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The discussion draft of a law to amend emergency care provides for drastic changes in medical emergency care. The draft contains some discussion material for a legislative project. It wants to radically change medical care in the preclinical area of emergency rescue.

  • The economic safeguarding of the rescue service should in future fall within the scope of competing legislation and thus possibly within the competence of the federal government. The draft thus primarily limits the possibilities of the federal states.
  • The draft dissociates itself from the mere “travel costs” in the social law code book V (SGB V); the medical emergency supply is to become a component of a medical supply in a new § 60 SGB V. The new SGB V is to be amended to include the new SGB V. The new SGB V is to be amended accordingly.
  • Joint emergency control centres for 112 and 116 117.
  • With integrated emergency centers the draft creates new mechanisms of the contract-medical supply.

The changes are intended to serve a “uniform, quality-assured initial assessment of the illness situations that the affected persons perceive as emergencies and a professional control and mediation”.

A draft for discussion

The draft for the discussion, which I received from various quarters, was “not coordinated with the house management”, but was transmitted to various associations and is also available to the media (WDR). According to the Federal Ministry of Health (BMG), there is no official bill to reform emergency care. Initial draft regulations are currently being discussed between the Federal Ministry of Health and the federal states.

The following presentation therefore deals with the discussion proposals in the present draft as of the end of July 2019. It is not exhaustive. The draft is not in the official legislative process. According to the BMG, there is no more detailed timetable for the submission of a draft law and its parliamentary consultation.

Amendment of the Basic Law

The amendment to the Basic Law is likely to have the greatest impact. To date, the rescue service has been exclusively in the legislative competence of the federal states under Article 70 of the Basic Law. The draft aims to change this by amending Article 74 of the Basic Law. The draft provides for a new Article 74 (1) No. 12a of the Basic Law, which creates the necessary federal competence: the economic safeguarding of the rescue service should then fall within the competing federal legislation.

In the area of competing legislation, the federal states have the power to legislate as long as and to the extent that the Federation has not exercised its legislative competence by law, Article 72 (1) of the Basic Law. In the opinion of the draft authors, however, the increasing misuse of emergency facilities in hospitals and of rescue service resources is giving rise to fears with regard to needs-based and comprehensive emergency care. It was therefore necessary to incorporate it into federal legislation.

Medical emergency rescue in SGB V

Changes in travel costs according to § 60 SGB V

The eighth section of SGB V in § 60 SGB V currently still regulates the travel costs of the insured persons. This also includes the costs for public transport, taxis, rental cars, ambulances or rescue vehicles. The draft does not only provide for a change of the heading – Section Eight: Emergency rescue, ambulance transport and ambulances. In terms of content, the draft distances itself from pure transport costs.
Emergency rescue

The revised § 60 SGB V regulates medical emergency rescue.

The medical emergency rescue is defined in § 60 para. 1 sentence 1 SGB V-E as

“the medically necessary care at the place of emergency as well as the rescue journey with a qualified rescue device in the event of further immediate need for treatment”.

A claim to this benefit exists in the case of immediate danger to life, if the state of health is such that a life-threatening deterioration can be expected or if serious damage to health is to be feared if medical care is not started immediately, § 60 Para. 2 SGB V-E.

If it is unclear whether the patient is to be admitted to hospital, the ambulance should drive to the nearest integrated emergency centre. The rescue service transmits the emergency protocol and the collected findings digitally to the facility in advance; this is the intention of the draft.

Also relocations are planned in § 60 SGB V-E as service of the medical emergency rescue. The prerequisite is that the relocation is necessary for compelling medical reasons and that the condition of the insured person requires the use of qualified rescue equipment. Patient transport and travel remain possible even in the event of relocation.

The draft also provides for an additional payment for patients of full age. As in the past, return transports to Germany are not covered.

Patient transport and patient journeys

The transport of sick persons and journeys to sick persons can be found in § 60a SGB V-E. The main difference between the two types of transport is still the lack of medical care for sick people.

Patient journeys are defined in § 60a Abs. 3 SGB V. If the insured person needs – as before – during the journey a professional care or the special equipment of a patient transport vehicle or if their necessity is to be expected due to their condition, then on the other hand a patient transport is present. Patient transport to outpatient facilities requires the advance approval of the health insurance company.

It is also made clear that repatriations abroad are not covered by statutory health insurance.

Change of the guarantee order

The guarantee order of § 75 Para. 1 SGB V shall no longer include, in addition to emergency medical care, outpatient medical care during consultation hours (emergency services). The federal states may, however, lay down different regulations and extend the guarantee mandate to these services.

Competence of the GBA to issue guidelines

The GBA should continue to be allowed to issue guidelines for the transport of sick persons and journeys as well as for medical emergency rescue and integrated emergency centres. The federal states are to retain the right to apply for and participate in consultations.

Contracts for the provision of services

Emergency medical care

§ Section 133 SGB V-E provides for future regulations concerning contracts for the provision of services. For the medical emergency supply on site and for the rescue journey flat rates are intended in each case. An independent accounting should be possible. In the future, this will mean two separate calculations: Emergency care and travel costs.

The costs are essentially calculated according to the operating costs. Investment and holding costs are not included, in particular not the construction of rescue stations or the central stations of the ground-based rescue service as well as the mountain and water rescue service or the establishment of air rescue centres.

Supply with patient transport and patient journeys

According to the draft, the provision of patient transport and travel should be regulated in § 133a SGB V-E. This is a concise provision:

“The regional associations of the health insurance funds and the substitute insurance funds jointly and uniformly conclude contracts with the competent state authorities or the appropriate institutions or companies on the remuneration of the services of the health insurance funds.
Patient transport and patient journeys. § 71 shall be taken into account.”

Integrated emergency centres (INZ)

Integrated emergency centres (INCs) will be created for hospitals – at least if the draft goes as far as it goes. § 123 SGB V-E contains the appropriate regulations for this, including a definition.

Definition of integrated emergency centres

For example, § 123 (1) sentence 1 SGB V-E also contains a definition of integrated emergency centres:

“Integrated emergency centres, as central, always accessible contact points for emergency care, provide a qualified and standardised initial assessment of the medical care needs of those seeking assistance on the basis of the nationwide procedure in accordance with paragraph 3, as well as the necessary initial medical care.

Part of SHI-accredited physician care

Integrated emergency centres are entitled to provide outpatient medical emergency care in accordance with the provisions of SHI-accredited physicians. They provide outpatient on-call service, unless national law provides otherwise.

According to § 6 Para. 1 of the German Hospital Financing Act (Krankenhausfinanzierungsgesetz-E), hospital planning also includes determining the locations of integrated emergency centres.

Independent facilities

The Integrated Emergency Centres shall be independent institutions under independent professional management. They should be separated from the hospitals in terms of space and economy. The hospitals are operated jointly with the respective Association of Statutory Health Insurance Physicians.

For the hospitals concerned, this should lead to a one-off expenditure of a maximum of 13,500 euros each for the agreement of the cooperation contracts with the Kassenärztliche Vereinigungen (Association of Statutory Health Insurance Physicians).

Reductions in emergency admissions

The draft provides for a reduction of 50% of the remuneration for outpatient medical emergency services provided in a hospital in accordance with § 76 (1) sentence 2 SGB V if these do not operate integrated emergency centres (INCs), § 120 (1) sentence 2 SGB V-E. The control takes place thereby increasingly over the emergency centers.
Competence of the GBA to issue guidelines

Policy competence of the GBA

The Joint Federal Committee is to create guidelines on specifications and quality requirements for the provision of services in integrated emergency centres. These should also include specifications on the spatial, personnel and equipment equipment of integrated emergency centres, as well as specifications on the implementation of a qualified and standardised initial assessment and on the scope of primary care.

Joint Emergency Control Centres (GNL)

The federal states are to create so-called joint emergency control centres with the participation of the associations of statutory health insurance physicians. The law prescribes binding cooperation between the telephone numbers 112 (fire brigade and rescue service) and 116 117 (on-call medical service). If necessary, telemedical structures can be added to the services offered.

133b SGB V-E contains regulations on emergency control centres.

Services of the emergency control centres

According to the draft, joint emergency control centres should provide medical emergency rescue services, as well as outreach medical care and scheduling in the integrated emergency centres. They are to furnish even – and that is also a small highlight – own medical achievements for the switching of assistance-looking for, § 133b exp. 1 sentence 2 SGB V-E.

Medical achievement of the control center

Something hidden in the 2nd half sentence of § 133b Abs. 1 Satz 2 SGB V-E is a novelty. The emergency control centers are to furnish medical achievements. This medical achievement of the control centers covers

  • Placement of those seeking help in the care structure offered, and
  • in individual cases, the medically necessary transfer of the performance of medical activities directly to the emergency paramedics and paramedics at the emergency location.

In addition, they can offer digital support services for those seeking help in medical emergencies.

Structure of the GNL

The Joint Emergency Control Centre is designed as an organisational and technical, in particular digital, but not necessarily spatial connection of control centres and appointment service centres. The operators should jointly establish a qualified, standardised and software-supported initial assessment procedure for assistance requests. The operators should jointly determine the care to be provided and the details of the personnel and technical equipment.

Digital rescue service

At numerous points, the design is pervaded by the establishment of digital structures. Among other things, § 133b para. 3 SGB V provides for the interactive use of digital documentation between the Joint Emergency Control Centre, medical emergency rescue service providers and the Integrated Emergency Centres. The supply capacities of the rescue equipment, but also those of the on-call service, the integrated emergency centres and hospitals are to be transmitted in real time.

Digital networking is to take place nationwide.

I eagerly await the discussions on this draft.

(Translated with www.DeepL.com/Translator)