Deficiencies in the statutory health insurance system - Possibilities and limitations of medical expertising

In Germany, the Federal Committee of Physicians and Health Insurance Agenci es is responsible for assessing which medical procedures are covered by the insurance agencies (therapeutic/economic value). The failure to evaluate c ertain medical procedures which promise therapeutic benefit may be consider ed a failure in the system of statutory health insurance as decreed by the German Federal Social Court. In cases of system failure the assessment of m edical procedures is taken over by social courts. Evidence of therapeutic v alue will continue to be the decisive criterion of evaluation. In special c ases, however, it may be replaced by the particular procedure's rate of inc idence in everyday medical practice, as reflected by a widespread resonance in medical discussion and its use by a considerable number of physicians. Medical experts may face various difficulties in handling these alternative criteria. They usually lack reliable data on the frequency of the procedur e, i.e, its distribution. Even if such data and data on secondary factors s uch as disease incidence etc. - were available to them, they would still no t be able to come up with a definite conclusion on the degree (widespread, considerable) of dissemination, as defined by the German Federal Social Cou rt. Nevertheless, on request of statutory health insurances, social medical experts may investigate facts in order to establish basic knowledge for la ter decisions that are to be done by others. Factual investigation includes clarification of etiology, incidence, importance and natural history of th e particular disease processes. Potential deficiencies in the medical servi ces rendered for specific diseases as well as the characteristics of the pr ocedure under scrutiny, and special requirements for evaluating the outcome have to be investigated as well. Additional attention needs to be paid to the quality of related publications (analysis of statistical data), possibl e recommendations for therapy (e.g. guidelines and their scientific basis), as well as to economic aspects. The result of such an investigation has to be stated without use of court criteria (widespread (considerable).