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Patients with chronic disease in Germany will now be penalised only if they explicitly declare that they have not taken drugs and followed their doctor’s advice and will continue doing this in the future.
The government originally wanted to impose financial penalties on any patient who did not follow medical advice. But the plan was abandoned after doctors and patient groups mounted vigorous protests, saying that it would destroy the doctor-patient relationship. The legality and ethics of the plan were also questioned.
The compromise was reached just before Christmas by the federal joint committee of doctors, hospitals, and health insurance companies (Gemeinsame Bundesausschuss), which informs government decisions on the refunding of health care costs. The ruling took effect at the start of this month.
“A legally sound regulation on therapy compliance has to be based on an agreement between doctor and patient,” explained the chairman of the Gemeinsame Bundesausschuss, Rainer Hess.
Doctors will now have to certify that all patients with long term conditions are sticking to their treatment unless the patient refuses the treatment. The certificate will limit a patient’s contribution towards health care costs to a maximum of 1% of their gross income. Patients without a certificate will pay 2%.
Exemptions to the new ruling include children under 18, people with severe mental or physical disabilities, and patients needing nursing care, who automatically qualify for the lower contribution level.
A similar plan in July 2007 to make breast, bowel, and cervical cancer screening compulsory and penalise those failing to attend was also dropped by the Gemeinsame Bundesausschuss (BMJ 2007;333:877).
Instead, the committee decided to make an explanation of the risks and benefits of screening compulsory. All women born after 1 April 1987 and all men born after 1 April 1962 without private insurance will have to certify in a health check-up passport that they have received counselling. The certificate will enable them to claim an additional refund of health care costs should they develop any of these cancers. The younger age for women takes account of cervical screening.
“We could not decide on any stricter regulation and force patients to take part in screening tests since all of them carry risks as well as benefits”, said Dr Hess.
Currently, all adults over 55 are advised to undergo faecal occult blood testing for colon cancer every two years and colonoscopy twice, 10 years apart. Men are advised to have an annual rectal examination for prostate cancer once they reach 45, and women are recommended to have annual check-ups for breast cancer from the age of 30, mammography every two years between the ages of 50 and 69, and cervical smear tests annually from the age of 20.