BApK

Bundesverband der Angehörigen psychisch erkrankter Menschen e.V.

Statement

Status: 14.06.2016

Statement by the German Federal Association of Relatives of the Mentally Ill (BApK) on the draft of a law for the advancement of care and reimbursement for psychiatric and psychosomatic services (Draft Bill - PsychVVG)

The BApK is a self-help association founded over 30 years ago which campaigns for the needs of mentally ill persons and their families. This includes not only political campaigning but also educating through publicity work in order to dispel false impressions and stigmas.

Under the umbrella of the Federal Association there are 15 regional associations with over 7000 members and over 500 self-help groups.

General Evaluation

The German Ministry of Health has presented a draft of a law for the advancement of care and reimbursement for psychiatric and psychosomatic services – PsychVVG. With this draft the German government is responding to the demands of scientific specialist associations, numerous associations from the fields of psychiatry and psychosomatics, associations of sufferers and the charitable welfare organisation “Freie Wohlfahrtspflege”. The umbrella welfare association “Paritätische” together with its members (which include the BApK) has also opposed from the outset the idea of a flat-rate reimbursement system for psychiatry and psychosomatics (known as PEPP) and actively supports the broad-based civic alliance “Weg mit PEPP” (“Abolish the PEPP”) in its demands.

The BApK welcomes the political will to advance the psychiatric support system but sees in many of the proposed new legal provisions unresolved issues and a need for improvement.

Central points for a positive advancement of psychiatric and psychosomatic care are, for the BApK, the intensification of cross-sector care and actual improvements in the care of persons suffering severe and chronic mental illness. Whether or not this draft bill will prove to be a PEPP system dressed up in a new legal framework, so that its implementation leads to a deterioration in the care of the mentally ill, cannot be judged definitively at this time.

But the decisive issue is this: People suffering mental illness need a support and care system that takes adequate account of the special circumstances of their illnesses and their living situations. The flat-rate reimbursement system for psychiatry and psychosomatics (PEPP) did not prove suitable because it set the wrong economic incentives and did not ensure care and treatment of the mentally ill which respected their human dignity. Specialist professional associations of psychiatry and psychosomatics have therefore presented a concrete alternative concept for a future reimbursement system.

The Federal Ministry of Health has now submitted a new draft law for the advancement of care and reimbursement in the psychiatric and psychosomatic sector which contains mainly the following major changes:

1.    Expansion of the options for outpatient treatment for psychiatric and psychosomatic clinics by way of hospital-equivalent “home treatment”,

2.    Introduction of a hospital-specific budget system instead of fixed prices with comprehensive control and negotiation options for the health insurers

3.    Binding introduction of the psych reimbursement system for all facilities, but no longer as a price system and no extension of the option phase,

4.    Provisions on minimum staffing levels for psychiatric and psychosomatic clinics and departments.

Statement of the BApK

On 1. Hospital-equivalent treatment / Home treatment

The option of psychiatric treatment in a domestic setting is to be seen as positive. However, relatives are asking what additional responsibility they will have to assume on account of the home treatment? There is a strong impression of a shift of responsibility to the family. If residential treatment is replaced by home treatment relatives must be consulted and involved. There must be binding support services in place for the families affected. These represent a profound relief for relatives and the hope of long-term improvement in their domestic situation and the living situation of their mentally ill relative.

The BApK points out that the mentally ill person remaining in the domestic setting could result in the following burdens on the family:

 

  • Confrontation with all the critical symptoms which a mentally ill person can develop in acute phases of their condition (running away, suicidal tendencies, aggression, fear of being poisoned, delusional actions, resumption of alcohol abuse, etc.),
  • Lack of clarity on legal aspects, particularly in the case of initially unrecognised danger to the patient and others, at what point must I intervene?
  • Relatives have been convicted for failure to render assistance in the past. The BApK demands an expert legal opinion on the question of home treatment in the case of “problem patients”. Who bears legal responsibility? The patient? The relative? The hospital physician? The GP? The specialist?
  • It is essential that a “domestic care allowance” (+pension insurance) is paid when the need for treatment has been established by a physician. The costs in terms of time and money are high.
  • Minimum levels of contact and minimum staff presence / qualifications should be established for the home treatment sector.
  • What will be the future role of the German Health Insurance Medical Service (MDK)?
  • There must be a right to choose. Only if the patient and the relatives/partner/persons living in the household who will be providing the care are in agreement can home treatment take place. If the relative feels unable to cope (dangerous care) a hospital physician must be able to assess the need for inpatient treatment at any time and hospitalise the patient at any time.

On 2. Hospital-specific budget system instead of fixed prices

The BApK has no comment on a budget system instead of fixed prices.

On 3. Introduction of the Psych Reimbursement System

The BApK is critical of retaining the PEPP system as the basis for calculation. Even if this is no longer to be used as a price system, there is still a need for improvement, the catalogue of reimbursements must be expanded, above all in the field of cross-sector care and care gaps for severely mentally ill persons must be closed.

On 4. Calculation of minimum staffing level

The Psychiatry Staffing Regulation (Psych-PV) is valid up to the end of 2019. From 2020 there are to be binding minimum requirements for professional staffing levels, established by the Federal Joint Committee (G-BA). These are to be a component of the quality assurance and if possible set out in guidelines based on evidence.

The BApK welcomes this new regulation. The observance of minimum requirements for the levels of therapeutic staff must be binding and given top priority.

Summary

In summary it can be established that the draft bill or its legal provisions on the advancement of care and reimbursement for psychiatric and psychosomatic services contains some improvements in comparison to the old PEPP system.

With the proviso that relatives are consulted and agree voluntarily, the BApK welcomes the fact that

  • a hospital-equivalent psychiatric treatment is to be introduced,
  • the G-BA must by 2019 establish minimum requirements for the numbers of therapeutic staff in inpatient facilities needed for treatment,
  • the clinics must verify implementation of the Psychiatry Staffing Regulation (Psych-PV) and later compliance with the minimum requirements for therapeutic staff.

If psychiatric clinics and specialist departments are to be supported in their function as a component of community-based care, this will require more efficient dovetailing  of hospital and other services for the mentally ill than is currently the case. In particular involvement of the relatives must be considered. This requirement is not given adequate consideration in this draft.

Furthermore, the BApK finds that the involvement of relatives is lacking. Relatives take part in conversations between sufferers and psychiatric care specialists on an equal footing. Therefore it would be desirable to recognise and involve relatives as experts.