Author + information
- Georg Ertl, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Georg Ertl, Universitat Wuerzburg, Medizinische Universitatsklinik, Oberdürrbacherstrasse 6, Wuerzburg, Bavaria D-97080 Germany
In this issue of the Journal, Flachskampf et al. (1) offer “a German perspective on reimbursement and its impact on cardiology practice.” The basic conclusion is that reimbursement has driven the rate of cardiovascular interventions in the German population to an international leadership. Obviously, it remains speculative as to whether this is a causal interrelation. This matter is widely discussed in Germany, as probably in any country running a healthcare system following rules of free market economy. Another question is whether German cardiologists do too many cardiovascular procedures or the others do too few.
The second question raised by the authors is to what extent invasive cardiology is overpaid in the German healthcare system. It is tempting to assume that invasive cardiology is indeed overpaid, because the number of procedures is continuously rising. However, there might be other reasons for such a rise, like the gain of life expectancy of our patients by 5 years during the last 2 decades and the nationwide move of therapy of acute coronary syndromes toward invasive procedures. In fact, in our institution elective coronary procedures rather decline, whereas acute interventions balance this decline. Finally, a valid conclusion would require calculating total costs including investments for invasive versus noninvasive procedures, again a difficult task to undertake. The population-based key numbers given by the authors show that German cardiologists conduct strikingly more coronary angiograms and interventions than U.S. cardiologists. That more procedures are done in Germany, despite being less-well-paid than in the United States, does not exclude but certainly does not support the statement of a reimbursement-driven number of procedures. My guess is that unnecessary profit-driven procedures might happen but do not comprehensively explain the numbers we observe.
In a free market economy healthcare system, the incentives are strong to produce a small spectrum of high-price goods with a high profit margin in large quantity. Clearly, today these are the technical procedures in medicine, invasive or noninvasive. Intellectual and communicative services are paid much less, at least in cardiology. The noninvasive cardiologists in private practice in Germany depend economically on personally conducting echocardiography, whereas anamnesis, physical investigation, and interpretation of the echo and putting it in a context with other findings are poorly paid. This is 1 reason why German cardiologists refuse to delegate echocardiography to technicians. Thus, a prominent problem in cardiology is that technical skills are paid better than intellectual capabilities. A patient-and-disease- rather than a procedure-oriented reimbursement might be more adequate. However, quantifying expenditure of procedures is easier than quantifying brainpower and is considered essential for a healthcare system open to economic competition.
Might a healthcare system that has been designed to fulfill caritative tasks obey the rules of a free market economy? What would be the alternative? Perhaps it might be valuable to conduct a comparison of the German or U.S. healthcare systems with the Swedish or British national healthcare systems, which are in general not reimbursement-driven. Nina Rehfeld reported in the Frankfurter Allgemeine Zeitung of October 1, 2007, on the neurologist Livingstone who left, frustrated with the British National Health Care System, England and went to the United States, where again he was disappointed by the leaks in distribution of medical services. The comparison of healthcare systems suffers from differences at several levels. For instance, the German system covers health care for everybody, including sick pay after 6 weeks when the statutory sick pay of the employer expires. Nevertheless, total healthcare costs seem to be less in Germany than in the United States. It is very difficult to define and compare total costs with total accomplishments of a healthcare system. Most Germans today probably would like to stay with their semi-free-market system with cautious interventions to combat excesses. One desirable correction would be a higher estimation of the intellectual, communicative, and scientific skills of cardiologists.
Please note: Dr. Ertl has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation