[Jurisdictions on the reimbursement of new medical technologies by public health insurance: A systematic review]

Z Evid Fortbild Qual Gesundhwes. 2018 Apr;131-132:8-16. doi: 10.1016/j.zefq.2017.12.004. Epub 2018 Jan 10.
[Article in German]

Abstract

Background: In Germany reimbursement for new medical technologies is often enforced before a social court. It is likely that these judicial decisions also affect the sickness funds' decisions on requests for reimbursement and thus patient access to new technologies in general.

Objectives: The aim of this study was to identify the technologies that have repeatedly generated court actions and whether these actions have been successful. The focus was on differences between sectors, technology groups and indications. Based on this, we analysed in a case study whether judicial decisions on the reimbursement of the same technologies vary across the years.

Material and methods: Based on a systematic review, we identified judicial decisions of German social courts on new technologies for the years 2011 to 2016. The analysis included social court decisions on reimbursements for technologies used in the treatment of individual patients.

Results: 284 judicial decisions on new technologies were considered in the analysis. In one third of the cases, the sickness funds were required to reimburse the costs, with a higher percentage in inpatient than in outpatient care. Technologies used in treatment of diseases of the eyes and the ears were granted most frequently. In cases involving similar circumstances the social courts sometimes came to conflicting decisions; these decisions are, in part, contradictory to subsequent assessments by the Joint Federal Committee (G-BA).

Conclusions: Decisions as to whether reimbursement for new technologies is granted or not do not appear to follow a systematic approach. In the context of the seemingly innovation-friendly policy in inpatient care, there is uncertainty with regard to the "generally accepted state of medical knowledge." It is problematic for both patients and their treating physicians that over a number of years legal proceedings are being initiated for technologies that have not been subjected to a systematic assessment of their benefit.

Keywords: Neue Untersuchungs- und Behandlungsmethoden; Nikolausurteil; Rechtsprechung Sozialgerichte; Systematische Übersicht; Verbotsvorbehalt; jurisdiction of St. Nicholas’ day; jurisdiction of the Social Courts; neue Gesundheitstechnologien; new diagnostic and treatment methods; new health technologies; permission with the reservation of prohibition; systematic review.

Publication types

  • Systematic Review

MeSH terms

  • Costs and Cost Analysis
  • Germany
  • Humans
  • Insurance, Health
  • Insurance, Health, Reimbursement* / legislation & jurisprudence
  • Public Health
  • Technology Assessment, Biomedical / economics*
  • Technology Assessment, Biomedical / legislation & jurisprudence*