Isabel Auf der Maur1, Daniel Gero1,2, Gesa Kampmann1,2, Tobias Prediger3, Stefan Schopf3, Jutta Peters3, Jeannette Widmer1, Jens Deerberg-Wittram4, Christel Köhler-Hohmann5, M Bueter1,2, Andreas Thalheimer6,7,8. 1. Viszeral- und Transplantationschirurgie, Universitätsspital Zürich, Zürich, Schweiz. 2. Department Chirurgie, Spital Männedorf, Männedorf, Schweiz. 3. Allgemein‑, Viszeral‑, Endokrine und Unfallchirurgie, RoMed Klinik Bad Aibling, Bad Aibling, Deutschland. 4. RoMed Klinik Verbund Stadt und Landkreis Rosenheim, Rosenheim, Deutschland. 5. arztundklinikrecht.de/Dr. iur. Christel Köhler-Hohmann, Rechtsanwältin - Fachanwältin für Medizinrecht, Gilching bei München, Deutschland. 6. Viszeral- und Transplantationschirurgie, Universitätsspital Zürich, Zürich, Schweiz. a.thalheimer@spitalmaennedorf.ch. 7. Department Chirurgie, Spital Männedorf, Männedorf, Schweiz. a.thalheimer@spitalmaennedorf.ch. 8. University Hospital Zurich: UniversitatsSpital Zurich, Zürich, Schweiz. a.thalheimer@spitalmaennedorf.ch.
Abstract
BACKGROUND: Only a small proportion of patients with morbid obesity in Germany have access to the currently most effective treatment, bariatric surgery. A major reason for this is the restrictive attitude of health insurance companies regarding the reimbursement of costs. OBJECTIVE: To record the postoperative rate of cost coverage by health insurance companies without the currently common preoperative application for morbidly obese patients who received a guideline-indicated bariatric surgery. METHODS: The process of postoperative reimbursement was evaluated through a prospective database over a 2-year period. Cases of primary reimbursement were correlated with respect to age, BMI, comorbidities and membership of a specific health insurance company. Rejected coverage cases were followed up for further advocacy and social court process. RESULTS: A total of 188 patients underwent bariatric surgery as indicated in the guidelines without prior application. Primary cost coverage was achieved in 76.6% (n = 144). There was no correlation with BMI, comorbidities or health insurance affiliation. Patients over 40 years of age were significantly more likely to be covered for costs. For patients without postoperative cost coverage, an out of court settlement was reached in 7 cases, 8 cases were heard by the social courts and 29 cases were still being processed by lawyers. CONCLUSION: Despite the relatively high rate of primary cost coverage, this analysis also shows the restrictive attitude of the health insurance companies regarding bariatric surgery with corresponding economic pressure on the service providers. The consistent implementation of application-free surgery seems necessary to increase the political pressure on health insurers and social courts.
BACKGROUND: Only a small proportion of patients with morbid obesity in Germany have access to the currently most effective treatment, bariatric surgery. A major reason for this is the restrictive attitude of health insurance companies regarding the reimbursement of costs. OBJECTIVE: To record the postoperative rate of cost coverage by health insurance companies without the currently common preoperative application for morbidly obese patients who received a guideline-indicated bariatric surgery. METHODS: The process of postoperative reimbursement was evaluated through a prospective database over a 2-year period. Cases of primary reimbursement were correlated with respect to age, BMI, comorbidities and membership of a specific health insurance company. Rejected coverage cases were followed up for further advocacy and social court process. RESULTS: A total of 188 patients underwent bariatric surgery as indicated in the guidelines without prior application. Primary cost coverage was achieved in 76.6% (n = 144). There was no correlation with BMI, comorbidities or health insurance affiliation. Patients over 40 years of age were significantly more likely to be covered for costs. For patients without postoperative cost coverage, an out of court settlement was reached in 7 cases, 8 cases were heard by the social courts and 29 cases were still being processed by lawyers. CONCLUSION: Despite the relatively high rate of primary cost coverage, this analysis also shows the restrictive attitude of the health insurance companies regarding bariatric surgery with corresponding economic pressure on the service providers. The consistent implementation of application-free surgery seems necessary to increase the political pressure on health insurers and social courts.
Authors: Arne Dietrich; Jens Aberle; Alfred Wirth; Beat Müller-Stich; Tatjana Schütz; Harald Tigges Journal: Dtsch Arztebl Int Date: 2018-10-19 Impact factor: 5.594