Necessary general anaesthesia remains in the SHI benefits catalogue: zm-online

The anaesthesia decision of the doctors’ evaluation committee, which is fatal for the dental profession, is finally off the table – the dentist will also be able to switch off the pain caused by anaesthesia during treatment in the future. Due to the concentrated work of the KZBV, the interests of the dental profession are largely taken into account in the new regulation: In medically necessary cases, general anaesthesia will continue to be part of the statutory health insurance’s obligation to pay, while the patient will have to pay for desired anaesthesia privately.

Whether children, the handicapped or “hard cases”: At the dentist the treatment can often only be carried out under general anaesthesia. Photo: DAK

We remember: The evaluation committee of the doctors and health insurance companies had more or less confronted the dentists with faits accomplis in October last year and with the new EBM had banned the medical anaesthesia in dental practices from the GKV benefit catalogue. Only exceptions: Mentally handicapped patients or patients with dyskinesia. Only they should continue to receive a general anaesthetic on their health insurance card. All others, for example infants with a lack of compliance and anxious patients, should pay for central anaesthesia out of their own pockets.

A fatal decision – for the patients as well as for the entire care landscape: Even though the subject of “anaesthesia” has increasingly been seen from the perspective of wellness and desire in recent years, a number of therapies in the tooth, mouth and jaw area cannot be performed with a local anaesthetic – an anaesthetic is necessary here.

Coherent solution required

Mouth, maxillofacial surgeons, oral surgeons and dentists therefore agreed on at least the tenor: this decision was not acceptable. “The planned exceptions would not have reflected the indication framework to some extent and would have called the safeguarding of care into question,” says Dr. Wolfgang Eßer, deputy chairman of the KZBV, describing the original plan of the evaluation committee. “Although it is the declared intention of the KZBV board of directors to rule out any possible misuse of anaesthesia to the detriment of the SHI, it is completely wrong to deal with these individual cases by means of a blanket spin-off”.

It was therefore crucial for the dentists to correct the decision. This should be done in such a way that medically necessary anaesthesia is clearly separated from the desired anaesthesia. The KZBV and the Federal Dental Association made this unequivocally clear. It was also important that the GKV’s obligation to pay for anaesthesia depends solely on the service required, but is completely independent of the type of billing – regardless of whether it is via KV or KZV. While the now revised decision refused anaesthesia for dental services at the expense of the statutory health insurance, it continued to make it available to doctors across the entire range of services. Eßer: “With this regulation one would not only have disadvantaged the dentists, but also completely ignored the interests of the patients”.

The KZBV Board of Managing Directors initiated intensive discussions with the German Society for Pediatric Dentistry, the German Society for Oral and Maxillofacial Surgery, the Professional Association of German Oral Surgeons and the Professional Association of German Anaesthetists and, on behalf of all parties involved, drafted a professional statement which was coordinated with the Professional Association of German Anaesthetists. The BZÄK supported the work of the KZBV by clarifying the position of the dental profession in a letter to the German Medical Association and the BMG. The efforts were successful: not only were the proposals of the KZBV largely adopted, but the committee even went beyond them in its new resolution. This means that as of 1 January 2007, central anaesthesia in connection with dental and oral and maxillofacial surgery will be included in the SHI benefits catalogue if the pain cannot be eliminated in any other way. This is the case with interventions according to Section 31.2.8 EBM – i.e. also corresponding surgical BEMA or GOÄ services, as an example the extensive osteotomies are mentioned here – if treatment under local anaesthesia is not possible. The anaesthetist is obliged to indicate the ICD code.

In addition, the SHI system is liable to pay benefits in individual cases for

– Patients with contraindications against performing the procedure under local anaesthesia or analgosedation – with indication of the ICD coding including justification by the anaesthetist. This point also includes recognised phobics with ICD-10, F 40.2 and urgent need for treatment – provided that the certified phobia means a contraindication against treatment under local anaesthesia or analgosedation.

– necessary treatments for children up to the age of 12, unless the pain can be eliminated by other means than anaesthesia due to lack of compliance, which should be documented by the dentist after unsuccessful treatment attempts, and/or due to the intervention. The anaesthetist is obliged to indicate the ICD coding.

– Patients with lack of cooperation in mental retardation and/or severe dyskinesia. Here, too, the anaesthetist must indicate the reason for the anaesthesia using ICD coding.

The originally planned regulation would have virtually banned dental anaesthesia from the SHI catalogue. We have had the effect that desired anaesthesia is excluded, but the patient still receives general anaesthesia in medically necessary cases.

Dr. Wolfgang Eßer, Vice Chairman of KZBV

All in all, when applying the decision of the evaluation committee of physicians in practice, a responsible and uniform approach of the anaesthetists, dentists and health insurance companies involved is necessary, above all also in unison with the patient, in order not to create any false incentives there.

At present, however, there are obvious irritations in the different or incorrect interpretation of the decision, in particular also by the KVs. Therefore, in the interest of all parties involved, the Board of the KZBV feels compelled to draw the attention of the KZVs, associations, central associations of the health insurance funds and the KBV once again to the proper application of the resolution. zm

The case of “anesthesia”

According to the law, the Evaluation Committee of Doctors and Health Insurance Funds has, among other things, the task of reviewing the Uniform Evaluation Scale (EBM) to determine whether the service descriptions and their evaluations still meet the requirements of economic use of scarce resources.

In the case of anaesthesia, a decision had to be made which took into account the economic efficiency, necessity and expediency of the anaesthesiological service in times of weak funds of the SHI system and tight budgets, whereby the budget responsibility lies with the anaesthetist carrying out the anaesthesia.

In contrast to the provisional decision of the evaluation committee doctors of October 2006, the KZBV was able to ensure that the final decision continued to focus on the patient and his or her oral health, i.e. that medically necessary anaesthesia was covered by the SHI, but that desired anaesthesia on the insurance card was prevented.

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Christina Cherry
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