start of the IGeL-Monitor , press release from January 25, 2012.
  20. ↑ Jörg Blech: unholy medicine. Fischer-Verlag, ISBN 3-10-004413-4 , online: [2] .
  21. ↑ Doctor & Business, IGEV makes sense! 9/2007, p. 10.
  22. ↑ Surprised in the consulting room. In: Süddeutsche Zeitung. November 21, 2011, accessed January 26, 2012 .
  23. ↑ Wolfgang Mulke: Additional services - Doctors put patients under pressure. September 19, 2015, accessed September 21, 2015 .
  24. ^ Medical Society for Health and Prevention . Retrieved November 15, 2015.