Can urologists without additional training also perform tonsil operations? Or ENT doctors operating on their patients’ abdomen? Theoretically yes, as long as it concerns private medical services. As unbelievable as it may sound: According to current case law, every doctor in this country is allowed to provide and bill private patients for treatments outside of their own specialty without being able to show quality-assured further training. In contrast to the more strictly regulated system of the statutory health insurance funds, the license to practice medicine, i.e. the statutory license to practice a profession, is sufficient.
Although the relevant judgments are a bit older, they have not been much discussed so far. That’s why radiological associations are now sounding the alarm. If it stays that way, the “quality of service provision (…) will no longer be adequately ensured,” says a jointly written warning letter from the German Radiological Society, the Professional Association of German Radiologists, the Radiologists Group 2020, the German Society for Neuroradiology, the Professional Association of German Neuroradiologists and of the Society for Pediatric Radiology, which is available to the Tagesspiegel. There is a double danger: on the one hand for patient safety, on the other hand for the “economical provision of medical care”.
Orthopedists are allowed to perform an MRI for private patients
The reason for the commitment of this specialist group is that it is directly involved through recent court decisions. Specifically, it was about the question of whether orthopaedists without appropriate further training are also allowed to provide and bill for radiological MRI examinations in private practice. The two courts involved – the Higher Regional Court in Frankfurt/Main and the Supreme Regional Court of Bavaria – affirmed this. On January 18 and July 14, 2022, they rejected corresponding appeals, including from AXA Krankenversicherung AG, against physicians from Regensburg and Darmstadt who had been active in this way.
There is a risk that something will slip when it comes to medical care.
Gerald Antoch, radiologist
According to the judgments, quality-assured further training is not necessary for the billing of non-specialist services for private patients. As proof of quality, it is sufficient if the doctor has completed courses that do not come close to meeting the requirements of the model further training regulations in terms of scope and content. And the Frankfurt Higher Regional Court provided yet another justification for the strange-looking decision: the Hessian judges argued that there were no standards at all that could be used to check the qualifications of a non-radiologist for the billing of radiological services.
According to the joint statement by the six radiologists’ associations, if this case law were to remain in place, “specialist activities outside of statutory health insurance would be reduced to the level of a license to practice medicine”. As a result of the most recent judgments, the quality of private medical treatment threatens to “sink below the level of statutory health insurance”, which – unlike in private health insurance – is legally bound to the qualification according to the further training regulations. This would jeopardize patient welfare and safety.
In addition, there was a risk of enormous cost increases. If the “performance and diagnosis of an MRI as well as the subsequent therapy decision qua self-referral are in one hand”, the result could be “an increase in MRI volume, extensive interpretation of the findings and costly treatment measures that are not absolutely necessary”.
Concern for patient safety and cost increases
All of this is not about a distribution battle between medical specialist groups, assured the director of the Institute for Diagnostic and Interventional Radiology at the University Hospital Düsseldorf and Deputy President of the German Radiological Society, Gerald Antoch, the Tagesspiegel. “There is a risk that something will slip when it comes to medical care”. Theoretically, as a radiologist, he could then “operate on open-heart patients, which of course I would never do”.
And in the long term, the charter for doctors to work in other fields could also become a substantial problem for private health insurance. In addition to the increase in costs, there is a risk of image damage. After all, advertising with higher quality through private medical care would then “not only become obsolete, but the opposite”.
So what else could be possible? So far, the quality of medical service provision has been secured via two tracks: via the further training regulations of the state medical associations and via the health professions laws of the states. These state that there are “specialist boundaries” – such as ophthalmology, ENT and internal medicine – beyond which doctors are not allowed to work without appropriate further training. In addition, there are agreements on quality assurance in the GKV, which private insurers do not have.
So it could help to tighten the health care laws of the countries. The requirement not to cross the boundaries of a specialist field should become a legally watertight ban. Furthermore, the state medical associations could specify their further training regulations.
In addition, there would be the possibility of adapting the private medical fee schedule (GOÄ), on the basis of which the private health insurance funds pay for the services of the doctors, so that there would no longer be any billing options for non-specialist activities.
Liability risks could act as a deterrent to too much non-specialist activity, says the radiologist
In any case, the expectation that physicians would limit themselves to specialist areas in which they know their way around and feel safe without appropriate guidelines and only out of their own ethos and sense of responsibility would be naive from Antoch’s point of view. After all, the gap in the law gives them the opportunity to earn significantly more money with additional non-specialist treatments. And without time-consuming and energy-consuming additional training.
Liability risks could act as a deterrent for too much non-specialist activity, says the Düsseldorf radiologist. However, it is not easy to prove that damage that has occurred is due to a lack of qualifications. And as a patient, you first have to get the idea that the doctors treating you are cavorting in specialist areas outside of what you have learned.
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