Practice doctor on bureaucratic hurdles and the burden of telemedicine providers

Doctors and staff feel increasingly burdened by excessive bureaucracy, not only in hospitals but also in doctors' surgeries. Government digitization has hardly brought any relief so far. In addition, many doctors are displeased with telemedicine providers who offer their services outside the doctor's surgery.

While the National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Funds are trying to counteract the prescription of addictive drugs without personal contact with a doctor, for example, the Central Association for Digital Health is criticizing the new agreement. It is calling for easy access to telemedical services (PDF). GPs such as Laura Dalhaus, however, are annoyed by providers who advertise quick prescriptions and sick notes in just a few minutes.

We spoke to Dalhaus about why this is not a fundamental criticism of telemedicine and about burdensome bureaucracy. She sheds light on these and similar topics in her new “5-Minus” podcast and is not afraid to take offense.

heise online: Telemedicine providers such as Teleclinic and Zava are not very popular, especially with registered doctors like yourself. Why is that?

Laura Dalhaus: The billing system is structured in such a way that you log in to a GP with your card, and they first charge a basic flat rate. Teleclinic or similar providers also charge the basic flat rate for each visit to the doctor. This means that money is missing from the funding pot without improving care. This exploits the system.

Couldn't you care less if the funding pot gets emptier?

No, frankly I feel underpaid with a remuneration of less than 80 euros for three months per patient for GP care and if providers now help themselves to the already underfunded pot, all colleagues will soon give up their health insurance license.

People who want a second opinion are also a burden on the system, aren't they?

Yes, that's true. However, visits to telemedicine providers are on top of that.

And how do you assess it when people can't get an appointment and therefore go to an online doctor?

Providers such as Teleclinic usually only treat uncomplicated cases, for example when someone wants a sick bill for a cough, cold, or hoarseness. A person who has been discharged from cardiology with two stents will not go to an online consultation.

We don't have a shortage of doctors, we have a shortage of doctor's time. If we had less bureaucracy, we could look after patients more and save time and money overall. When I write a prescription for a rollator, I have checked that the indication exists by writing the prescription. I then automatically receive a letter from the health insurance company asking me to comment on sitting angles and arm strength.

But nowhere else do we have as many contacts with doctors as in Germany. Instead of tackling the issue of “health literacy” and getting people to stay at home for three days with a cold.

And when employers demand a sick bill?

Yes, the challenges are very complex. But instead of solving problems, yet another player is now coming along and saying “Hey, it's no problem, and I'll give you doctor's time not only during normal office hours, but also seven days a week”. But that doesn't make the service any better. You can't listen to patients remotely, and the GP doesn't know the patient for any length of time. The tele-doctor sends the prescription, and you can then submit it directly to DocMorris, which bought out Teleclinic, and Shopapotheke.

But you also have colleagues who like to do video consultations with telemedicine providers in their free time?

Yes, they are part of the problem. At the same time, one day I won't be able to manage all the complex cases. We are all getting older and sicker, and I need the people who go to the teleclinic with a harmless cold to cross-finance the more difficult cases. As long as this financing system remains in place, such providers will be digging the grave of local outpatient care.

What impact do online doctor services have on the doctor-patient relationship?

The doctor-patient relationships that we still had in the 1980s and 1990s will hardly exist one day. Medicine is in the process of being reduced to a purely functional, technical level. For good medicine, however, it is important to be able to assess the patient not only based on a one-off contact, but also, for example, based on their development, family history and the like. This also determines the quality of treatment, the medical art. I must have examined a lot of knees to recognize even subtle meniscus injuries. I must have examined many abdomens in order not to overlook appendicitis. The doctor-patient relationship is not a service provider-customer relationship.

With the large telemedicine providers, however, this relationship is degraded to such a service provider relationship. The patient says: “I need a certificate of incapacity for work and a prescription” and the other party has no choice but to say: “Yes, I'll do it”.

The National Association of Statutory Health Insurance Physicians and the National Association of Statutory Health Insurance Funds are aware of the problem and a few days ago agreed on supplementary “Requirements for ensuring the quality of care of telemedical services”, which are to apply from March 1. Is that surely in your interests?

Yes, I think the definition of “unknown patient” and Section 11 with the additional quality requirements are very good. (Editor's note: Among other things, it stipulates that doctors may no longer prescribe narcotics and addictive drugs to patients unknown to them during video consultations). This will definitely increase the quality of treatment because GP care is more than “just getting a sick note”. I therefore welcome this initiative. The medical profession, including self-administration, must offer telemedicine within a sensible and meaningful framework, not a corporation, to lead the “patient” value chain to its online pharmacy.

Was the whole thing promoted by the coronavirus era?

In the coronavirus era, Teleclinic was still a start-up from Munich and relatively small. I practised telemedicine for six months and 80 percent of what I did was garbage and the other 20 percent wanted me to give them prescriptions for narcotics, i.e., Tavor and the like.

However, the patients' desire to be prescribed prescription drugs is also a problem in the practices. One of our colleagues was beaten up in his practice because he didn't want to prescribe a prescription drug. Of course, these are exceptions, but the question still arises as to what kind of discussions you get involved in. We only have 9 minutes per patient in a 3-month period in which we can take care of the patient. Individualized medicine is not possible.

However, Health Minister Karl Lauterbach promises that individualized care will be possible with the electronic patient file and that doctor hopping will be prevented. Will the electronic patient file help?

No. Let's not kid ourselves, the ePA will not help. Our solidarity system can no longer afford the availability of GP services 24/7 and 365 days a year. Citizens must realize that things cannot continue as they are. However, such statements are not conducive to election campaigns, even if they are extremely relevant. But things cannot go on like this. We need real patient control and a citizens' insurance scheme.

It is also important to take the relevance of prevention seriously. An incredible amount of money is made from diseases and their treatment. The pharmaceutical industry, which sells its money with diabetes medication, has no interest in us having fewer diabetics in Germany. This is a development that has gained momentum in recent years. We have to discuss things, even if it is ethically difficult. Can we afford expensive drugs such as Hemgenix from the US company CSL Behring for the treatment of haemophilia B, which costs 3.5 million US dollars?

Medicine is becoming more and more individualized and should become even more individualized. If we both have colon carcinoma, which is common, we have been treated the same up to now. In the future, however, it will be possible to examine the entire genome of the tumor, for example, and search specifically for a mutation. There will be differences, and suddenly, we will have two completely different diseases. You have 150 different mutations than I do, and then we will receive different individualized tumor therapies. One common disease becomes two rare ones. This makes treatment exorbitantly pricier. We need to think about the increasing healthcare expenditure in the area of pharmacotherapy (editor's note: treatment of diseases with drugs) and in the area of increasingly individualized therapies.

But a common platform, such as the ePA, on which doctors can share all their documents for patients would be good, wouldn't it?

We'll see, but I'm not yet hopeful. At the moment, the ePA is just a digital folder for unsorted information, nothing more and nothing less. I feel like a beta tester of outdated software. Government digitization is frustrating. Despite the TI flat rate, we often have to pay extra money ourselves to use the telematics infrastructure products. Gematik is highly unprofitable and the mountain of debt is getting bigger and bigger. This is being ignored and simply carried around. I stand there with my medical practice and think: the state is somehow telling me what I have to digitize, regardless of whether it works or not. And if I don't do it, my fee will be cut. That's such an incredible double standard. Then we have to use the digital certificate of incapacity for work (eAU) and who can't use an eAU? The state as an employer.

We currently mainly send emails back and forth via the KIM service – CDs with MRI images even by post. A common exchange platform would be desirable, but I'm a little uneasy about all the products that we have to use via the telematics infrastructure. What has really brought the whole thing forward is the e-prescription. Patients who just want a prescription come to the practice less often as a result. However, we are desperately waiting for the narcotic prescription to finally arrive. However, this is being delayed due to a lack of budget funds.

What do you think about telemedicine in general?

Telemedicine is very important, and we need it in rural areas in particular if it is to be used sensibly. It also makes a lot of sense if there is a PA (Physician Assistant) on site, for example, and a tele-doctor working in the background with whom I can go through the findings. I am in favor of teleconsultations.

GPs could treat their patients digitally or over the phone. For example, I also have a patient who has moved away and now lives two hours away. He comes to the practice once a year. It would also be helpful to finally abolish the unspeakable quarterly flat rates from the last century. Continuous GP care has a price, and this must be paid once a year.

Telemedicine, especially regarding video consultations, is a huge hype. But I need a good photo for a proper dermatological diagnosis. With the exception of psychotherapy, video consultations are rarely needed. For example, during the coronavirus pandemic, Dr. Robert Sarrazin built a platform on which psychotherapists in private practice from all over Germany offer online consultations. This is only possible as a private medical service under the German Medical Fee Schedule (GOÄ) and not via the standardized evaluation scale for statutory health insurance physicians (EBM), which can only be used to bill 30 percent of the hours. But the need is there.

Do you also prescribe digital health applications, or DiGA for short?

That depends on the symptoms, I differentiate strongly. There are DGAs that I completely boycott, such as weight loss apps. As a nutritionist, I earn 0 euros with my services in the health insurance sector. But then I'm supposed to prescribe an app that is no better than diets from magazines like Brigitte in terms of quality, but costs 500 euros a quarter. In other areas, such as smoking cessation or mental illness, for example, I think they make sense.

(mack)