Evaluation Committee
Evaluation committees are legally prescribed bodies of the self-administration of the German health care system. They are from the physicians' Confederation or the cash-dental Federal union and the Central Federal Association of Health Insurance Funds (GKV-leading association) formed to frame compensation systems for ambulatory and independent sector care.
The doctors ' evaluation committee (“evaluation committee according to Section 87 (1) sentence 1 SGB V”) consists of representatives from the National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Funds. With the uniform evaluation standard (EBM) , it creates the remuneration system with which contract doctors and contract psychotherapists can bill the statutory health insurance funds for their services provided on an outpatient basis within the framework of collective agreements and makes fundamental decisions that are made by the statutory health insurance associations (KV) and the state associations of statutory health insurance companies must be taken into account in their regional collective agreements. Regarding regulations for outpatient specialist medical care, the evaluation committee is supplemented by representatives of the German Hospital Society . The institute of the evaluation committee is responsible for the management of the evaluation committee for doctors and the supplemented evaluation committee and supports the committees in their work.
In the Dentists Evaluation Committee, the National Association of Statutory Health Insurance Dentists and the National Association of Statutory Health Insurance Funds use the evaluation standard for dental services (BEMA) to create the remuneration system with which contract dentists can invoice their services to the statutory health insurance companies.
Historical development
The legal basis of the evaluation committees for medical and dental services is Section 87, Paragraph 1, Clause 1 of Book V of the Social Code (SGB V). They were established in 1977 with the then Health Insurance Cost Reduction Act (KVKG). Their original staffing consisted of seven representatives of the doctors (or dentists) and seven representatives of the health insurance companies; On the part of the health insurance companies, the seven so-called insurance types were represented. As a result of the health reform of 2007 ( law to strengthen competition in statutory health insurance - GKV-WSG), the health insurance funds have been represented in the two evaluation committees by three voting members of the National Association of Statutory Health Insurance Funds since July 1, 2008; the doctors and dentists also have three voting members.
Specifically, the evaluation committee decides u. a. over:
- Changes in the uniform assessment standard (EBM) including material costs
- the orientation value
- the rates of change in the morbidity structure of the insured
- the procedure for adjusting the morbidity-related total remuneration
The supplemented evaluation committee decides on:
- Adjustments to the uniform assessment standard for the remuneration of outpatient specialist medical care services in accordance with Section 116 b SGB V
- Regulations for billing services and costs in the context of obtaining second opinions
- Regulations for care in an emergency and emergency service with differentiation according to the severity of the cases
Regulatory powers of the doctors' evaluation committee
Uniform evaluation standard
The Doctors Assessment Committee uses the Uniform Assessment Standard (EBM) to create and approve the list of fee schedule items that can be billed to statutory health insurers by contract doctors and contract psychotherapists participating in statutory health insurance. This concluding list describes the service content and evaluations for both statutory and outpatient specialist care. The evaluation of the services in the EBM - with the exception of material costs - takes place in points. The actual evaluation of a contract doctor's service in the regional euro fee schedule results from the multiplication of the EBM score by the regionally agreed point value.
Orientation value
In accordance with Section 87, Paragraph 2e of Book V of the Social Code, the Doctors Evaluation Committee sets an orientation value in euros for each year, which serves as the basis for negotiations between the associations of statutory health insurance physicians and the state associations of the statutory health insurance companies on the level of regional point values in the seventeen KV districts. With this regional point value, the point performance of the EBM in the respective KV district is converted into euro amounts (regional euro fee schedule). On the other hand, the so-called treatment need is converted into a euro amount using the regional point value (total remuneration due to morbidity). The orientation value for 2019 has been set at 10.8226 cents (increase compared to 2018: 1.6%). The Association of Statutory Health Insurance Physicians have the option of agreeing on surcharges on top of the benchmark with the state associations of the health insurance companies for services that are worthy of support and for services by service providers who need special support, especially in undersupplied planning areas.
Recommendations and specifications for adjusting the regionally agreed morbidity-related total remuneration
Section 87a SGB V provides for the annual adjustment of the volume of the morbidity-related total remuneration (MGV) to be paid by the statutory health insurance funds to the statutory health insurance associations. To this end, the statutory health insurance associations and the regional associations of statutory health insurances agree annually on the treatment requirements associated with the number and morbidity structure of the insured (as the sum of EBM points). The basis of the agreement on the adjustment of treatment needs are, among other things, the change in the number of insured persons and the change in the morbidity structure of the insured persons. The recommendations and guidelines of the Doctors Evaluation Committee must be taken into account in the annual adjustment of the treatment requirement. The morbidity-related total remuneration results from the multiplication of the regionally agreed treatment requirement by the regionally agreed point value. The Doctors Evaluation Committee decides, among other things, procedural requirements for determining the initial values of the treatment requirement and for adjusting the treatment requirement to include services from selective contract and outpatient specialist medical care. In addition, the doctors' evaluation committee makes annual recommendations on changes in the morbidity structure of the insured. The subject matter is demographic change rates (based on the age and gender of the insured person) and diagnosis-related change rates (especially based on the treatment diagnoses of the insured person) for each individual KV district. Based on these recommendations, the actual rate of change of the morbidity structure to be used is negotiated and agreed regionally in each KV district with the state associations of the statutory health insurance companies. The rates of change in the morbidity structure of insured persons recommended by the evaluation committee express the average change per insured person. These rates of change in the morbidity structure are calculated by the institute of the evaluation committee . The calculations are based on the currently applicable model of a classification process, the basis of which is specified by law, but which can be checked and further developed for the diagnosis-related rates by the assessment committee for its further suitability for use in statutory health care.
Extended Evaluation Committee
The agreements to be made in the evaluation committees can only come about through the unanimous decision of all members (by mutual agreement). If this is not possible, the evaluation committee will be expanded to include an impartial chairman and two additional impartial members (extended evaluation committee) if at least two members request this. Of the two other impartial members, one is appointed by the National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Dentists, the other impartial member is appointed by the National Association of Statutory Health Insurance Funds. Both sides must agree on the impartial chairperson (term of office of the impartial chairperson: four years). The impartial chairman of the Extended Doctors Evaluation Committee has been the Essen health economist Jürgen Wasem since 2007 ; Munich health economist Günter Neubauer has been the impartial chairman of the Extended Dentists Evaluation Committee since 1995 . In the extended evaluation committee, decisions are made by a majority of the members (Section 87 (5) sentence 1 SGB V). This means that a resolution requires at least five votes; in contrast to the arbitration offices, abstentions are permitted.
Effects of the decisions of the evaluation committee
Resolutions of the two evaluation committees as well as the extended evaluation committees have a dual character according to the case law of the Federal Social Court : They act as an administrative act against those directly involved (National Association of Statutory Health Insurance Physicians or National Association of Statutory Health Insurance Dentists; National Association of Statutory Health Insurance Funds), which they can complain to in court (at the State Social Court of Berlin-Brandenburg ) . The resolutions act like sub-statutory norms for the statutory health insurance companies and health insurance companies as well as for doctors and patients. In some cases, the state level (associations of statutory health insurance companies and state associations of statutory health insurance companies) has the option of regulating regional structures within the framework of the decisions of the evaluation committee. The Federal Ministry of Health has been able to object to resolutions since the 2007 health reform. If resolutions are not passed within the legally prescribed period, the ministry can act as an alternative.
literature
- Karin Ziermann: Definition of content and delimitation of the standard-setting competencies of the Federal Joint Committee and the assessment committees in the law of statutory health insurance. Duncker & Humblot, Berlin 2007, ISBN 3-428-12264-X .
- Benjamin Reuter, Christoph Weinrich: The leeway of the evaluation committee . In: Medical Law . tape 31 , no. 9 . Springer, September 2013, ISSN 0723-8886 , p. 584 ff ., doi : 10.1007 / s00350-013-3501-6 .