But health insurance companies wouldn’t pay for ineffective drugs!

(This contribution describes the legal situation in Germany which currently applies to the reimbursement of homeopathy by the statutory health insurance.)

Unfortunately the health insurances do this indeed, even if one hardly considers it possible. Because the legislator allows the health insurance companies the reimbursement of homeopathy.

This is caused by the difference between regular reimbursements based on law and additional permissible reimbursements based on the insurance’s own stating orders.

First of all, you have to know what the regular reimbursements of a statutory health insurance company are. Those are the reimbursements for therapies, methods and means approved by the Federal Joint Committee (an independent institution of the self-administration of the German health system) for which proof of effectiveness has been provided. This must pay each health insurance company according to § 12 of the Social Code V under consideration of the principles “sufficiently, expediently and economically”.

The same § 12 stipulates that benefits that are not necessary or not economical may not be claimed by insured persons, not provided by healthcare providers and not approved by health insurance funds. That would not belong then to the regular reimbursements.

In view of this, how does it come now nevertheless to the fact that in the meantime more than 75 per cent of the legal health insurance companies take over costs for homeopathy?

For that one must know, what “additional permissible reimbursements” are.  This is what the Ministry of Health itself says on its website:

“Additional permissible benefits are those that a health insurance company can provide in addition to the statutory benefits. Those benefits are generally at the discretion of the health insurance funds (based on the company’s own bylaws) and can be used for competition between the health insurance funds. Insofar as they exist, the health insurance fund is bound by its own bylaws vis-à-vis all insured persons”.

The instrument of additional permissible benefits has existed for some time by legal authorisation. However, it only became exciting with a legal amendment in 2012, the 3rd SHI Care Structure Act, which greatly expanded the catalogue of possible additional permissible benefits.

The Trojan Horse

These permissilbe benefits are something like the Trojan horse for means and methods which, according to the clear statement of the Social Code V, should actually be excluded from the statutory benefits.

Two of the things that were allowed as statutory services in 2012 were the reimbursement of over-the-counter medications and the reimbursement of services provided by “other health service providers”.

It is well known that homeopathic remedies in Germany are medicinal products by law – because of the unspeakable “internal consensus”, not because of scientific proofs of efficacy. They share this privilege with anthroposophical and phytotherapeutic remedies. And here it is important to understand:

Homeopathic remedies as such have never been excluded from reimbursement. After all, they are medicines by law. But: practically all of them are available over the counter – and the over the counter medicines were completely excluded from reimbursement by the SHI in one of the legislator’s cost containment rounds in 2004. It was not because of the dubious homeopathy method that the health insurance funds were prevented from reimbursing homeopathy until 2012, but only because all over-the-counter medicines had been exempt from reimbursement since 2004. With a few exceptions, especially for children and adolescents up to a certain age. And in fact: for this group of persons costs for prescribed homeopathic medication has been reimbursed for years and days and to this day as regular benefits!

And with the reimbursability of services provided by “other health service providers”, the door also opened for the reimbursement of medical homeopathic services, for which there simply were no billing figures until now. The Central Association of Homeopathic Physicians, via its marketing company, concluded so-called selective contracts with the health insurance funds, which stipulated that medical homeopathic services could be invoiced at special rates outside the normal SHI budgeting. (The idea of selective contracts was intended to ensure better care for the chronically ill, but – like so much else – has long since spread to completely different areas).

And so the regulations of the 3rd SHI Care Structure Act, without the word “homeopathy” even appearing anywhere in them, had become the “Trojan horse” with which homeopathy could establish itself in statutory health insurance.

And this should make one thing clear to us: An end to health insurance reimbursement as a statutory benefit would only be a “stage victory” for homeopathy criticism, an actuarial process, so to speak. The barn door of the medicinal property with which homeopathy is placed within medicine remains open. And thus also the possibility of turning the whole thing around again at some point through a legal or insurance process. As long as homeopathy is not equal to all other medicines in the approval procedure, but is preferential treated by the “internal consensus” the basic problem remains unsolved.

Competition – with what?

This all is already a rather confused matter. Why extends is the legislator the catalogue of additional permissible reimbursements in this way?

Well, the underlying thought was the introduction of “competition” between the insurance companies. (Important: Unlike as in the UK, in Germany namely exists a unified system of SHI, but divided into a number of separate insurance companies based on civil law; a unified organisation like the NHS doesn’t exist.) Competition within the framework of the regular reimbursements was not possible, competition over the contribution rate and over rationalisation inventions was practically exhausted in 2012. The idea of effectiveness competition has undoubtedly also had an effect, as can be seen from the significant reduction in the number of statutory health insurance funds. And so the legislator invented an offer competition, pure marketing with a colourful vendor’s tray of “benefits” for the potential customer, especially the wellness oriented, consistently healthy “midage generation”.

This happened in 2012 beyond the regular reimbursements by the extended catalogue of additional permissible benefits. And homeopathy was at the top of the wish list – both the homeopathic lobby and the health insurers, who saw it to be lucrative in competiting new “customers”.

Marketing takes precedence over effectiveness

Due to the already existing “popularity” of homeopathy and the busy lobbying of the usual suspects, the health insurance funds began to outbid each other by assuming the costs of this ineffective method – with the blessing of the legislator, under the supervision of the responsible departments and institutions and – very importantly – at the expense of all contributors to the respective fund. Because there is no election or additional tariff offered (there was once such in the SHI; however, ist was 2018 abolished because only some 500 insured persons remained), but the statutory tariff for regular benefit plus additional permissible achievements has to be payed by each member equally.

Even the homeopathy lobby was apparently somewhat surprised by this performance of the legislator. Even the then chairwoman of the German Central Association of Homeopathic Physicians stated in astonishment: “For the health insurance funds, this is probably a marketing instrument to set themselves apart within competition”. There is little to nothing to be added.

Conclusion

On a broad front – i.e. with about three quarters of the statutory health insurance funds – the money of all contributors is spent with the blessing of the legislator predominantly for marketing reasons for the ineffective method “homeopathy”. From the point of view of a rationally thinking insured person, this can actually only be seen as an embezzlement of his contribution money. From the point of view of homeopathy lobbyists and, in many cases, of the insurance companies themselves, one usually hears that “people want that” or “demand is high”. What a wrong way in the truest sense of the word. To put it nicely, the legislator has obviously set the wrong incentives, as one would say in economics. To put it mildly, social insurance offers little room for competition and marketing, especially not with medically worthless means and methods. It is a community based on solidarity in which other principles have to stand in the foreground.

More about health insurance companies and homeopathy can be found on our Homöopedia and on VICE with Dr. Natalie Grams: Why health insurance companies should finally stop paying for homeopathy (both in German).

Picture credits: Gerd Altmann on Pixabay