“So okay” – no way, Minister Spahn! – A “Too long – Didn’t read” for those in a hurry.

DecorativeProf. Tina Salomon’s detailed article on the “homeopathic 20-million peanuts”, which we recently published under the heading “Points of View”, met with great interest – and the desire to provide a “short version” of it.

We would like to thank Prof. Salomon for the effort she has put into a “TL:DR”. We publish it here as a separate article:


Too long, didn’t read

Since one could not quite wrongly accuse the contribution “So okay, Minister Spahn? – No way!” of coming across as a deterrent wall of text, here are the most important statements once again, in a different order, but with the same result:

A health service that is not effective cannot be cost-effective – which means that the reimbursement of homeopathy violates the economic principle of the SHI.

The most scientific sentence of all time is probably Ben Goldacre’s “I think you will find it’s a bit more complicated than that” because scientific statements are rarely unambiguous, but always only small steps towards gaining knowledge. This is exactly what distinguishes them from the promises of salvation in alternative medicine. But also in science, there are cases where some steps towards gaining knowledge have already been taken, so that today there are scientific statements that we can put an exclamation mark on them. “Gravity!” and “And yet it turns!” fall into this category. “Homeopathy does not work beyond the placebo effect” is pretty darn close. And “There is no free lunch!” ((explanation here). This describes – in economics as the theory of scarcity – the inevitability of scarcity and thus the necessity of economic thinking and action. Even in those areas in which we would rather believe in free lunch, such as health care.

The existence of scarcity is undisputed among the actors in the health care system; conflicts arise only over the question of how to deal with this scarcity. Jens Spahn’s “only 20 million” argument tempts us to see the health care system as a land of milk and honey where there is no shortage and therefore no better ways of using these funds so that no harm is done by tying up “only 20 million” for a proven ineffective method. However, the “land of milk and honey in health care” is an illusion, which is only due to the current prosperity and the need principle in the SHI system. We are confronted with shortages in the health care system in all corners and ends: In the lack of time for discussion and attention, in the refusal to reimburse for measures with no or only uncertain proof of effectiveness, in the restriction of reimbursement to services with a probable health gain and in the exclusion from reimbursement of measures that only lead to gains in quality of life.

With “only 20 million euros” Jens Spahn denies the basic fact of scarcity in the health care system and disregards the need for an operationalisable, consensus-based and scientifically sound demarcation criterion for the decision between “reimbursement” and “no reimbursement”. And this causes much greater damage than “only €20 million”.


On the subject of “greater damage”, we also refer to the positioning of other health scientists from more recent times. There is a lot of scientific literature on the topic of “prioritisation” and “marginal benefit” in health care systems.

Minister Spahn need only read it.


 

“So okay”, Minister Spahn? – No way! – A guest article by health economist Prof. Dr. Tina Salomon

Manager in front of conference roomHealth economics is an established science. It provides the basis for how modern health care systems function in themselves and in economic environments. It defines a framework for decisions on sustainable health policy under the special economic criteria of this field.

Tina Salomon is a researching and teaching health economist in Bremen, Germany. She co-signed our Open Letter to Minister Spahn. On this occasion an exchange of views has taken place, as a result of which we are pleased to publish a guest article by her on the “20 million Euro statement” today. This makes it clear how much Mr Spahn, with his nonchalance, is basically moving outside the real context of the problem, not to say ignoring it in favour of a “ministerial decision” that appears to be down-to-earth.We thank Tina Salomon very much and recommend her text for attentive reading. Her decidedly health-economic view and the homeopathy-critical view of the INH meet in the simple sentence: “Nothing is always too expensive”. There is no room for sweets from the Minister of Health’s bag of goodies. With no justification.

We have published a summary of the following article (“TL:DR”) under the heading “Briefly explained”.


This is not “so okay” – not from a medical, not from a health policy and certainly not from a health economic point of view!

This is not BuzzFeed or the Huffington Post, but it is still the right place for a thoroughly emotionalized statement on the question of why I, as a health economist, am personally affected by Jens Spahn’s “only 20 million” argument. As the INH emphasizes again and again, the question of how much money is spent on homeopathic medication within the framework of the statutory health insurance (GKV) is not in the foreground, which of course does not mean that Jens Spahn’s argument is valid on this point.

Because it is by no means. “Only 20 million” is not an economic argument.

And here’s why.

Every discipline has its “founding documents”: The scientific publications that became the starting point for further research in this field and thus set the course for the scientific discussion of social challenges. There are also a number of such papers in health economics – and since science thrives on dissent, there is probably only limited agreement among health economists as to which publications should be included. But: my two cents, my rules. For this article I have given some thought to my top 3 and have chosen the following papers, which I can only recommend to anyone who wants to read up on health economics in order to have a say (not only) in the homeopathic debate:

    • Arrow, Kenneth (1963): “Uncertainty and the Welfare Economics of Medical Care”, American Economic Review, 53(5): 941 – 973.
    • Neuhauser, Duncan & Lewicki, Ann (1975): “What Do We Gain from the Sixth Stool Guaiac?”, New England Journal of Medicine, 293: 226 – 228.
    • Sackett, David; Rosenberg, William; Gray, Muir; Haynes, Brian; Richardson, Scott (1996): “Evidence based medicine: what it is and what it isn’t (Editorial)”, British Medical Journal, 312: 71st .

Did you notice that two of the three papers from my top 3 were not published in economic journals but in medical journals? This “balancing act” between the disciplines illustrates the field of tension in which health economics operates – and it makes it clear why there should not be a nonchalant “only 20 million Euros” here. Neither from a medical, nor from a health policy point of view, and certainly not from a health economic point of view.

Every single one of the three papers contributes to forming an opinion on homeopathic reimbursement – and every single one of the three papers contains strong economic arguments against reimbursement, whereby it is completely irrelevant whether homeopathy is or should be reimbursed as a regular or statutory service or as part of an elective tariff. The argument is congruent with the core statement of the INH: The effect of homeopathy does not go beyond the placebo effect and therefore it is completely irrelevant how the reimbursement is justified. The “only 20 million”, which Jens Spahn uses in his justification (and which I consider a PIDOOMA), we need more urgently elsewhere.

The first of the three papers, Arrow (1963), deals with the question of how individual behaviour is changed by insurance. Arrow, a mathematician, economist, Nobel Prize winner and US American, advocated social insurance against illness. At the same time, however, he also issued a warning, because the possibility of passing on the costs of using health services to the general public changes individual behaviour: The insured person takes advantage of services that he would not take advantage of if he had to pay for them himself. Not because he could not afford it otherwise, but because these measures would otherwise not be worth it to him: The expected individual benefit is too small to justify the costs for the individual. [1]

Neuhauser and Lewicki (1975), a health scientist and a doctor, show that the marginal principle, which economists know as Gossen’s First and Second Law from Microeconomics, also applies to the health care system. They use a simple calculation that can be understood by everyone and, with colorectal cancer screening, a relevant example in terms of health policy. The starting point is false-negative findings, because even the best screening in the world still has cases of disease that are not correctly detected. If screening is now used with the aim of finding all cases of disease, several rounds are necessary in which an almost constant number of people are tested for colorectal cancer. However, the yield in terms of detected cases of disease decreases with each round. In the first screening round, most cases are detected and the benefit to cost ratio is as good as possible. In the second round, far fewer cases are detected, but there are still many people to be screened, so the cost-benefit ratio deteriorates. And at some point the screening strategy reaches a point where a further round is no longer justified because although a large number of people are screened, hardly any cases are detected. In Neuhauser and Lewicki (1975), even in the sixth round of screening (Sixth Stool Gaiac) there was still a risk that a colorectal cancer case would go undetected. And yes, undetected colorectal cancer is a fatal disease, which is why considerable effort and high costs are justified in order to diagnose cases early. However, when you realise that we are talking about money that is not available elsewhere, you have to ask yourself whether 47 million in non-inflation-adjusted US dollars from 1975 for the chance to detect even the last case is still justified – or whether this 47 million could not be better used elsewhere and save more lives.

Finally, Sackett et al (1996) define evidence-based medicine as the “conscientious, explicit, and judicious use of current best external scientific evidence in making decisions about the care of individual patients”. This small editorial in the British Medical Journal is a turning point from both a medical and economic perspective. From a medical point of view, the revolutionary content of the article is to move away from theoretical considerations of the principles of action and towards empirical verification of the actual effect. It is completely irrelevant how extensively the theory of “water memory” is substantiated and how plausible this closed body of ideas may sound to the layman in the natural sciences. It is irrelevant how many “experts” speak out in favour of homeopathy, because they want to have had good experiences with it in individual cases. Relevant is only the proof of a statistically significant, clinically relevant effect. [2]

For health economists, who are not concerned with the individual treatment situation but with health policy decisions, this paper is so important because it provides them with a suitable decision-making criterion for the often difficult distinction between “reimbursable” and “non-reimbursable”: If there is a measure that already has no place in the individual treatment situation because no effect can be proven, then there can be no health policy reason to reimburse this measure – completely independent of how cheap or expensive the measures are in absolute amounts.

What can we learn from these three papers – and why is this relevant to the discussion on the reimbursement of homeopathy? Firstly, we can learn from them that the basic concept of scarcity, which defines economics as a discipline, has not been abolished for medicine and health care. We are a rich country, the standard of care in Germany is high and the SHI system, which is characterised by self-administration, is deliberately designed as a system open to innovation. Health expenditure at the societal level is not determined as a budget ex ante, but according to need. In the Federal Joint Committee, and especially in the area of services provided on an outpatient basis, representatives of service providers and service financiers jointly decide on the question of which innovations should be included in the catalogue of services, thus ensuring that innovations can be incorporated into regular care. This could perhaps be done more quickly, but on the whole it has led to a very high level of care by international standards – and it is just because the level of care is so high that we need to have a discussion at present on whether we can afford to reimburse measures that we know are not working.

Because we also learn something else from the articles, namely that there is a difference between an individual and a collective decision. The individual doctor may, should and must decide differently from Jens Spahn, who decides for us, the insured as a community. In the context of an individual treatment decision, utilitarian arguments do not play a role: If colorectal cancer is suspected, the necessary tests must be carried out, even if they are cost-intensive. The orientation towards the needs-based rather than the budget-based principle is a great strength of our health care system worthy of protection. But for our health care system to be able to afford this and for rationing decisions not to be made more than absolutely necessary by budgeting to the individual physician, delegated to the individual physician, it is necessary that the collective actors in health policy, first and foremost the Minister of Health, but also self-government, act consistently. Here there is no “only 20 million euros”, here there is only the distinction between “effective” and “not effective”, because since the triumph of evidence-based medicine in the mid-1990s this has been the criterion that draws the line between “reimbursement” and “no reimbursement”.

In 1976, when the Medicines Act (AMG) was passed, this development was not yet foreseeable. At that time the question of whether globules and other homeopathic dosage forms should be reimbursed did not even arise. The AMG is not a socio-political law, but serves to avert dangers in consumer protection [3], which is why the hurdle for approval was deliberately kept low. For homeopathic drugs it was lowered even further, precisely because the legislator could not assume a general effect or side effects even then. These products can therefore be registered, which means that they only have to be registered and do not have to be tested. Since the Reich Insurance Code, as the forerunner of today’s Social Code Book V, which governs statutory health insurance, already provided that only authorised drugs were reimbursable, there was also no socio-political reason to prevent market access and distribution via pharmacies in the AMG. In other words, the special approach to homeopathics has always been justified by the fact that in the vast majority of cases they do not have an effect beyond the placebo effect – and it was justified precisely by the fact that they may not be reimbursed. In the cases of “complex remedies”, i.e. in those cases in which effective, herbal substances are only slightly diluted, an approval is necessary and here, in the sense of the purpose of the AMG as a consumer protection law, an adjustment of the test to the current state of science is overdue. These are preparations for which the benefit-risk profile is unclear, which is why the clinical trial of the complex agents is necessary in order to achieve drug safety and to comply with the purpose of the AMG.

Apart from the “only 20 million”, the legislator feels increasingly committed to the basic idea of EbM, even if this has led to sometimes painful consequences in the field of drugs. The catalogue of services in the field of pharmaceuticals has been successively restricted since 1983: First in 1983, the trivial drugs were excluded, then in 2004 the non-prescription drugs and in 2007 the drugs that did not primarily lead to health gains but only to gains in quality of life. Since 2004 there has been a legal possibility and since 2011 even an obligation for health insurance companies to test new drugs on the basis of EbM. [4]

The marginal principle from the work of Neuhauser and Lewicki plays a central role here: additional costs compared to the previous standard of care are justified if and only if they are offset by an appropriate additional effect in the form of health gains (the German Act on the Reorganisation of the Pharmaceutical Market – AMNOG – has stipulated this principle of proving additional effects compared to already marketable drugs since 2011 and binds pricing decisions to it). The possibility of reimbursing homeopathic drugs breaks all these principles, which are intended to control the development of costs in the pharmaceutical sector without, on the other hand, jeopardising the system’s openness to innovation: Homeopathic drugs are often used in minor cases, they are not subject to prescription, they almost always only increase the quality of life and not health, and the additional costs are not offset by an appropriate additional effect. [5]

Perhaps you are now wondering how the economic view can be reconciled with the argument that the statutory health insurance funds should differentiate and compete through benefit catalogue decisions. Would a ban on the reimbursement of homeopathy impair the health insurance companies’ room for manoeuvre in marketing to such an extent that competition between the insurance companies would come to a standstill? This presumption is based on the assumption that the level of service in the SHI system is so high that all proven effective measures are reimbursed, so that homeopathy can be seen as a nice “add-on” that comes on top of the already maximum care. The service level in Germany is very high, but nevertheless there is a zone between the standard services on the one hand and the proven ineffective measures on the other hand, in which health and quality of life gains can still be realized with statutory benefits and optional tariffs and which is therefore much better suited for the differentiation of health insurance funds than homeopathy. This zone includes many behavioural preventive measures and thus also the ever-increasing field of Digital Health. By excluding a traditional but outdated measure from reimbursement, health policy would do what it is supposed to do, namely set the necessary course: Without homeopathy, the health insurance companies would have at least 20 million euros at their disposal for the digitalisation of the health care system and, as the marginal costs per additional user of apps are negligible, a great deal can be achieved with the many expensive clinical pictures that can be prevented by changing behaviour. This means that the original aim of the competition between health insurance funds, which was aimed at the emergence of specialised “diabetics’ health insurance funds”, for example, can be met much better than by the widespread reimbursement of “special therapy directions”. [6]

The current situation, which is characterised by bubbling income in the SHI system, should not lead us to believe that we can afford everything. We cannot afford every innovation and we cannot afford every tradition. Since we cannot deny the basic fact of scarcity, we must consider where we draw the line. The question of whether a measure is economic in the sense that its costs are matched by an appropriate effect is a weighty criterion, but by no means the only one. Because the central, relevant, decisive criterion is whether there is a demonstrable effect. For good reasons, health insurance companies do not reimburse acetylsalicylic acid (ASA) if it is to be used for headaches, even though its effectiveness is undisputed. The need is temporary, the price competition intense, so that every insured person can be expected to pay for this service out of his or her own pocket. And it is reimbursed if it is used as part of secondary prevention of stroke. Nobody would come to the idea of expecting health insurance companies to reimburse the full price of aspirin, no matter how many brand-conscious patients believe that aspirin is so much better for them than a generic alternative, and completely irrelevant how small the total expenditure on aspirin as part of stroke prophylaxis may be – and a health minister who would find this “so okay” would probably have to justify himself on the grounds of unreasonable proximity to the pharmaceutical industry.

To illustrate the weight of this system break and the danger exaggerated in the “only 20 million euros” argument and the questionable way Jens Spahn repeatedly overlooks self-administration, the system principles of the SHI system and economic logic, imagine the following, hopefully dystopian, situation:

Rising unemployment and demographic change threaten the social security systems. Due to decreasing contributions, benefits have to be prioritized and ultimately rationed. Painful cutbacks are necessary. Much more important than the question of what measures will be reimbursed in such a situation of extreme scarcity is the question of what criteria will be used to decide on reimbursement. If we only had a few million available to supply the 82 million German citizens, we would spend a long, very long time thinking about which measures are not only demonstrably effective, but are also at least characterised by an appropriate cost/effect ratio, i.e. are “cost-effective”. Obviously, we would first do the things that would relieve the maximally strained health care system, because they save costs. With high probability we would find these measures in the area of vaccinations, because by avoided health costs it is not in all, but in many cases health relevant measures with a considerable “value for money”. If we then had any money left over, we would continue to work our way through the possible measures and accept a slightly worse ratio of additional costs to additional effect for each additional measure. But only when we have identified and included in the reimbursement all measures that are cost-saving, cost-effective or even “only” effective, would we come up with the idea of discussing the reimbursement of measures that we know are not more effective than milk sugar pressed into globules. And we would certainly not be thrilled if a health minister with ambitions for the Chancellery were to justify the reimbursement of milk sugar balls by saying that it is “so okay”.

The deliberate reimbursement of a measure without proof of effectiveness represents a breach of the system that jeopardises the legitimacy of the argument that sometimes painful cuts are necessary in the health care system even when the level of care is high. These “only 20 million euros” are withdrawn from the health care system without us, the community of insured persons, receiving any appropriate compensation.

We all have to forego possible health gains because these “only 20 million” are missing elsewhere. It makes the work of the health care professions more difficult, because they have to make up for the “only 20 million euros” elsewhere, e.g. through fewer appointments per quarter or shorter meetings. While we are discussing the “only 20 million euros”, ventilation patients have to fear that they will have to give up their home environment and thus their remaining autonomy because intensive care in the SHI system is to be transferred to inpatient facilities – in order to save costs. Jens Spahn devalues the work of self-administration in the SHI system by taking on the role of the “strong man”, who in part authoritatively disregards the decision-making criteria used by individuals and committees to make decisions on benefit catalogues that deal with the above-mentioned area of conflict on a daily basis. And if we take Arrow (1963) as a starting point for the growing awareness that economic action is also indispensable in the health care system, then he also devalues the scientific achievement of health economics as a discipline over the last 56 years.

And that is just not “so okay”.


The author: Prof. Dr. Tina Salomon is Professor of Pharma Management and Pharmacoeconomics at the Apollon Hochschule der Gesundheitswirtschaft, Bremen


1] Note INH: The example of England shows this. Since the NHS has stopped prescribing homeopathic medicines and taking over clinical homeopathic treatments, homeopathic sales on the island have been marginalised. Apparently, there is little willingness to replace the cancelled health insurance benefits with own funds.

2] Note INH: Which, however, leads to the fact that homeopathy tries to take over the EbM in a pseudo-legitimatory way by maintaining a sham discourse about allegedly proven empirical evidence (but there are studies …). This is one of the central points of homeopathy criticism, which is also reflected in many contributions on this website. On the relationship between empirical evidence in the sense of EbM and overall scientific plausibility, e.g. Prof. David Gorski here: https://sciencebasedmedicine.org/plausibility_bias/

3] Note INH: The AMG, however, has an enormous legitimizing effect, which homeopathy makes use of through the easy attainment of the drug’s properties – the consumer protection aspect “inverts”, so to speak.

4] Note INH: This is a continuous process. See: https://www.aerzteblatt.de/nachrichten/97429/Netzwerk-Evidenzbasierte-Medizin-fordert-Durchsicht-des-GKV-Leistungskatalogs

5] Note INH: Not to mention the potential delays – even in the long term – caused by the use of homeopathy for non-self-limiting diseases.

6] Note INH: The “meaningless competition” between health insurance funds of a solidarity system has been the subject of criticism by INH on several occasions. See for example our Open Letter to the Siemens BKK .


Bildnachweise: Gerd Altmann auf Pixabay

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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