Lange J, Gönner C, Vollmann J, Rauprich O
Abteilung Sozialpolitik, Recht und Soziologie, Institut für Sozialwesen Universität Kassel, Kassel.
Institut für Medizinische Ethik und Geschichte der Medizin, Ruhr-Universität Bochum, Bochum.
Gesundheitswesen. 2015 Jan;77(1):8-15. doi: 10.1055/s-0034-1367021. Epub 2014 Apr 2.
Germany is at the beginning of a discussion about possible rationing in the health-care system. Cancer treatment, which is often cost-intensive but not always cost-effective, is frequently considered as a field for rationing.
Against this background, we conducted semi-structured, guideline-based interviews with different stakeholders of the German health-care system and analysed them with the help of grounded theory techniques. The goal of the study was to collect the experiences and opinions of members of the German Medical Review Board of the Statutory Health Insurance Funds (MDK), leading officials in central administrations of the German health-care sector and health politicians (members of the Parliamentary Committee for Health of the Federal German Parliament, the Bundestag) regarding cost-considerations in treatment decisions in health care with a special focus on oncology.
(1) Cost-considerations have a limited role in the daily routine of the interviewed experts; (2) the interviewed personnel of the MDK were open to discuss rationing, while the group of leading officials was ambivalent and the health politicians rejected rationing and its discussion altogether; (3) the awareness of the opportunity costs of medical services varied with the profession of the interviewee: the members of the MDK saw opportunity costs primarily within the field of medicine, the leading officials noted the opportunity costs for other social services, and the health policy makers interpreted opportunity costs under fiscal budgetary aspects; (4) according to the interviewees, decisions on rationing require a legal basis, which should be based on a broad public discussion and an interdisciplinary debate among experts; (5) defining criteria for rationing was regarded as being outside of the professional competence of the interviewees; however, a preference with regard to the criterion of cost-effectiveness became apparent.
The results of this study indicate that the strongest opposition to a debate on rationing in Germany does not stem from the medical, but rather from the political sector. The criteria for rationing suggested in the theoretical debate are in need of a context-sensitive examination and specification for the field of oncology. A possible approach to constructively promote the debate on rationing is a stronger focus on social opportunity costs of health care. The exact role of experts in a discourse on rationing, which was emphasised by the interviewees, requires a thorough determination. It is necessary to differentiate between the roles of impartial experts and stakeholders. Decisions on rationing can ultimately only be legitimised politically by parliament.
德国正处于关于医疗保健系统中可能的资源分配的讨论初期。癌症治疗通常成本高昂但并非总是具有成本效益，常被视为资源分配的一个领域。
在此背景下，我们对德国医疗保健系统的不同利益相关者进行了基于指南的半结构化访谈，并借助扎根理论技术对其进行分析。该研究的目的是收集德国法定医疗保险基金医疗审核委员会（MDK）成员、德国医疗保健部门中央行政机构的主要官员以及卫生政治家（德国联邦议会健康委员会成员）在医疗保健治疗决策中考虑成本方面的经验和意见，特别关注肿瘤学领域。
（1）成本考量在受访专家的日常工作中作用有限；（2）MDK的受访人员对讨论资源分配持开放态度，而主要官员群体态度矛盾，卫生政治家则完全拒绝资源分配及其讨论；（3）对医疗服务机会成本的认识因受访者职业而异：MDK成员主要在医学领域看到机会成本，主要官员指出其他社会服务的机会成本，卫生政策制定者从财政预算方面解读机会成本；（4）据受访者称，资源分配决策需要法律依据，该依据应基于广泛的公众讨论和专家间的跨学科辩论；（5）确定资源分配标准被认为超出了受访者的专业能力范围；然而，对成本效益标准的偏好变得明显。
本研究结果表明，德国对资源分配辩论最强烈的反对并非来自医学领域，而是来自政治领域。理论辩论中提出的资源分配标准需要针对肿瘤学领域进行因地制宜的审查和细化。建设性地推动资源分配辩论的一种可能方法是更加强调医疗保健的社会机会成本。受访者强调的专家在资源分配讨论中的确切作用需要彻底确定。有必要区分公正专家和利益相关者的角色。资源分配决策最终只能通过议会在政治上合法化。
