medical service of the health insurance
The Medical Service of Health Insurance ( MDK ) is the socio-medical and nursing advice and assessment service for statutory health and nursing insurance. On behalf of the law, he supports the health and nursing insurance funds in medical and nursing questions. In Germany there are 15 independent MDK, which are organized according to federal states. The medical service of the National Association of Health Insurance Funds (MDS) coordinates and promotes the national cooperation of the MDK, for example through guidelines for a uniform assessment.
The role of the MDK in healthcare
The solidarity principle is intended to enable an efficient and safe health system in Germany. The statutory health and long-term care insurance funds are responsible for investing the premium income in providing the best possible care for their insured. To do this, they negotiate contracts with doctors and other service providers. In accordance with Section 12 (1) SGB V, the services must be “ sufficient, appropriate and economical ” in each individual case . This also applies to social long-term care insurance , which supports people in need of care with funds financed by solidarity ( § 1 SGB XI). The advice and assessment of the MDK (Medical Service of the Health Insurance) is intended to ensure that the benefits of the health and long-term care insurance benefit all insured persons according to objective, medical criteria and under the same conditions.
The social law guarantees the professional independence of the MDK. The experts assess on behalf of the health and care insurance funds. In their medical and nursing assessment, they are independent and subject exclusively to their medical and nursing conscience in accordance with Section 275 (5) SGB V. You are not entitled to intervene in medical treatment. The reviewers are bound by the current state of science and social law requirements.
The assessment guidelines are the basis for the assessment. These specify legal requirements so that the assessments are carried out nationwide according to uniform rules. The assessment guidelines are developed in close cooperation between the National Association of Statutory Health Insurance Funds and the MDK Association. The guidelines are decided by the National Association of Statutory Health Insurance Funds and - if provided for by law - approved by the Federal Ministry of Health (BMG).
Tasks and services of the medical services
Tasks for the statutory health insurance (GKV)
The MDK advises the statutory health insurers on general issues of principle and carries out individual assessments. The tasks of the MDK for health insurance are regulated in § 275 SGB V.
Assessments for health insurance
The MDK works to ensure that the insured receive benefits that correspond to the generally recognized state of medical knowledge and are at the same time economically justifiable. Insured persons should be cared for according to their needs. The resources are to be used for services whose evidence-based benefit and quality has been proven. On the one hand, medically necessary treatments should be guaranteed and, on the other hand, unnecessary or even harmful interventions should be avoided. Therefore, the health insurance companies are obliged to obtain an expert opinion from the medical service in cases specified by law or if the illness or the course of the illness of the insured person requires it. These relate, for example, to questions from the health insurance company regarding:
- incapacity for work
- Need to type, scope and duration of rehabilitation services
- Prescription of drugs , bandages , remedies and aids
- Necessity and duration of hospital treatment and billing for hospital treatment
- Necessity and duration of home nursing
In 2017, the medical services issued a total of 5,778,000 socio-medical reports for the statutory health insurance companies.
The statements related to:
| number | |
|---|---|
| Hospital billing audits | 2,773,000 |
| incapacity for work | 1,221,000 |
| Rehabilitation services | 549,000 |
| Tools | 333,000 |
| Home nursing, domestic help, specialized outpatient palliative care | 244,000 |
| Pension benefits | 150,000 |
| New or unconventional examination and treatment methods: | 125,000 |
| Remedies | 93,000 |
| Psychotherapeutic services | 37,000 |
| Dental services | 15,000 |
| Medical malpractice | 14,000 |
| Other occasions | 224,000 |
| total | 5,778,000 |
Advice on fundamental questions of medical care
The MDK advise the statutory health insurance companies and their associations on fundamental questions of medical care as well as on the design of service and care structures. These include:
- quality assurance in outpatient and inpatient care
- advice on hospital planning issues
- the further development of the remuneration systems in outpatient and inpatient care
- the effectiveness and profitability of new examination and treatment methods
In addition, the medical service supports the health insurances in contract negotiations with the hospital companies , associations of statutory health insurance physicians and other service providers. Experts from the medical services take part in the deliberations of the Federal Joint Committee (G-BA) and support the social insurance side .
Tasks for social long-term care insurance
The tasks of the MDK for social long-term care insurance are set out in § 18 and §§ 114ff. SGB XI regulated. On behalf of the care insurance funds , the MDK determines whether an insured person is in need of care . In addition, the MDK advises the long-term care insurance funds on fundamental questions of long-term care.
In 2017, the medical services carried out a total of 2,423,000 socio-medical recommendations for long-term care insurance.
- Assessments to determine the need for care: 1,886,000 recommendations
- Care appraisals with a shortened appraisal period and appraisals of applications for care services: 254,000 recommendations
- Other socio-medical recommendations for the SPV (care aids, measures to improve the living environment, semi-stationary care / short-term care for existing care needs): 283,000 recommendations
New care appraisal since 2017
With the Long-Term Care Strengthening Act II, the new definition of the need for long-term care was introduced into long-term care insurance on January 1, 2017. This fundamentally changed the assessment procedure for determining the need for care - the standard today is the degree of independence of the person in need of care. During the assessment, it is no longer important to determine how many minutes a person needs help with washing and getting dressed or with eating. The focus now is on the question of how independent a person is in coping with their everyday life - what can they do and what can they no longer do, or how much help does they need? For this purpose, his abilities are comprehensively assessed in all areas of life: mobility, cognitive and communicative abilities, behavior and psychological problems, self-care, dealing with illness-related demands and stresses, structuring everyday life and social contacts.
When assessing the need for care at home or in the nursing home
- the MDK checks that the conditions for long-term care are met
- he recommends a level of care
- he proposes prevention and rehabilitation measures
- it makes recommendations on the type and scope of care services
- he formulates instructions for an individual care plan
The basis for the assessment is provided by assessment guidelines, which have been freely accessible online since the nursing reform, so that the caregiving relatives can use the formalities of the domestic survey.
Since the reform, the carer has also been sent detailed documentation of the comprehensive series of questions, which add up in the point system according to weighting, so that a control function has also been in place for the carer since 2017.
Control function
Thanks to the questionnaire, which is completely available online, it can be verified to what extent the expert has collected specific and realistic information on the need for care.
As a rule, the reviewer does not go through the entire catalog of questions, but - especially when assessing dementia diseases - usually only asks the questions about age, career, yesterday's lunch and the date.
Furthermore, the expert asked 1–2 current questions about those present and the cognition of the "test situation" and included them in the expert opinion, with the possibility of objections arising from this.
If, for example, the person with dementia does not recognize the person present (usually the person providing care) and (if possible) a witness, it cannot be ticked in the report that he has no cognitive problems.
Often the findings obtained about the patient contradict the assigned points on the rating scale.
Examples of expert assessments:
The beginning patient with dementia tends to illusory misjudgment of his competencies, which the expert classifies as seemingly real.
For example, an 84-year-old who had to walk with a walking aid had her fables that she was digging up the garden, removed and denied any level of care.
In the case of dementia patients, careful checking of the reports reveals other contradictions that result from incorrect points awarded in the report.
Objection to MDK report
Thanks to the downloadable evaluation of the appraisal, the appraiser should be given a completely and truthfully completed appraisal at the MDK visit, which can be referred to in the event of an objection.
First of all, in contradiction to the MDK, the discrepancy that creeps up between reality and "fake" or incorrect assessment of the expert should be discussed.
Systematic comments should be made on all points awarded and, if possible, an attempt should be made to find a disease-specific explanation in the German edition of the ICD, the DIMDI.
A new (anticipated) awarding of points is by no means recommended, but naming witnesses (nursing staff or relatives / neighbors / friends) or doctors for the dementia-specific behavior of the patient increases the informative value.
The assessment usually only takes a few minutes instead of the announced hours and the reviewers probably draw their (auditing) results from the overall impression of the person being assessed.
Since 2017, however, not only have the physical ailments been augmenting points, but also the dementia age diseases have contributed to the assessment of the need for care, more and more appropriately trained experts have been required.
["Probably the diagnostically only descriptive and difficult to grasp symptoms of dementia overwhelm the cognitive skills of some experts, since only physical and" tangible "ailments previously defined a care status?"]
An objection to a nursing classification should be true and well-founded: for a maximum correction to the next higher nursing level (s).
In addition to Wikipedia 's Alzheimer's in tracts, compendia from the German Alzheimer's Society and current medical knowledge databases, such as the ICD11 or, if applicable, the NCBI should be consulted.
Applicable guidelines (DIN ISO 9001) of the MDK / GKV
In particular, the valid assessment guidelines according to DIN ISO 9001 of the MDK should be mentioned, which should be used in any communication to the MDK.
They specify the general requirements of the Long-Term Care Insurance Act so that the assessments are carried out nationwide according to uniform rules. The guidelines must be issued by the National Association of Statutory Health Insurance Funds and approved by the BMG. The currently applicable assessment guidelines were drawn up in close cooperation between the National Association of Statutory Health Insurance Funds and the MDS with the medical services and the associations of long-term care insurance funds at the federal level. Representatives of those affected and the relevant federal ministries were involved.
In 2017, the medical services carried out a total of 1,886,000 assessments to determine the need for care for long-term care insurance. The assessments concerned applicants for outpatient care (81.9%), for fully inpatient care (15.3%) and for care services in fully inpatient facilities for the disabled (2.8%).
Results of all care assessments according to the new procedure in 2017:
- Care level 1: 17.3%
- Care level 2: 29.1%
- Care level 3: 22.3%
- Care level 4: 12.9%
- Care level 5: 5.8%
- does not require care: 12.7%
MDK care quality checks
Care must be based on the individual needs of people in need of care and be based on medical and nursing standards. To ensure compliance with these standards, the quality of care is checked once a year in all outpatient care services and all care homes (regular check). In addition, examinations can be carried out for specific reasons - these are mostly complaints (event examination). 90 percent of the tests are carried out by the medical services of the health insurance (MDK), 10 percent by the testing service of the private health insurance (PKV-Prüfdienst). In addition to the quality of care, the billing check is a mandatory content of the quality checks for outpatient care services.
The MDK receives the order for an examination from the regional associations of the long-term care insurance funds . The exams in nursing homes are not announced. The exams of outpatient care services must be announced the day before for organizational reasons. The audit includes advising care facilities with the aim of preventing quality defects and strengthening the responsibility of the care facilities and their providers for ensuring and further developing the quality of care.
In 2017, the MDK audited 11,200 inpatient care facilities and 10,500 outpatient care services.
Quality inspection guidelines
The quality testing guidelines (QPR) and the quality testing guidelines for home nursing care (QPR-HKP) ensure a uniform procedure for the tests. These guidelines are technically developed by the MDS - with the participation of the MDK - and issued by the National Association of Statutory Health Insurance Funds. The guidelines must be approved by the Federal Ministry of Health.
Quality review and presentation reform
Since 2009, the quality of outpatient and inpatient care facilities has been rated in the form of grades between “very good” and “poor”. The basis for this assessment is the annual MDK quality check of an outpatient nursing service or nursing home. On this basis, the care insurance funds create a transparency report for each care facility and publish it on the Internet. The report contains an overall grade for the facility, grades for various care areas and the results of individual test criteria. Which criteria are included and published in the transparency report and how the grades are calculated are defined by the National Association of Statutory Health Insurance Funds, the supra-local social welfare institutions and the central municipal associations with the associations of service providers in transparency agreements.
The representation of the quality of care in care ratings has come under fire in recent years because quality defects in the facilities are not clearly recognizable for consumers. That is why the legislature set up the Care Quality Committee in 2016 with the Care Strengthening Act II and commissioned it to develop new test procedures and an alternative to the previous care grades through scientific projects. A new test system was established on this basis. The tests of fully inpatient elderly care facilities according to the new test system are to begin from October 1, 2019. This is provided for by the Nursing Staff Strengthening Act (PpSG), which the Bundestag passed on November 9, 2018.
Advice to the regional associations of long-term care insurance funds
The MDK advises the long-term care insurance funds in the federal states on the further development of the long-term care range. For example, it is about the development of special forms of living for people with senile dementia . The MDK is also involved in drafting framework contracts for economical and effective nursing care. He participates in the nursing conferences at the municipal level. As a member of the working group according to § 20 HeimG he cooperates with the respective home supervisory authority of the federal states.
Structure and organization of the medical services
The medical service of the health insurance is a joint institution of the statutory health and long-term care funds and is organized as an independent working group in each federal state . The medical services of Berlin and Brandenburg have merged to form the MDK Berlin-Brandenburg, the medical services of Hamburg and Schleswig-Holstein to form the MDK Nord. In North Rhine-Westphalia there is the MDK Nordrhein and the MDK Westfalen-Lippe. There are a total of 15 MDK. In the old federal states, with the exception of Berlin, the MDK are legally responsible public corporations ; in the new federal states, the medical services are organized as registered associations , i.e. in a legal form under private law. The MDK is subject to state supervision ( Section 281 (3) SGB V).
The MDK community
The 15 MDK and the Medical Service of the Central Association of Statutory Health Insurance Funds (MDS) form the MDK community. They cooperate closely with one another on a technical level.
At the federal level, the MDS coordinates and promotes the implementation of the tasks and the cooperation of the MDK in medical and organizational issues in accordance with Section 282 (2) SGB V. The aim is to ensure assessment and advice according to nationwide uniform criteria. In addition, the MDS organizes a nationwide training program for the experts at the MDK.
The health insurance funds and their associations have a great need for system advice in special care areas and on cross-sectional tasks. For this purpose, competence centers provide systematic basics and scientific advice for the health insurance system. Together with the National Association of Statutory Health Insurance Funds, the MDK Association has set up four competence centers, each of which is located at an MDK:
- the Geriatrics Competence Center (KCG)
- the Competence Center Oncology (KCO)
- the Competence Center Psychiatry / Psychotherapy (KCPP)
- the competence center for quality assurance and quality management (KCQ)
In addition, there are six cross-border social medicine expert groups (SEG). They promote the exchange of information within the MDK community and provide medical and nursing expertise for the central areas of advice and assessment of the MDK.
Organs of the MDK
The organs of an MDK are the board of directors and the managing director. The members of the administrative board are appointed by the administrative boards of the health insurance associations. The board of directors decides on the statutes , determines the guidelines for the work of the MDK, determines the budget and elects the manager. The management represents the MDK in and out of court.
Financing the MDK
According to Section 281 (1) SGB V, the MDK is financed through an allocation and not according to individual orders from the health and care insurance funds. This is to ensure that the MDK assesses and advises independently of results and success. The allocation is based on the number of members of the statutory health insurance in the respective federal state or in the catchment area of the MDK. Health insurance companies and long-term care insurance companies each bear half of the contribution. In 2017, health insurance and long-term care insurance paid a total of 803 million euros for the MDK. This corresponded to a share of 0.18 percent of the total expenditure of the statutory health insurance and a share of 1.09 percent of the total expenditure of the social long-term care insurance.
staff
Specialists from all areas of the health sector work at the MDK, including doctors , nurses, medical technicians and pharmacists . MDK experts regularly take part in practical training courses. This guarantees a high quality standard and an assessment according to nationwide uniform criteria.
At the end of 2017, MDK had a total of 9,369 employees. This corresponds to 8,373 full-time positions.
The employee structure is divided into:
| Number of employees | Number of digits | |
|---|---|---|
| doctors | 2,299 | 2,038 |
| Nursing experts | 3,220 | 2,925 |
| Healing and health professions | 74 | 70 |
| Coding specialists | 371 | 340 |
| Assistant staff reports | 2,612 | 2,272 |
| Administrative staff | 793 | 793 |
literature
- Bernhard van Treeck (2006): MDK - Counseling and Assessment in Psychiatry , Neurotransmitter 12, 42–44
Web links
- www.mdk.de - Nationwide MDK portal with information on the work of the medical service and links to all MDK
- www.mds-ev.de - website of the MDS
- DIMDI
- Assessment guidelines
Individual evidence
- ^ Social medical recommendations of the MDK for health insurance. (PDF) Retrieved December 10, 2018 .
- ↑ Advice and assessments related to insured persons for long-term care insurance in 2017. Accessed on December 10, 2018 .
- ↑ The new assessment tool. Medical service of the umbrella organization Bund der Krankenkassen e. V., accessed December 10, 2018 .
- ↑ a b Dependency. In: bundesgesundheitsministerium.de. Federal Ministry of Health, June 26, 2018, accessed on December 17, 2018 .
- ↑ Sabine Puttins: Crime scene: Care Mafia + MDK. In: https://frankfutt.de/ . Sabine Puttins, March 17, 2017, accessed April 23, 2020 .
- ↑ MDK care appraisals 2017 according to the requested service. Retrieved December 10, 2018 .
- ↑ MDK care appraisals 2017 Results of the care appraisals according to the new appraisal procedure. Retrieved December 10, 2018 .
- ↑ MDK care quality checks. (PDF) Retrieved December 10, 2018 .
- ↑ decision caregivers-Support Act (PPSG). (PDF) In: bundesgesundheitsministerium.de. Federal Ministry of Health, November 9, 2018, accessed on December 17, 2018 .
- ↑ Personnel of the Medical Services 2017. (PDF) Accessed December 10, 2018 .
