3.3 Maintaining essential services
On April 17, the Minister of Health announced that hospitals will return to regular operation step by step starting as of beginning of May. They will keep 25-30% of all ICU beds with ventilators for COVID-19 patients. On March 12, the government required hospitals to postpone elective surgeries and treatments. In the previous weeks, less patients went to emergency services than usual, including patients with myocardial infarction or stroke which shows that patients with acute care needs seem to avoid seeking health care.
On April 27, the Ministry of Health recommended a step-by-step procedure for re-planning hospital bed capacities in Germany. The ICU capacity for COVID-19 patients is set at 25% of available ICU beds (instead of 50%). In addition, surgical capacity will be opened for elective interventions with capacity for these surgeries up to 70%. This will take place in a stepwise approach, with a 10% increase every two weeks coupled with re-evaluation of ICU bed capacities. Once the elective surgical capacity has reached 90%, there will be a step-by-step adjustment of the ICU bed capacity with increments of 5% every three weeks. In addition, the Ministry of Health recommends that all patients are tested on COVID-19 prior to hospital admission.
As of July 1, the special regulations for ambulatory care established by the Federal Joint Committee (G-BA) at the outbreak of the pandemic to limit physical contacts between patients and health care providers expired. End of June the Federal Joint Committee extended many of these measures until September 30, 2020, March 31, 2021 or unlimited, among others:
• Teleconsultations can be offered unlimited by physicians and psychotherapists until September 30. The Federal Association of Statutory Physicians and the SHI funds lifted the restrictions in regard to number of cases and the maximum time of teleconsultations. Video consultations are possible for all indications and also if the patients had not previously been treated by the physician.
• Ambulatory physicians and psychotherapists stay spared from fee cut due to temporary reduction of consultation hours as a result of lack of PPE or a directive of a public health office
• Ambulatory physicians and psychotherapists can receive compensatory payments for additional costs incurred as a result of treatment of COVID-19 patients or suspected cases without a time limit. The extrabudgetary payments for COVID-19 related treatments applies since February 1, 2020 and was agreed by the Federal Association of SHI Physicians and the Federal Association of Sickness Funds beginning of March 2020.
• Hospitals may arrange services or issue attestations for an extended period of time of 14 days after hospital discharge for the transition to ambulatory care. This includes the following services: medical certificate, home care, medical aids, ambulatory palliative care, socio therapy, physical therapy, ergotherapy, speech therapy. This regulation holds as long as the Federal Parliament declares a pandemic situation of national importance.
• The ordinance regarding the provision of pharmaceuticals which came into force on April 22, will be extended until March 31, 2021 at latest. Pharmacists, after consulting with doctors, may dispense with the same active ingredient in case a prescribed drug is not available or can be supplied to the pharmacy, even if it is more expensive. This even applies if the prescribing doctor has ruled out exchanging one medicinal product for another. Pharmacies may in such cases deviate from doctor’s prescriptions in terms of package size, package quantity, dispensing partial amounts of finished medicinal products, and strength without consulting with the prescribing doctor provided there are no pharmaceutical concerns.
• Based on an agreement from the Federal Association of SHI Physicians and the Federal Association of Sickness Funds on July 16, the suspension of certain quality assurance requirements may continue until March 31, 2021. Examples of this would include spot checks on documentation review, hygiene for colonoscopies and reviews of mammography cases.
On September 18, the Federal Association of SHI Physicians and the Federal Association of Sickness Funds agreed to further extend teleconsultations for physicians and psychotherapists until end of the year. In a continuation of special regulations for outpatient care from the second quarter of 2020, video consultation hours will continue beyond September 30 until the end of the year. The National Association of Statutory Health Insurance Physicians (KBV) and the National Association of Statutory Health Insurance Physicians agreed to continue to suspend the limits on the number of cases and services offered.
On October 30, the German Federal Joint Committee agreed to expand temporary regulations that enable doctors to guarantee prescribed services via telephone or video and without requiring physical presence in a practice or an office. Certain deadlines for prescriptions have also been relaxed, giving patients more time to potentially also use the post to receive them. The regulation applies from November 2, 2020 until January 31, 2021, with the option to be further extended if COVID-19 continues to spread.
Most hospitals implemented the ordinance of the federal states to postpone elective procedures within days. However, the decision to postpone elective procedures is made solely by the treating physician. The German Society for Surgery points out that the mortality risk from postponing an intervention should not be higher than that of a severe hospitalized COVID-19 case. There exist contingency plans for certain patient groups with chronic diseases to assure service provision, for example for dialysis treatment.
The RKI provides guidance documents for prevention and management of COVID-19 disease in stationary and ambulatory elderly care, for persons belonging to high-risk population, as well as recommendations for handling contact persons under shortages of professionals in all areas of care.
On March 27, the Federal Joint Committee (G-BA) which is the highest decision-making body of the joint self-government of physicians, dentists, hospitals and health insurance funds in Germany, announced a number of special regulations of its directive which will be in place for a limited period of time . Among others, physicians are able to determine if the training and treatment sessions with chronically ill patients should continue as normal or should be postponed, or potentially conducted with telemedicine capacities. The patients, part of the Disease Management Programs (DMP), and their prescribed quarterly check-ups can now be adjusted or cancelled if it is medically justifiable, based on risk of infection from COVID-19. The new policy is in place until September 30.
On April 3, the Federal Association of SHI Physicians and the Federal Association of Sickness Funds agreed to extend teleconsultations for physicians and psychotherapists up to three hours and 20 minutes per patient between April to June 2020 due to increased demand for this type of consultation. Teleconsultations were added as procedures to the Uniform Value Scale. However, teleconsultation is only possible with patients that consulted the physician/psychotherapist at least once during the past 18 months prior to this period. The maximum time of teleconsultation varies by specialty.
On April 8, the Federal Association of SHI Physicians reported that about 19,500 teleconsultations were performed in March 2020, compared to 1,700 teleconsultations in January and February 2020 which is an increase of 1,047%.
On April 3, the Federal Association of SHI Physicians announced that all kinds of therapies, such as physiotherapy, speech therapy or nutritional therapy are now possible via video upon patient consent. Therapies still require physician prescriptions which can be issued from distance. The new regulation applies to all treatments up to including May 31, 2020.
According to a report of the Central Institute for SHI Physician Care (ZI) from July 27, during the last two weeks of March, ambulatory physicians and psychotherapists have treated 330,000 more patients via telephone consultation compared to the previous year. Moreover, there were 127,000 more video consultations than in the same period last year.
On April 22, the Ministry of Health’s ordinance regarding the provision of pharmaceuticals came into force (SARS-CoV-2-Arzneimittelversorgungsverordnung). The ordinance aims to ensure the supply of medicinal products to the population during the epidemic and to reduce insured persons’ risk of infection from visiting pharmacies. It provides for various temporary exemptions from pharmacy, medicinal products, and narcotic drugs law and the Social Code Book V which concerns Statutory Health Insurance. First, the ordinance provides, among others, a temporary surcharge for pharmacies for dispensing medicinal products by courier (EUR 5 for each delivery and a one-time fee of EUR 250 for protective equipment of courier services) and expanded regulations on drug exchange for pharmacies in case of unavailability. Second, pharmacists, after consulting with doctors, are empowered to distribute medications with the same active ingredient in case a prescribed drug is not available, even if it is more expensive. The aim is to ensure access to pharmaceuticals and to avoid contacts for people with chronic diseases and COVID-19 patients in quarantine and isolation. Pharmacies may in such cases deviate from doctor’s prescriptions in terms of package size, package quantity, dispensing partial amounts of finished medicinal products, and strength without consulting with the prescribing doctor provided there are no pharmaceutical concerns. SHI funds cannot contest and refuse reimbursement of pharmacies’ invoices when medicinal products are exchanged. Third, the ordinance empowers the Federal Ministry of Health to restrict the trade in certain drugs, their active ingredients, starting materials and additives, medical devices, laboratory diagnostics, aids, PPE items and disinfectant products. The Ministry also has the option of banning the sale of medical products, or to order them to be sold at fixed prices. A number of duties are imposed on manufacturers and distributors of medical products whose relevance for supply has been determined, such as (1) information on stocks, storage location, production, distribution and prices upon request of the Ministry of Health; (2) reasonable and continuous provision of the products within the limits of what is reasonable; (3) pricing based on costs of providing the products; (4) no mark-ups vis-à-vis consumers based on the epidemic; (5) precautions against apparent stockpiling or deliberately bringing about a shortage.
On May 7, the Federal Chamber of Physicians (BÄK) and the Association of Private Health Insurance Companies (PKV) reached agreements for the remuneration of services for people with full private health insurance cover (11% of population). Physicians can charge a flat rate of EUR 14,75 due to increased expenditures on hygiene measures during direct patient contact. Invoicing of this amount will be possible until 31 July. They also agreed to expand the use of telemedicine (either video or telephone if the patient has no access to video consultation) for psychotherapy until June 30. For patients who are unable to visit a physician and to use video teleconsultation, physicians can invoice longer telephone consultations until July 31. Both groups saw the importance of maintaining necessary appointments to receive regular medical care.
On May 14, the federal parliament passed the ‘Second Act for protecting the Population in the Event of an Epidemic Situation of National Importance’. The new law also provides support for long-term care recipients and providers in ambulatory care
Currently, employees are entitled to a paid leave of 10 days to organize care at home in case of long-term care dependency and receive care support allowance in lieu of the salary. Until September 30, the care support allowance will also be paid in case that care providers are absent (e.g. personal carer or ambulatory care provider) and the entitlement will be increased from 10 to 20 days per year. In addition, short-term care in residential facilities will be provided to bypass shortfalls in ambulatory care.
Until September 30, care recipients in Grade I may use the monthly support allowance of EUR 125 (Entlastungsbetrag) use for other purposes than those prescribed by state law. Providers of daily support services will receive compensation for lower revenue (up to EUR 125 per care recipient per month) and extraordinary expenditures.
On May 26, results of a survey of representatives of professional associations and Regional Associations of SHI Physicians and Dentists, carried out by media, were presented. The survey evaluated patient seeking behaviour. Cardiologists and oncologists reported a decline of appointments by 30-50%, including people with severe cardiovascular disorders and cancer sufferers. Dentists even reported an 80% decrease of dental visits. According to the appointment services of the Regional Associations of SHI Physicians requests for appointments declined up to 50%, between mid-March and early May. This goes in line with April figures from German health insurers that show a 30% reduction in the number both of stroke and heart attack patients in emergency wards around the country over the past three months.
On June 29, analyses of patient data of one of the main German SHI funds (AOK, with 27 million members) showed that the number of inpatient cases decreased by about 39% between March 16 and April 5, 2020, compared to the same period of last year. The largest decrease was observed for elective surgeries such as hip replacements which saw a drop of 79%. The number of some urgent interventions even increased such as treatments of acute appendicitis (8%) and removal of breast cancer (11%) while non-urgent treatments decreased (e.g. drop of breast reconstitution by 76%). However, the WIdO – AOK Research Institute also reports a decrease of emergency cases which gives reason for concern. Myocardial infarctions and strokes decreased by 31% and 18% respectively in this period. This indicates that patients may have avoided to seek care or contacted emergency services at a late stage.