Prioritization of medical services

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Prioritization of medical services describes procedures with which the priority of certain treatment and examination methods over others is to be established. It is not only possible to prioritize methods, but also cases of illness, groups of illnesses and illnesses, health care goals and, above all, indications (ie the linking of specific health problem situations with services that are suitable for their solution). Its opposite is called posteriorization .

meaning

Prioritization leads to a ranking or describes a higher priority that something has within a ranking. At the top end there is what is considered to be indispensable or important, at the bottom end what is ineffective or what does more harm than good.

In general, a distinction can be made between vertical and horizontal prioritization. The vertical prioritization relates to rankings within a defined service area e.g. B. Treatments for heart disease. The horizontal prioritization is about urgency considerations between different disease and patient groups or care areas e.g. B. Cardiac surgery before cosmetic surgery .

Prioritization means a gradation of the granting of services according to the principle of priority and for this reason is not to be equated with rationing , under which the withholding of medical necessary or useful services for reasons of scarcity is to be understood. Prioritization can serve as a basis for rationing decisions, but does not necessarily lead to rationing. In the case of rationing, prioritization should be a prerequisite. For this purpose, a ranking of services should be established based on the need for care, because if funds are to be withheld from meaningful medical use, there should be a social consensus beforehand about the reason and where these funds can be used more effectively. When prioritizing, an upgrading of possibly previously underestimated services in the sense of an upward prioritization is possible.

Need for prioritization

Due to the medical-technical progress, the demographic development and the increasing financial bottlenecks in the social security system , the medically feasible will move further away from the financially. How this discrepancy can be countered in a health system based on solidarity will determine the public, scientific and political discussion. There is a consensus in the literature that when funds are scarce, prioritization should be preceded by the exhaustion of rationalization potential. For the health care system , however, it can be assumed that, despite the exhaustion of rationalization reserves, medical services cannot be made available to all patients in the future to the extent that they are used to.

The Central Ethics Commission (ZEKO) at the German Medical Association states that, despite all efforts to rationalize medical care, setting priorities in the context of prioritization cannot be avoided. The question is therefore not whether priority must be given, but rather how.

Proponents believe that an open and public health policy and medical ethical debate about prioritization is better than concealed rationing. One member of the Bundestag admitted, however, that he would not be able to convey his knowledge as a health politician to the citizens if he wanted to be re-elected. If the question of what is medically and healthily necessary is clarified for society as a whole, prioritization could help to distribute the available funds as fairly as possible according to socially agreed criteria. According to the German Medical Association, it has not yet been possible to bring the subject of setting priorities in health care to a broad public discussion.

Criteria for prioritization

If the prioritization is approved, the question inevitably arises as to which criteria can be used to allocate health services as fairly as possible. Prioritization should always include formal criteria that describe the prioritization procedure and content-related criteria, i.e. the content-related orientation.

Formal criteria are particularly necessary from a constitutional point of view. Transparency, comprehensible reasons, consistency in application and democratic legitimacy can increase the awareness of equal treatment and the acceptance of the priority and subordination of measures and thus meet the high demand for information of the population.

When asked about the content criteria, ethical, legal and economic aspects are taken into account. When it comes to the question of which criteria should actually be prioritized, opinions sometimes diverge widely. For the ethical platform of the parliamentary prioritization commission in Sweden, respect for the constitutional norm of human dignity and, with regard to allocation, the need and cost efficiency are decisive. The Central Ethics Commission of the Federal Medical Association sees a fair setting of priorities in the orientation towards the medical need (severity and danger of the illness, urgency of the intervention), the expected medical benefits and the cost effectiveness. The Federal Joint Committee (G-BA) is discussing no longer offering services whose cost-benefit ratio (KNV) is too poor. However, determining the KNV of a medical service is difficult and often controversial.

foreign countries

In 1987, the US state of Oregon wanted to introduce all-population health insurance without increasing the overall cost of Medicaid . This only appeared possible with a reduction in the scope of services. Instead of z. B. Organ transplants in children were therefore funded preventive medical check-ups for socially disadvantaged pregnant women and children - with the risk that some children were severely impaired because transplants were not performed. The holistic approach was laid down in a priority list for all medical measures.

The prioritization and rationing debate is much more advanced in some other countries than in Germany. In 1997 the Swedish Parliament passed guidelines on prioritization. It defines three ethical principles for all future prioritization decisions:

  • All people are equal in value and dignity;
  • resources should be distributed according to needs and solidarity ;
  • the cost efficiency of all measures should be taken into account.

Prioritization is done there by the “Prioritizing Center” ( National Center for Priority Setting ).

In the UK, the National Institute for Health and Care Excellence is developing priorities; the Institute for Quality and Efficiency in Healthcare was modeled on him in Germany .

See also

literature

  • Björn Schmitz-Luhn / André Bohmeier (eds.): Prioritization in Medicine - Criteria in Dialog , Springer, 2013. ISBN 978-3-642-35447-2
  • Erik Hahn: Influence of jurisprudence on resource decisions and priority setting in medicine - A contribution to the distribution debate , Health Law 2010, pp. 286–295.
  • Walter A. Wohlgemuth, Michael H. Freitag (ed.): Prioritization in medicine. Interdisciplinary research approaches, MWV Medizinisch Wiss. Publisher, 2009. ISBN 393906985X
  • Behnam Fozouni, Bernhard Güntert (Hrsg.): Conference volume " Setting priorities in the German health system" . Logos Verlag, Berlin 2002, ISBN 3-89722-870-X .
  • Heinz Lohmann, Uwe Preusker (eds.): Prioritization instead of rationing: Securing the future of the health system . Economica, 2010, ISBN 978-3-87081-589-9 .
  • Andreas Bäcker: Rationing and prioritization in health care . GRIN Verlag 2010, ISBN 978-3-640-66624-9 .

Web links

Individual evidence

  1. ↑ a b c d e f Opinion of the Central Commission on Safeguarding Ethical Principles in Medicine and its Border Areas (Central Ethics Commission) at the German Medical Association: Prioritization of medical services in the system of statutory health insurance (GKV) - long version -. (pdf, 166 kB) In: Zentrale-ethikkommission.de. September 2007, archived from the original on February 10, 2012 ; accessed on November 28, 2019 .
  2. ↑ Proceedings "Setting Priorities in the German Healthcare System"
  3. ↑ a b Heinz Lohmann, Uwe Preusker (ed.): Prioritization instead of rationing: Securing the future of the health system .
  4. ↑ a b rationing. In: AOK Lexicon. Retrieved November 28, 2019 .
  5. ↑ Andreas Debski: President of the State Medical Association Schulze: “Rethinking the health sector in principle”. In: LVZ-Online . July 3, 2014, archived from the original on July 14, 2014 ; accessed on November 28, 2019 (interview).
  6. ↑ Gabi Stief, Veronika Thomas: Cost explosion - does medicine have to be rationed in Germany? In: Hannoversche Allgemeine. January 27, 2012, accessed on November 28, 2019 (interview with Johann-Matthias Graf von der Schulenburg and Benno Ure ).
  7. ↑ Harro Abrecht: Health Care: Medicine at the Limit. In: The time . 51/2009, December 10, 2009, accessed November 28, 2019 .
  8. ↑ Rationing and prioritization in health care
  9. ↑ Federal Joint Committee : Decision on the publication of an overview of the topic-finding and prioritization procedure 2012. (pdf, 694 kB) January 17, 2013, accessed on November 28, 2019 .
  10. ↑ National Center for Priority Setting in Health Care. In: liu.se . October 15, 2010, archived from the original on January 14, 2012 ; accessed on November 28, 2019 (English).