Two-class medicine

The neutrality of this article or section is disputed. A reason is given on the discussion page . You can get more information here .

This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

This article or paragraph describes the situation in Switzerland . Help us to describe the situation in other countries.

This article or paragraph describes the situation in Austria . Help us to describe the situation in other countries.

“Two-class medicine” is a political slogan with negative connotations . It describes a health system in which the quality of medical care depends on whether the patient is insured with statutory or private health insurance. The terms cash patient and private patient are also used , whereby the latter can also be legally insured and bear the additional costs for private treatment himself.

Discussion in Germany

In the political discussion in Germany, the term (by different interest groups) is often used for the different entitlement to benefits of those with statutory health insurance compared to private health insurance (PKV) patients. Privately insured, so the argument goes, would have better medical care and shorter waiting times for doctor's appointments.

The different life expectancy of statutory and privately insured patients according to various statistical surveys is also cited as evidence of the negative effects of two-tier medicine. Often, however, a possible causal connection is tacitly implied ("Because you are poor, you have to die sooner."), Which is not mandatory and would also be difficult to prove. For example, it should also be taken into account that wealthier population groups are often also more educated and therefore behave more health-consciously, which in turn can have a positive effect on their life expectancy.

On the other hand, there is Bernd Kalvelage's thesis, based on case studies: the medical business is - like the school (see Pisa study) - socially selective, its guidelines and in practice geared towards patients of the middle and upper classes, the lower social classes would often not be achieved by the offers, failure to understand complex medical issues is often dismissed as an "incompliance" of the patient, at the same time this patient group lacks the otherwise lamented "claim thinking". A change of perspective in medicine from 'from above down' to 'from below' ('instant social descent') is necessary, which is described under 'class medicine' with concrete recommendations for action and required for future medical training.

In contrast to the public discussion of recent years, a representative forsa survey of 1005 insured persons in 2013 on behalf of the IKK classic showed that only 9 percent of those questioned complained about a trend towards "two-class medicine". The survey yielded similar results on the subject of quick appointments and long waiting times.

Multi-class medicine

Sometimes there is also talk of three-class medicine, which divides into those with statutory health insurance, those with statutory health insurance with additional insurance and those with private insurance. In statutory health insurance, on the one hand, benefits are excluded (e.g. § 28 SGB ​​V), or limited to standard care (e.g. fixed allowances for dentures) or limited by the economic efficiency principle. This includes all services that violate the economic efficiency requirement in accordance with Section 12 (1) SGB V, i.e. that exceed the criteria of the benefit in kind. The wording of Section 12 (1) SGB V is as follows:

“The services must be sufficient, appropriate and economical; they must not exceed what is necessary. Services that are not necessary cannot be claimed by the insured, service providers are not allowed to provide and the health insurances are not allowed to approve. "

Privately insured can in turn be divided into

• Private partial insurance for beneficiaries (civil service law)
• Private full health insurance for employees with income above the compulsory insurance limit
• Private full health insurance for the self-employed
• Insured in the basic tariff
• Insured persons in the standard tariff, which is only open to certain groups of people defined by law
• Insured in the emergency tariff
• private student health insurance

The scope of services of the private insurances mentioned are extremely different, which results in a "multi-class insurance" and the resulting "multi-class medicine". The claim that only the wealthy ("higher earners") have private health insurance is not tenable either:

• 42.2% of those with private health insurance are civil servants, of which 17.5% are retirees
• 7.5% are retirees
• 19.9% ​​are other non-employed persons (including children)
• 15.7% are self-employed. The self-employed status does not imply a high income.
• 11.6% are employees (including some public sector employees)
• 2.9% are students.
• The basic tariff corresponds to the scope of services provided by statutory health insurance.

A total of 9 million people have private health insurance (11.3%). The number of private supplementary health insurances is 22.6 million, of which 13.3 million are dental supplementary insurances.

The correct umbrella term for patients with statutory health insurance with entitlement to benefits in kind would be “self-payer”, because all privately claimed medical and dental services must initially be paid for by the patient himself. Their entitlement to reimbursement depends on the type of private health insurance they have and the tariff chosen.

Discussion in Austria

In Austria, the debate revolves around special class patients ( private patients ), i.e. those policyholders who have taken out voluntary supplementary insurance in addition to compulsory statutory insurance . It is about 12% of the population.

After a long discussion in Austria, which also preoccupied the media, an amendment to the KAKuG is in the legislative process. In the future, hospitals throughout Austria should have a mandatory, transparent waiting time management system. The waiting list regime applies to subjects with a particularly high number of interventions that can be planned:

• Ophthalmology and Optometry
• Orthopedics, orthopedic surgery
• Neurosurgery.

In the future, it will be anonymized how long you have to wait for a certain operation in a hospital. The special class patients must also be made visible. Waiting time management must be implemented within eight months of the decision being taken. The transparent waiting time management should be an efficient measure against a 2-class medicine. It should be excluded that patients with special insurance are ranked first.

The Austrian Insurance Association  (VVO) warned against the “classless hospital” and described private patients as “indispensable massive support” for the hospital system. The deputy federal chairman of the employed doctors in the Austrian Medical Association  (ÖÄK), Robert Hawliczek, described the outrage over the alleged two-tier medicine in operations against cataracts as “double standards”. "Patients with additional private insurance contribute significantly to the financing of Austrian hospitals with significantly more than one billion euros annually".

Discussion in Switzerland

In Switzerland, two-tier medicine is the subject of controversial discussion in specialist circles and the media. Health economist W. Oggler: “Two-class medicine has always existed and will always be. The question is at what level the second grade is ”.

F. Mathwig advocates justified unequal treatment and invokes Aristotle , according to which the same should be treated equally, the unequal unequal.

See also

• Socially determined inequality of health opportunities
• Prioritization of medical services

literature

• Karl Lauterbach : The two-class state . Rowohlt, Berlin 2007, ISBN 978-3-87134-579-1 .
• Bernd Kalvelage Klassenmedizin, plea for a social reformation of the healing arts Springer, Berlin 2014 ( ISBN 978-3-642-54748-5 )

Web links

• Rationing in Health Care: Limits to Progress , Deutsches Ärzteblatt, January 8, 2007.
• Two-Class Medicine: Summaries of New Empirical Studies.

Individual evidence

1. ↑ Forsa study: Two-class medicine - felt more than reality ( memento of the original from August 30, 2013 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. IKK-classic press release, accessed on May 24, 2013  
2. ↑ ^{a b} DZW 3/2013 p. 4, Volker Leienbach, executive board member in the Association of Private Health Insurance eV (PKV)
3. ↑ Overview of the employees in the ÖD flegel-g.de, status 2002
4. ↑ PKV Publik 07/2012, Scientific Institute of PKV (WIP): Structure of the PKV insured
5. ↑ PKV boss after massive premium increases: The interest is to blame focus.de, on December 15, 2016
6. ↑ ^{a b c d e f} The double standards of "two-class medicine" , diePresse.com, 25 August 2011.
7. ↑ Die Presse, cash patients wait longer , diePresse.com, date ?.
8. ↑ Draft law on hospitals and health spa facilities (PDF, 167 kB, parlament.gv.at)
9. ↑ Page no longer available , search in web archives: two-class medicine and insurance (PDF; 168 kB), advanced training conference of the college for family medicine
10. ↑ Observer, two-class medicine has always existed
11. ↑ F. Mathwig, Ethical Notes on the Discussion of Two-Class Medicine (PDF; 60 kB)