Ex Patricia, Felgner Susanne, Henschke Cornelia
TU Berlin, Management im Gesundheitswesen, Berlin, Deutschland.
TU Berlin, Management im Gesundheitswesen, Berlin, Deutschland.
Z Evid Fortbild Qual Gesundhwes. 2018 Apr;131-132:8-16. doi: 10.1016/j.zefq.2017.12.004. Epub 2018 Jan 10.
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.
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.
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.
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).
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.
在德国，新医疗技术的报销事宜常常要在社会法庭进行裁决。这些司法判决很可能也会影响疾病基金在报销申请方面的决策，进而影响患者对新技术的总体获取情况。
本研究旨在确定那些引发多次法庭诉讼的技术，以及这些诉讼是否成功。重点关注不同领域、技术类别和适应症之间的差异。在此基础上，我们通过案例研究分析了多年来关于相同技术报销的司法判决是否存在差异。
基于系统综述，我们确定了2011年至2016年德国社会法庭关于新技术的司法判决。分析包括社会法庭对个体患者治疗中使用技术的报销判决。
分析共纳入284项关于新技术的司法判决。在三分之一的案例中，要求疾病基金报销费用，住院治疗案例中的比例高于门诊治疗。用于眼睛和耳朵疾病治疗的技术获批报销最为频繁。在情况相似的案例中，社会法庭有时会做出相互矛盾的判决；这些判决部分与联邦联合委员会（G-BA）随后的评估相矛盾。
关于新技术报销与否的决策似乎没有遵循系统的方法。在住院治疗看似有利于创新的政策背景下，“医学知识的普遍公认状态”存在不确定性。多年来，对于未经系统效益评估的技术提起法律诉讼，这对患者及其治疗医生来说都是个问题。
