From the point of view of aligner orthodontics, its users and patients, the following comments are made on the proposed legislation. The focus is on the fact that aligner orthodontics is a "new" procedure within the meaning of Section 6 (2) GOZ, which was only used in the Federal Republic of Germany in 2001, ie after the valid GOZ came into force on October 22.10.1987, 2006 , has reached maturity and has been recognized as conventional medicine since 1,5 at the latest. It is considered to be one of the best-documented dental procedures, with which around XNUMX million patients have been treated to date. In contrast to the conventional multi-band treatment (“brackets”), this procedure is only covered insufficiently and unclearly in the draft. A modification of the referent-E therefore seems urgently necessary.
First of all, it should be noted that the current version of the GOZ does not contain any regulations on billing for aligner orthodontics. With regard to the dental fee in the context of orthodontic treatment, the submitted referent E only provides for a single textual insertion according to GOZ 6080 old version with the following wording:
"The measures within the meaning of numbers 6030 to 6080 include all services for jaw reshaping and retention or for adjusting the lower jaw to the normal bite, regardless of the treatment methods used (e.g. insertion, activation and / or removal of loops, arches, attachments for aligners or fixed ones retainer) or the therapy devices used (e.g. also plastic splints).”
Otherwise, the planned changes and additions to section G. are editorial changes or clarifications on the billing of material and laboratory costs for orthodontic treatment.
I. New regulation or explanation of the existing
It therefore remains unclear - especially taking into account the reasoning of the referent E - whether the legislature intends to regulate by inserting the text passage according to Item 6080 old or only to clarify. The latter is supported by the wording in the justification of the draft bill that the (known) service content of numbers 6030 to 6080 is "described in more detail", i.e. the legislature only explains the existing regulations without wanting to change the content of the regulation itself. This is also supported by the fact that the legislature in section G. refrains from changing the text of the service items themselves, adding them or inserting new service numbers. Such changes to the GOZ service items relate to the area of prophylactic, conservative and implantological services in the referent E, while in the area of orthodontic services a regulatory intention is only recognizable with regard to the agreement of additional costs. Furthermore, the only further textual addition according to 6160 (on the material and laboratory costs included in the fee) also contains merely clarifying content without any regulatory content.
The payers will tend to understand the questionable wording of the draft bill as a regulation that justifies no longer reimbursement for the insertion of attachments for aligners in the analogous application of item 6100 in the future. The analog accounting of the attachment of attachments according to the integration of an adhesive bracket according to item 610 GOZ is currently common practice, which has been confirmed by expertly advised, consistent case law. This billing practice would in future be objected to by payers. Since the use of plastic attachments is necessary for practically every treatment with aligner splints and represents a special service in its own right, a significant part of the expenses associated with aligner therapy would simply no longer be billable in the future.
It seems questionable whether the authors of the draft, who only wanted to describe the service content of the existing service items, were aware of the effect that cost bearers are claiming the questionable formulation as a billing block for essential treatment features not only for the new aligner therapy could. Based on the justification of the draft bill, the assumption is more likely that a regulatory effect in the sense of a billing block for the newly developed aligner procedure was not intended and that the possible regulatory effect of his explanations remained hidden from the legislator. In this respect, it would be necessary to delete the words "attachments for aligners" in the draft. This should also apply to all other lists listed here (insertion, activation and / or removal of loops, arches or fixed retainers) that contribute to the misunderstanding in the same way.
II. Inadequate regulation of aligner orthodontics
The draft bill does not implement the mandate contained in the coalition agreement to adapt the fee schedule for dentists (GOZ) to the state of the art and to take cost developments into account." This target, formulated as a political postulate, also results directly from the statutory regulation of 6 GOZ, according to which newly developed and practiced treatment approaches are to be accounted for by a corresponding application of the existing GOZ service items. At the same time, the legislature is obliged to adapt the billing provisions to scientific and dental progress when there are amendments to the law (as was done, for example, with the introduction of item 900 after dental implantology had emancipated itself as part of conventional medicine).
Merely through the single mention of the aligner treatment device in an exemplary list, in addition in a parenthesis and outside of a specific billing item, it cannot be assumed that the treatment approach as such has been recorded and included by the legislator at all. With regard to the future billing of aligner orthodontics, the draft bill creates ambiguity as to whether the previous analog billing will continue to apply or even whether the fact that this treatment approach has not been taken into account in an independent service item suggests that these orthodontic measures will be included in the future (in the absence of an explicit regulation) cannot be billed either directly or analogously.
III. no need for regulation for the fragmentary regulation that has taken place
There was no need for regulation for the insertion according to item 6080 old version. In its explanatory statement, the ministerial draft explains that the insertion was made "in order to avoid ambiguities that have arisen in practice". Such ambiguities may have arisen when billing the other treatment approaches mentioned. For the billing of an aligner treatment, it has been clarified since 2006 at the latest that it is an established, new procedure that is to be billed in analogous application of the GOZ. On this basis, a billing practice was consolidated, the contours of which were made more precise by case law. The ambiguities addressed in the justification for the draft bill therefore do not relate to aligner orthodontics.
The cost aspects addressed in the coalition agreement also do not require the addition mentioned: Orthodontic therapy with aligners does not regularly result in higher costs than treatment with conventional brackets. It should be emphasized that this applies even if the insertion of the attachments – as is currently the case – is billed in accordance with item 610 GOZ. Thus, these treatment costs of the aligner treatment for minors were regarded by case law as necessary and economically reasonable expenses within the meaning of Section 6 (1) of the Federal Subsidy Ordinance. Ultimately, the aligner procedure also meets the performance requirements of statutory health insurance in accordance with Section 28 (2) sentence 5 SGB V from an economic point of view.
IV. Undesirable Regulatory Effects
Finally, regulatory effects are to be expected that are not supported by the objectives of the draft bill, but run counter to them:
The implementation of the draft would mean that the innovative aligner procedure would be worse off from a billing point of view than conventional multi-band treatment ("brackets"). To clarify the economic adequacy of the aligner procedure, the aid agencies and the administrative courts compared the costs of both treatment approaches, which proved that there was no difference in cost between the two procedures, under the previously valid premise that the gluing of the brackets or the Attachments can be billed in both cost variants via GOZ 610. If this billing would be closed to the users of the aligner procedure in the future, the legislature would have set fee incentives at the expense of the innovative procedure. This would not be compatible with his intention to adequately integrate innovative methods into the billing system.
Furthermore, the regulatory objective of the draft, to prevent double billing by emphasizing the target performance principle, would be missed. As the cost comparison just shows, the emancipation of the innovative aligner procedure on the market has led to a cost alignment with the conventional multi-band procedure. As far as the aligner procedure is concerned, undesired double billing has neither become known nor is it to be feared, so that this regulatory objective cannot justify the insertion in question either. On the contrary, it even appears to be contrary to the system that the legislature influences the method competition through the subsequent design of the service items.
V. Proposed Amendment
From the point of view of aligner orthodontics, its users and patients, the draft bill presented is a fragmentary, ambiguous regulatory torso. The greatest clarity would be achieved if aligner orthodontics were not addressed at all (by deleting the words "attachments for aligners") and the previous and secure legal situation remained.
Furthermore, the deletion of the general provision before item 6000 GOZ on the compensated standard materials is suggested. Such an additional cost regulation is a breach of the system in the law of private liquidation and neither promotes the transparency of the settlement nor does it result in increased consumer protection. Above all, cost bearers will in future want to limit reimbursement to the cheapest materials in each case, which does not take into account the principle that privately insured patients should be able to choose freely between several therapy options even if there is a difference in costs.
