A new report based on the German experience examines how medical reimbursement systems influence the practice of cardiology and in particular the likelihood of performing interventional procedures.

The essay, the latest in the “From Around the World” series, appears in the April 24, 2012, issue of the Journal of the American College of Cardiology.

Although the authors, led by Frank A. Flachskampf, MD, of Uppsala University (Uppsala, Sweden), focus on Germany, they draw parallels with the US health care system. For example, neither country has long waiting lists for doctors’ appointments and no apparent rationing. And even though Germany has fewer cardiologists per 1 million inhabitants than the United States and spends about 5% less of its gross domestic income on health care, German patients generally rate their care highly.

A Mixed System

In both countries, health care is financed through a mix of government and private insurance, although in Germany government “statutory” coverage is the default option, insuring approximately 90% of the population.

German reimbursement is determined by flat fees tied to diagnosis-related groups (DRG), with the final payment adjusted for factors like comorbidities and length of hospital stay. The authors comment that in theory this approach should discourage overuse of resources, but “procedures play a powerful role in the German reimbursement system, because they modify the final diagnosis code.”

To illustrate how payment escalates, Dr. Flachskampf and colleagues offer the following scenarios of patients admitted with acute chest pain, together with the approximate costs:

• Patient A receives an exercise ECG and echocardiography—which are unremarkable—and is released on day 2; total cost, $832
• Patient B undergoes angiography on the second day; no lesion requiring intervention is found and he is released on day 3; although angiography as such is not reimbursed, it justifies an additional day in the hospital; total cost, $2,100
• Patient C has angiography and a significant stenosis is found; he undergoes PCI and receives a DES (about $800); he is released on day 3; total cost (including stent), $4,712

For outpatients, cardiologists receive a low flat fee per yearly quarter (currently approximately $84), as long as an echo is performed in addition to a physical examination and an ECG, regardless of additional ambulatory tests or treatment. However, for private outpatients, cardiologists can charge on a fee-for-service basis.

Invasive Procedures ‘Inordinately’ Favored

According to the authors, this system “inordinately favors performing procedures such as PCI, whereas conservative (and preventative) efforts in comparison result in very low compensation. Not surprisingly, this has affected and continues to affect the practice of cardiology.”

Over the past 20 years, the number of cath labs in Germany has grown from 234 to 830, coronary angiography rates have more than quadrupled, and PCIs have increased almost tenfold. The per-capita number of procedures exceeds the figures for other European countries with similar health care standards and age distributions, they add.

Although in theory a DRG-based “flat fee” system may better allocate resources than a fee-for-service model, the current German reimbursement rules are “deeply dysfunctional” and “financially penalize conservative clinical management, deemphasize ischemia testing, and continue to encourage invasive procedures,” the authors observe. “These features need to be corrected to align the financial logic with medical reason.”

Correction Needed to Value Cognitive Cardiology

In a separate commentary, German Society of Cardiology president Georg Ertl, MD, of Wurzburg University Hospital (Wurzburg, Germany), writes that while it is easy to infer that German interventionalists are overpaid because the number of invasive procedures has been rising, so has Germans’ life expectancy.

Dr. Ertl does acknowledge, however, that the German system gives cardiologists a strong incentive to perform better-compensated services, which generally means technical procedures. “One desirable corrective would be a higher estimation of the intellectual, communicative, and scientific skills of cardiologists,” he writes.

Echoing the same theme, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), told TCTMD in a telephone interview that “in both the German and US systems, there is a huge disparity between what [doctors] get paid for thinking and what [they] get paid for doing—and that’s a problem.”

An Insidious Effect

“This distorts practice not only in the obvious way—that [physicians] might do more procedures to make more money. The more pervasive and insidious effect is that it prompts them to practice less optimal medicine,” he added.

Dr. Brener explained that cardiologists who do not perform procedures are forced to see a great many patients a day just to bring in enough income to keep their practice afloat. And that decreases the chances that they can practice good medicine. For example, if a clinician needs to spend a half hour to think a problem through but will earn nothing extra for it, he may reluctantly decide he cannot afford to spend the time.

Dr. Brener pointed out that both the German and American systems are in contrast to the British National Health Service, in which doctors’ income does not depend on the type or amount or treatment given since physicians are basically salaried. He acknowledged that this system is often tarred with the need for rationing but insisted that all systems ration care in some way.

Critique May Unintentionally Inhibit Innovation

Society for Cardiovascular Angiography and Interventions president-elect J. Jeffrey Marshall, MD, of Northeast Georgia Medical Center (Gainesville, GA), described the article as a kind of op-ed piece, noting that drawing inferences from the kind of administrative data presented is “fraught with methodological problems,” he stressed. It is a little like trying to determine why people buy the color cars they do from looking at car dealers’ sales bills—there just isn’t enough information, he added.

Although the authors quote a study that found only 2% clearly inappropriate catheterizations in Germany, 1 possible explanation for the relatively high overall number, Dr. Marshall suggested, is that the system does not seem to pay for many noninvasive tests, so doctors  “have to spread a large net” to determine who needs angiography.

“I think the most important line in the article is where the authors say that they cannot establish on the basis of the available data whether or not doctors are overusing procedures for financial reasons,” Dr. Marshall said.

In addition, he noted that “there is no incentive for American doctors to do more [procedures] when they do a cath because reimbursement is bundled.”

“The [United States] and Germany have 2 of the best medical care systems in the world. One of my fears about papers like this [drawing conclusions from administrative data] is that it may have the unintended side effect of squashing innovation, which is in part responsible for a lower death rate from coronary artery disease,” Dr. Marshall concluded. “So although this [commentary] is meant to be provocative, it can also be deleterious.”

2. Ertl G. Medicine in free market economies. J Am Coll Cardiol. 2012;59:1566-1567.

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