Gleiss Lutz obtains landmark decision in favour of statutory health insurance funds on remuneration for accredited physicians

In a landmark decision handed down on 13 August 2014 the Federal Social Court rejected, for the State of Saxony-Anhalt, a significant increase in remuneration for SHI-accredited physicians on the basis of a change in patient morbidity statistics - i.e. on the basis of treatment needs to be expected based on statistical data. In 2013 alone this would have meant additional costs in the order of approximately 120 million euros for the statutory health insurance funds in Saxony-Anhalt.  

Within the remuneration system for SHI-accredited physicians patient morbidity is an important factor for determining the financing volume to be provided by the health insurance funds. The Federal Social Court ruled that the principle of previous-year linkage applies to the adjustment of treatment needs. The only criterion for determining treatment needs was, it argued, changes in patient morbidity as compared to the year before.

After negotiations broke down between the health insurance funds and the Association of SHI-accredited Physicians of Saxony-Anhalt, the Medical Arbitration Authority (Landesschiedsamt) of Saxony-Anhalt decided that remuneration would increase by around 15% on the basis of a so-called basic adjustment of treatment needs for 2013. In doing so it was complying with the request from the Association of SHI-Accredited Physicians to redefine the morbidity level of patients in Saxony-Anhalt independently of the value the previous year on the grounds that this had previously been set too low. The Medical Arbitration Authority’s decision had already been overturned by the lower court, the Social Court of the State of Saxony-Anhalt. The Federal Social Court has now confirmed this in its judgment and laid down new stipulations for determining the annual changes in treatement needs.  

This has been a test case for similar proceedings in other states. In view of the decision made by the Medical Arbitration Authority in Saxony-Anhalt many other associations of SHI-accredited physicians had called for a redefinition of treatment needs in their areas. Nationwide this would have resulted in additional costs of some three billion euros per year.  

Gleiss Lutz represented the state associations of health insurance funds and substitute funds in Saxony-Anhalt in the proceedings before both the State Social Court and the Federal Social Court and is also handling arbitration and court proceedings in Hamburg, Hesse, Rhineland-Palatinate and Saxony. The matter is being handled by Dr. Reimar Buchner (lead, partner) and Dr. Jan-Peter Spiegel (counsel, both healthcare, Berlin).