Fehlende Planungssicherheit verärgert die Sportorthopäden am meisten
Auf dem Weg von der 3-Minuten-Medizin zur 1-Minuten-Medizin
Es wird zunehmend schwieriger, als niedergelassener Facharzt für Orthopädie zu bestehen. Dies ist die einhellige Meinung der Orthopäden, die das unternehmerische Risiko einer Selbständigkeit weiter eingehen. Der tägliche Kampf gegen sinkende Punktwerte und steigende Kosten zermürbt und frustriert. Jede Woche eine schlechte Nachricht, die Mediziner würden sich über eine einzige gute Nachricht freuen. Dazu meint die Gesellschaft für Orthopädisch-Traumatologische Sportmedizin” (GOTS):
“In den letzten Monaten herrscht vor allem eine große Verunsicherung bei nicht vorhandener Planungssicherheit. Die Quartalsabrechnung, bei der im Durchschnitt fünf bis sechs Monate nach Erbringung der Leistung erst feststeht, welches Kasseneinkommen erzielt wurde, schrumpfen aufgrund des sinkenden Punktwertes immer weiter. Der Punktwert sinkt, da immer mehr Leistungen aus dem gedeckelten Ausgabentopf für die Fachärzte gezahlt werden.
Aufgrund des hohen orthopädischen Versorgungsbedarfes der Bevölkerung, sichtbar an den immer und überall überfüllten Wartezimmern, ist die Zahl der niedergelassenen Fachärzte seit den siebziger Jahren kräftig gestiegen, die angeforderte Bezahlung für die erbrachten Leistungen somit ebenfalls. Da die Kassenhonorare für die gestiegenen Leistungsanforderungen nicht reichten, wurde der Facharzttopf gedeckelt. Seither teilen die Facharztgruppen den gedeckelten Facharzt-Betrag unter den einzelnen Fachärzten auf. Facharztgruppen, die aufgrund der Verteilung der sicheren Pleite zusteuern, werden von allen anderen Fachgruppen gestützt. Zuletzt wurden die bisher nicht aus dem Facharzttopf gespeisten Psychotherapeuten ebenfalls in den Facharztbereich aufgenommen, zusätzliches Facharzthonorar wurde dafür von den Kassen nicht zur Verfügung gestellt. Vor dieser Zeit wurden psychotherapeutische Leistungen von den Kassen aber mit separaten Mitteln bezahlt. Der Honorarverteilungsschlüssel, der die Verteilung der Kassengelder regelt, ist selbst nach eingehendem Studium nicht zu verstehen und wird sowieso alle paar Wochen geändert.
Das Honorar, das für einen orthopädischen Patienten für eine fachorthopädische Betreuung im Quartal ausgezahlt wird, sinkt weiter. Bei betriebswirtschaftlicher Berechnung stellt der niedergelassene Orthopäde schnell fest, dass ihm die Ziffer 1 für den ersten Besuch des Patienten im Quartal ungefähr 12 Euro inklusive Spritzen und Gipsen bringt. Spritzen und Kanülen muss der Orthopäde dabei noch selbst bezahlen. Jeder Zweitbesuch im Quartal wird mit der Ziffer 2 abgerechnet. Die Ziffer 2 bringt dem Orthopäden ca. 1,75 Euro ein. Da die laufenden Kosten einer orthopädischen Praxis bei ca. 1,50 Euro/Minute liegen, erfolgt der Zweitbesuch des Patienten im Quartal quasi ohne jede Honorierung, es sei denn, er dauert nur ca. 1 Minute. Da die meisten orthopädischen Kollegen mit ihren erbrachten Leistungen über dem gedeckelten Leistungsvolumen liegen, viele erbringen 140 Prozent der zu vorgenanntem Honorar bezahlten Leistungen, werden zum Beispiel 40 Prozent der Leistungen nur hälftig oder gar nicht vergütet.
Dies ist nach einhelliger Meinung der Kollegen ein Skandal, da orthopädische Krankheiten nicht immer mit einem Besuch zu diagnostizieren und behandeln sind. Die Kassen verlangen im Gegenzug und bei sinkendem Honorar, Top-Qualität, permanente schriftliche, ausführliche Auskünfte und Dokumentation der Arzttätigkeit. Nachfragen der DAK erkundigen sich zum Beispiel bei uns Ärzten, ob die verordnete Krankengymnastik wirklich erbracht wurde. Die AOK möchte zum Beispiel wissen, wo der Patient seinen Elektrorollstuhl denn abstellen würde. Mit solchen Anfragen werden Orthopäden und ihre Helferinnen in zunehmendem Umfang und Häufigkeit beschäftigt.
Dagegen stehen die ständig steigenden Praxiskosten: Personal wird durch steigende Berufserfahrung und Alter besser bezahlt, steigende Lohnnebenkosten, steigende Kosten für Softwarewartung, Röntgenwartungsverträge und Energiekosten. Wer in Zukunft als Orthopäde up-to-date sein will muss zudem in den nächsten Jahren auf digitale Röntgen-Bildspeicher und -Archivierung umrüsten, über immer leistungsfähigere PCs zur Verwaltung der Krankenunterlagen verfügen. Durch die geänderte Röntgenverordnung müssen Röntgenbilder von Kindern länger archiviert werden, was neue Lagerungskapazitäten erfordert.
Nebenbei kämpfen die Kollegen täglich mit Richtgrößen für Medikamente und Krankengymnastik. Eine Praxis, die die ureigene orthopädische Krankheit Osteoporose feststellt und mit adäquaten Medikamenten behandelt, stößt sehr schnell an die Obergrenze der Richtgrößen für Medikamente. Die Geldmenge, die ein niedergelassener Orthopäde pro Patient hierbei verordnen darf, ist bundesweit sehr unterschiedlich. Warum darf ein Berliner Orthopäde für seine Patienten die fünffache Menge an Medikamenten aufwenden, die ein hessischer Kollege verordnen darf?.
Als Orthopäden warten wir, wie alle Ärzte, seit Jahren auf die versprochene Überarbeitung unserer Gebührenordnung (GOÄ). Diese wurde zuletzt 1986 unzureichend reformiert. Grundleistungen wurden zum Teil 1996 neubewertet, die Steigerung des Punktwertes lag bei 6,5 Prozent für acht Jahre Laufzeit, die Inflation betrug im selben Zeitraum 25 Prozent. Bei arthroskopischen Kniegelenkoperationen kommt es regelmäßig zu einem Abrechnungsproblem, da arthroskopische Leistungen in der GOÄ nur unzureichend abgebildet werden, heutzutage aber der Standardeingriff sind. So sind Honorarstreitigkeiten mit den Privatpatienten und deren Versicherungen programmiert. Hier muss der Gesetzgeber endlich die Versprechung einer Überarbeitung der GOÄ einlösen.
Das Fass zum Überlaufen bringt die von Gesundheitsministerin Schmidt den Ärzten verordnete Nullrunde, das heißt, keinerlei Erhöhung der Honorare 2003. Bei steigenden Praxiskosten und der derzeitigen Inflation bedeutet dies eine klare Minusrunde für alle Ärzte.
Einen Vorgeschmack auf Einzelverträge mit den Krankenkassen gab es für die niedergelassenen Orthopäden mit dem Akupunktur-Modellprojekt der AOK. Viele Kollegen haben sich eine Schmerzgrenze gesetzt, ab der sie nicht mehr bereit waren, Akupunkturbehandlungen zu erbringen. Die AOK setzte als Honorar für eine von ihr im Rahmen des Modellprojektes bezahlte Akupunktursitzung einen Betrag deutlich unter der in der Gebührenordnung für Ärzte (GOÄ) üblichen Honorierung fest. Einige Kollegen waren nicht bereit, unter die bisher üblichen Sätze für eine Akupunktursitzung zu gehen und wurden daher kein Partner der AOK im Modellprojekt Akupunktur.
Die Modellprojekte der Krankenkassen für die Akupunktur sind aus orthopädischer Sicht generell zu begrüßen, da wenigstens in diesem Fall das Erkrankungsrisiko eines Patienten auf die Krankenkasse übergeht. Im Rahmen der Modellprojekte stellen wir Ärzte fest, ob ein Patient ein Beschwerdebild aufweist, das die von den Krankenkassen gestellten Voraussetzungen für eine Behandlung mit Akupunktur erfüllt. In diesem Falle müssen die Krankenkassen die Kosten der Akupunkturbehandlung ganz bzw. zum großen Teil übernehmen.
Der nächste Schlag der AOK betraf die ambulanten Operationen. Niedergelassene Orthopäden erbringen eine hohe Zahl der ambulant durchgeführten Operationen. In Hessen bestand eine, nach Meinung der Kollegen, gute Vereinbarung zum ambulanten Operieren. Es wurden festgelegte Euro-Beträge für eine Reihe von Operationen zwischen der kassenärztlichen Vereinigung und den Krankenkassen vereinbart. Mit dieser Regelung, die endlich einmal Planungssicherheit versprach, konnten Orthopäden ganz gut leben, vorausgesetzt, die Miete, die pro Operation an eine OP-Einrichtung zu entrichten ist, war nicht zu hoch. Die AOK kündigte einseitig diese Regelung von heute auf morgen auf. Die Orthopäden schickten, um überhaupt noch AOK-Patienten notwendige ambulante Operationen zu ermöglichen, die Patienten mit einem Kostenvoranschlag zur AOK. Erst nach Genehmigung durch die AOK konnten zum Beispiel akute Meniskusverletzungen dann zeitverzögert operiert werden.
Mittlerweile hat die AOK die Euro-Beträge pro Operation deutlich heruntergehandelt, für einige Operationen ist dies nicht mehr wirklich kostendeckend, zumal die Haftpflichtversicherungen für operativ tätige Orthopäden viele Tausend Euro kosten. Aufgepeitscht durch tägliche Fernseh- und Zeitungsbeiträge über Ärztepfusch und Kunstfehler steigt die Bereitschaft der Bevölkerung an, juristisch gegen Ärzte vorzugehen. Dies schlägt sich in den steigenden Haftpflichtprämien nieder, diese sind zwar noch nicht in amerikanischen Dimensionen, allerdings sind die Arzthonorare in Deutschland dies ebenfalls nicht.
Fazit: “Wir sind auf dem Weg von der 3-Minuten-Medizin zur 1-Minuten-Medizin!”
Autor im Namen der GOTS:
Dr. Andreas Marka
mediCenter Groß-Umstadt
26. Februar 2003
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