Von wegen, „so okay“, Herr Spahn! – Ein “Too long – Didn’t read” für Eilige

Der ausführliche Beitrag von Prof. Tina Salomon zu den “homöopathischen 20-Mio-Peanuts”, den wir vor kurzem unter der Rubrik “Standpunkte” veröffentlicht haben, stieß´auf reges Interesse – und auf den Wunsch, hierzu eine “Kurzfassung” zur Verfügung zu stellen.

Wir danken Tina Salomon für die Mühe, die sie sich mit einem “TL:DR” gemacht hat. Wir veröffentlichen es hier als gesonderten Artikel, unter “Kurz erklärt” damit der Ursprungsbeitrag nicht noch länger wird:


Too long, didn’t read

Da man dem Beitrag “Von wegen “so okay”, Herr Spahn!” ja nicht ganz zu Unrecht vorwerfen könnte, wie eine abschreckende Textwand daher zu kommen, hier noch einmal die wichtigsten Aussagen, in einer anderen Reihenfolge, aber mit dem gleichen Ergebnis: Eine Gesundheitsleistung, die nicht effektiv ist, kann nicht kosten-effektiv sein – womit die Erstattung der Homöopathie gegen das Wirtschaftlichkeitsgebot der GKV verstößt.

Der wissenschaftlichste Satz aller Zeiten ist wahrscheinlich Ben Goldacres “I think you will find it’s a bit more complicated than that”, denn wissenschaftliche Aussagen sind selten eindeutig, sondern immer nur kleine Schritte in Richtung Erkenntnisgewinn. Genau das unterscheidet sie von den Heilsversprechen in der Alternativmedizin. Aber auch in der Wissenschaft gibt es Fälle, in denen schon einige Schritte in Richtung Erkenntnisgewinn gemacht wurden, so dass es heute wissenschaftliche Aussagen gibt, die wir sie mit einem Ausrufungszeichen versehen können. „Schwerkraft!“ und „Und sie dreht sich doch!“ fallen in diese Kategorie. „Homöopathie wirkt nicht über den Placebo-Effekt hinaus.“ ist schon verdammt nah dran. Und „There is no free lunch!“ ((Erklärung hier). Damit wird – in der Ökonomik als Lehre von der Knappheit – die Unausweichlichkeit der Knappheit und damit die Notwendigkeit ökonomischen Denkens und Handelns beschrieben. Auch in den Bereichen, in denen wir lieber an den free lunch glauben würden, wie im Gesundheitswesen.

Bei den Akteuren im Gesundheitswesen ist das Vorhandensein von Knappheit unbestritten, Konflikte gibt es nur über die Frage, wie mit dieser Knappheit umgegangen werden soll. Das “nur 20 Mio.”-Argument von Jens Spahn verleitet dazu, das Gesundheitswesen als Schlaraffenland zu sehen, in dem es keine Knappheit und damit keine besseren Verwendungsmöglichkeiten für diese Mittel gibt, so dass durch die Bindung von “nur 20 Mio. €” in einer nachgewiesen ineffektiven Verwendungsmöglichkeit kein Schaden entsteht. Das “Schlaraffenland Gesundheitswesen” ist aber eine Illusion, die auf den derzeitigen Wohlstand und das Bedarfsprinzip in der GKV zurückzuführen ist. An allen Ecken und Enden werden wir mit der Knappheit im Gesundheitswesen konfrontiert: Bei der fehlenden Zeit für Gespräche und Zuwendung, bei der Ablehnung der Erstattung von Maßnahmen ohne oder mit nur unsicherem Effektivitätsnachweis, bei der Beschränkung der Erstattung auf Leistungen mit voraussichtlichem Gesundheitsgewinn und beim Ausschluss von Maßnahmen, die lediglich zu Lebensqualitätsgewinnen führen, aus der Erstattung.

Mit “nur 20 Mio. Euro” leugnet Jens Spahn den Grundtatbestand der Knappheit im Gesundheitswesen und setzt sich über die Notwendigkeit eines operationalisierbaren, konsensfähigen und wissenschaftlich fundierten Abgrenzungskriteriums für die Entscheidung zwischen “Erstattung” und “keine Erstattung” hinweg. Und das richtet einen sehr viel größeren Schaden als “nur 20 Mio. €” an.


Wir verweisen zum Thema “größerer Schaden” auch auf die Positionierung der Gesundheitswissenschaftlerin Ingrid Mühlhauser bei MedWatch (die wir schon auf unserer Facebook-Seite vorgestellt hatten). Zum Thema “Priorisierung” und “Marginaler Nutzen” gibt es viel wissenschaftliche Literatur, verwiesen sei nur auf diesen Beitrag im Ärzteblatt: https://www.aerzteblatt.de/dae-plus/serie/36/Priorisierung-im-Gesundheitswesen?aid=65534

Herr Spahn bräuchte es nur zu lesen.


 

Open letter of the INH to the Siemens health insurance company (SBK)

In the context of the discussion on the reimbursement of homeopathy by statutory health insurance funds, the CEO of SBK drew attention to himself on Twitter with the “argument” that the small amount spent on homeopathy in his company was ultimately irrelevant “from an insurance point of view”. After this position had been contradicted on Twitter, SBK published a “Background Information: Homeopathy at the SBK” on its website and explicitly referred to this as part of the debate.

The Information Network Homeopathy feels compelled to comment on this publication with an open letter to SBK, which is given below:

 

To the
Siemens Company Health Insurance Fund (SBK)

By e-mail (info@sbk.org)

09.01.2018

Open letter of the information network Homöopathie on the publication of the SBK “Background information: Homeopathy at the Siemens company health insurance fund”

Ladies and Gentlemen,

your institution is one of the many health insurance companies that reimburse the costs of homeopathic treatment, which has been under discussion for some time. On Twitter, your CEO drew additional attention by putting forward the “peanuts” argument, i.e. the opinion that the low expenditure on homeopathy was not a significant part of the total expenditure anyway. This has already been contradicted on Twitter to the extent that this is not the only, not even a priority aspect in the demand that homeopathy no longer be reimbursed by health insurance funds.

Thereafter, you have clarified your point of view on homeopathic reimbursement (https://www.sbk.org/themen-standpunkte/hintergrundinformation-homoeopathie/ ), for which we would like to thank you first of all, because this enables a discourse. In the following we therefore deal with what you state in your clarification and orient ourselves on the headings of the various points as used in your publication:

1. To what extent does the Siemens Company Health Insurance Fund (SBK) cover treatment by homeopaths?

At this point, you inform us that you offer a separate optional tariff for homeopathic services (“pharmaceutical tariff”), which is actuarially self-supporting (i.e. the area of statutory services “for all” is not affected).

However, this information is incomplete.

According to the information on the SBK website, this only applies to the drug part, i.e. the globules; the medical treatment part of homeopathy is covered by a selective contract with the management company of the Central Association of Homeopathic Physicians as part of the statutory benefits, as is the case also with other health insurance funds, and thus also affects all insured persons who have no “interest” in homeopathy.

Even in the case that homeopathy would be a complete part of an optional tariff offer: The health insurance funds, especially the statutory ones, are important players in the health care system. We can certainly see that the legislator – unlike in the vast majority of industrialised countries – has not (yet) consistently implemented the orientation of public health towards evidence-based medicines and methods. Unfortunately, indeed. However, it cannot then be the task of the health insurance funds to undermine the confidence of their policyholders in rational medicine by offering a “vendor’s tray” of unscientific and ineffective methods, not even within the framework of a “voluntary tariff”, and thereby make a not insignificant contribution to the irrationality and hostility towards science that unfortunately prevails anyway. Apart from the fact that such offers, understood correctly, should actually be an ethical problem for health insurance companies.

One should bear in mind that the offer of unscientific methods with the authority of a statutory health insurance directly threatens the necessary further development of the health system in terms of performance, effectiveness and sustainability. Homeopathy is the “entry point” for the acceptance of further pseudomedical methods and often correlates with things like vaccination “skepticism” (perhaps less in the medical profession, but basically very well). Thus homeopathy is the dividing line beyond which there is a danger of further attention by patients to more dangerous pseudomedical methods. The responsibility of the statutory health insurance funds here is considerable. They should send a clear signal against such tendencies.

2. To what extent has the effectiveness of homeopathy been proven and what is SBK’s opinion of studies which consider homeopathic treatment to be free of effects?

“It is true that there are no scientific studies which clearly prove the efficacy of homeopathic medicinal products, but this does not mean that they couldn’t be effective.” This sentence in your publication opens the door to any arbitrariness and has nothing to do with a scientific-rational view on the problem. As the INH has just stated in its article “Scientists claim that homeopathy is impossible“, the “reverse conclusion” quoted by you is an absolute empty statement – simply because the ineffectiveness (impossibility) of something can in principle not be proved. Homoeopathy, however, has the scientifically conceivably highest improbability against itself that it could ever succeed in proving its effectiveness, let alone in explaining a mechanism of action that is compatible with the state of scientific knowledge. It is highly implausible, contradicts everyday experiences and is also incompatible with natural laws. Any explanatory model of homeopathy would require a massive revision of the valid and proven scientific view of the world. One cannot therefore – especially not as a health insurance company that should position itself credibly and seriously towards its policyholders – retreat to the Hamlet argument of “There is between heaven and earth…”.

In response, it should be sufficient to quote once again the summary of EASAC, the Advisory Board of the European Academies of Science:

“[We conclude]  that the claims for homeopathy are implausible and inconsistent with established scientific concepts.
We acknowledge that a placebo effect may appear in individual
patients but we agree with previous extensive evaluations concluding that there are no known diseases for which there is robust, reproducible evidence that homeopathy is effective beyond the placebo effect.”

We conclude from our research that the claims about homeopathy are implausible and contrary to established scientific principles.
We recognize that individual patients may have a placebo effect, but we agree with previous detailed studies and conclude that there is no known disease for which there is robust and replicable evidence that homeopathy is effective beyond this placebo effect.”

This is the valid statement of the scientific world on homeopathy. The position you have formulated is thus untenable according to generally valid rational standards.

3. Why is it not a problem for the SBK to pay for an unprovable form of treatment (= homeopathy), while this is not possible with glasses, for example?

In fact, the statutory health insurance funds are not allowed under German social insurance law to replace homeopathy reimbursements with benefits for spectacles and higher grants for dental prostheses. This is well known to the Homeopathy Information Network and has been explained in detail in an article on its website. Nevertheless, we understand that this is often mentioned as a wish by policyholders who reject homeopathy.

Here, too, we encounter a fundamental misunderstanding in your argumentation when you refer to the possibility granted by law to include homeopathy in the catalogue of statuory benefits. As also mentioned in the article from the INH website quoted above, no health insurance company is forced to do so. You yourself write that reimbursement of the special therapeutic directions is “not excluded” – but that brings your consideration to an end. However, the Federal Social Court has already decided several times that the same criteria of “necessity, economic efficiency and expediency” must be applied to the means of special therapeutic directions (homeopathy, anthroposophy, phytotherapy) as to all other drugs. A relevant social-legal commentary states in agreement: “An advantage of drugs of the special therapy directions with the consequence that quality and effectiveness of the achievements do not correspond to the generally recognized conditions of the medical realizations … contradicts … the legal defaults”.

Already in point 2 it was stated that homeopathy, according to worldwide scientific judgement, contradicts established scientific principles and that there is no reliable and reproducible evidence of specific efficacy for any disease. Such a method can never meet the social security reimbursement requirements of “necessity, cost-effectiveness and expediency” – in our opinion, any health insurance fund that reimburses homeopathy by way of statutory benefits is moving on very thin ice under the current legal situation. In this context, we see interest in the fact that you describe homeopathy as an “unprovable form of treatment” in your statement.

One more word on the objection that even in the field of “normal” medicine, ineffective drugs and methods are paid for: A health insurance company shouldn’t do that either. However, the legal situation here is different: every statutory health insurance fund is for “normal” pharmaceutical drugs and therapeutic methods bound by the approval decisions of the Federal Joint Committee for Drugs and Medicines: What the Federal Joint Committee allows in this area is by law standard benefit of the statutory health insurance funds. It is inconclusive and unreasonable to play this fact off against the reimbursement of homeopathy, for which or against which each statuary insurance fund can decide for itself.

4. What are the annual costs of homeopathic treatments for the contributor?

Here we come to the initial argument, which has led users on Twitter to criticize the statement made by your CEO in this regard. It should suffice to point out that the exclusion of homeopathy from the British public health system was associated with the explicit statement of the NHS (National Health Service) that it was not – not even secondary – a matter of cost savings, but rather of “lack of clinical efficacy” and the resulting “low cost-effectiveness”, i.e. the non-existent cost-benefit ratio. Because: Nothing is always too expensive. From the statements of the other government agencies that removed homeopathy from their health systems in 2017 (Australia and Russia), we also couldn’t find that costs played a role, let alone a decisive one. The same shall apply to the statement of the Scientific Advisory Board of the European Academies of Sciences (EASAC) quoted above. Once more, it is about honesty and probity towards patients, credibility and the best possible care within the healthcare system. The statutory health insurance funds should play a pioneering role in this and not focus on the “wishes” of the insured, but on objectifiable standards. Nihil nocere – above all, do not harm, this old Hippocratic principle also applies here. And damage is – as explained – produced in many ways when statutory health insurers handle homeopathy with their authority as a proven effective method.

5. Why does the SBK not rather reduce the additional contribution (above regular taxes) for policyholders instead of further paying for homeopathic treatments?

The comments made under point 4 make it unnecessary to comment on this matter. Of course, we do not wish to endorse the ‘peanuts’ argument that EUR 1.1 million would not ultimately be important. Every euro of contributions from insured people must be used with due care in the interests of honesty towards the members. For example, the money would be very well spent on voluntary therapies for very rare diseases or similar cases. But this doesn’t affect our core concern.

Concluding remark

In principle, we oppose a strategy of health insurance companies to drive on a “competition” that has gone out of control with a “magic shop” full of things that are ineffective, but are “desired” by a certain clientele. The original idea of health policy, to initiate competition within the statuary insurance system via rationalisation effects and the level of contributions, has – as the merger of many health insurance funds makes clear – certainly had its results. However, we consider it fundamentally wrong to extend this to “competition for benefits” as a means of “catching customers”. We also consider it completely out of the question that ineffective and potentially dangerous methods such as homeopathy should be used for this purpose.

Yours sincerely

Information Network Homeopathy

Dr. Natalie Grams.
Dr. Norbert Aust
Dr. Christian Lübbers
Udo Endruscheit


 

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.)

A plethora of letters and numbers symbolizing the confusion of German health legislation described in the following contribution
Rather confused, one would say…

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.

Learn more at us: Read why the cash insurances may not pay glasses and higher subsidies for dental prosthesis at all and why these may not be exchanged against homeopathy therefore according to valid right – and why substantial doubts exist whether the reimbursement for homeopathy really goes despite medicinal property and legalized permissible benefits is in fact legal.


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

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