[Case management and expert assessment of work disability]. / Fallmanagement und Begutachtung bei Arbeitsunfähigkeit.

More than 3 years ago the MDK in Bavaria established a new way of handling medical expertising concerning incapacitation for work. Until that time the physical examination of the patient was seen as an indispensable condition for the statement of capacitation for work. All former efforts to qualify the consultations together with the staff of the institutions of the social health insurance served the purpose of preparing and improving this physical examination oft the patient.--The new bavarian way here presented tried from the beginning to make those examinations unnecessary by improving the cooperation and communication with the treating physicians.

[Expert assessment of work disability--do we realize the effects?]. / AU-Begutachtung--Wissen wir eigentlich, was wir bewirken?

Three inquiries on the results of medical expertises concerning incapacitation for work in cases where employers had doubted this fact, seem to establish that the Medical Service of the Social Health Insurance (MDK) is quite capable of keeping improper use of the epithet "unfit for work" in check. If the design of the studies is critically analysed, it becomes evident that most problems are still unsolved. More clarity regarding the sense or nonsense of this work-intensive topic may result from a carefully and completely planned randomised trial. Such a study appears mandatory, the more so since the economic benefit of the expertises does not seem to be very bright, taking several hypotheses into consideration.

[Mortality and nursing home admission of severely disabled patients]. / Sterblichkeit und Heimeinweisung bei Schwerpflegebedürftigen.

242 people had been interviewed 1-4 years (average 2 years) after first receiving benefits because of urgent need of nursing care. Meanwhile 57 persons had died at home. 17 persons had moved into a nursing home, and 8 of them had died there. For another two persons transfer to a nursing home was imminent. -Among those older than 60 years the probability of dying at home is more than three times greater than the risk of changeover to a nursing home. The highest transferrat to a nursing home (more than 18% within the observation period) was seen in women of 80 years of age and older.

[Excess mortality of severely handicapped patients in mandatory health insurance]. / Ubersterblichkeit bei Schwerpflegefällen der gesetzlichen Krankenversicherung.

The introduction of compulsory long term care insurance as of 1.1. 1995 has temporarily brought to an end a whole range of controversial discussions, which have been strongly coloured by party political interests. The originally planned expenditure figure of at least DM 30 billion represents an enormous outlay in these time of economic recession. It is already abundantly clear that the premium payments will not be sufficient in the long run, nor will it be possible to increase these premiums arbitrarily. This therefore elicits the question as to whether it is possible to calculate in advance the cost of treatment for those "in serious need of nursing care" on the basis of various factors such as age, sex, underlying illness, therapy and social integration. Up to now, there has been very little statistical analysis of these parameters. For this reason, the company MDK has carried out a preliminary survey (which so far has only looked at a limited number of cases) in order to obtain a general idea of the variations in the period required for long term care. This survey has shown that there are two main groups of cases requiring care, which can be differently assessed on the basis of age and sex. On the one hand, there are those in serious need of nursing care, who, due to a life-threatening disease or as a result of an acute deterioration of an existing chronic condition (e.g. severe KHK, cirrhosis of the liver, decompensated renal insufficiency) die a relatively short time after the application for care is made.(ABSTRACT TRUNCATED AT 250 WORDS)

["The same disease"--a problematic legal concept]. / "Dieselbe Krankheit"--ein problematischer Rechtsbegriff.

The legal concept "the same disease" according to a clause in the German Social Code, is questioned as a problematic one. This is compared with the broad interpretation of this concept in actual practice by those specialists who are engaged in expertising concerning limitation of claims by insured persons for compensation payment, since legal interpretations may reduce the possibilities of the statutory insurance body to reject such claims or to declare that no further payments will be made. This article has been written to stimulate a conceptional clarification and greater uniformity in expertising.

[Need for nursing care--severely disabled patients. Problems in determining disability prerequisites in legal health insurance]. / Pflegebedürftig--Schwerpflegebedürftig. Probleme bei der Feststellung der Leistungsvoraussetzungen in der gesetzlichen Krankenversicherung.

The report describes the legal and administrative regulations concerning the medical examination of the new Leistungstatbestand "Schwerpflegebedürftigkeit" (i.e. a situation characterized by "urgent need of nursing care"). The numbers of applicants and the results of the medical examinations during the period 1989-1992 are also reported. The main difficulties consist in clarifying the meaning of some important legal terms and the relatively vague formulations of the administrative guidelines. Another important aspect is seen in the fact that the result of the medical examination is largely dependent on the informations supplied by the patients or their relatives. Two case reports are presented for the purpose of demonstrating these difficulties. Finally short reports of the first few judgements regarding the definition of situations with "urgent need of care" by different social-courts of appeal are presented.

[Assessment of risk factors and their modification in rehabilitation applicants]. / Risikobelastung und deren Anderung bei Reha-Antragstellern.

Compared with the general population male workers applying for medical rehabilitation show a higher risk-load, especially regarding smoking and alcohol consumption. However, at present it can't be decided, if the risk-load within this group of applicants is even higher than among the non-applying workmen. Such a selection would be intended. Overweight is the main risk-factor among applicants for medical rehabilitation. It is present far more often than generally within the general population and even within the working class. Male workers with repeated courses of medical rehabilitation exhibit a significant lower risk-load than applicants for a first rehabilitative procedure. A causal relation might be suggested, but at present other explanations regarding the observed relationship have to be considered. A long-term Follow-up study is necessary.

[Need for intensive disability care. Part 3: Classification of nursing care stages--relation to time requirements]. / Schwerpflegebedürftigkeit. Teil 3: Einteilung der Pflegestufen--Orientierung am Zeitbedarf.

The proviso "a requirement for constant intensive care" in almost all "care-requirement situations" is an extremely strict criterion. It may even exclude some people with an extremely urgent need of care--for example if some of these situations completely fail to apply. In practice, a less strict criterion needs to be applied if the intended sociopolitical aims are to be achieved. On the basis of our experience of the actual situation presenting, orientation to the time-requirement for the services needed in the individual case is recommended as the basis for an assessment of Schwerpflegebedürftigkeit. A minimum requirement of a daily "bodily" care need of about two hours would appear to be necessary. However, an analysis of time requirement must be supplemented by an evaluation of the overall situation.

[Eligibility for intensive nursing care. Part 1: Guidelines and current experience]. / Schwerpflegebedürftigkeit. Teil 1: Richtlinien und bisherige Erfahrungen.

Against the background of the planned statutory Pflegeversicherung (insurance for nursing care) in Germany, a report is presented on experience gained to date with the new Leistungsbestand "Schwerpflegebedürftigkeit" (situation requiring social benefit "urgent need of nursing care") (Para. 53 ff. SGB V). The experience gained so far is of particular interest since, for the first time on a large scale, monetäre Erstattungsleistung (the provision of a monetary entitlement) replaces the Sachleistungsprinzip (benefit in the form of services) that is otherwise applied in the area of health insurance. It is intended that this form of entitlement will form the core of the planned nursing care insurance scheme.

[Severe disability. Part 2: The difficult comparison with same age probands]. / Schwerpflegebedürftigkeit. Teil 2: Der schwierige Vergleich mit den Gleichaltrigen.

With their texts on Schwerpflegebedürftigkeit, the legislators have set the interpreters of legal texts a difficult task. In practice, attempts by the "users" of such texts to find solutions inexorably lead to aporias. Responsible for decision-taking is the health insurance carrier, with the physician exclusively acting as a counsellor on the medical aspects. The advised comparisons with persons of identical age with the intention of establishing Schwerpflegebedürftigkeit is not required by the legislator, and it is not easy to see what sense it is supposed to make. The corresponding guidelines drawn up by the leading associations are not unequivocal and are therefore open to misunderstanding.

[Duration of work incapacity before and after inpatient therapeutic procedures]. / Arbeitsunfähigkeitstage vor und nach stationären Heilverfahren.

An analysis has been made of days off work prior to and following a course of treatment in clinics for rehabilitation. A comparison of pre-treatment and after-treatment three-year periods revealed a small decrease of 8 days (9.2%). The youngest age group had the most time off work and--measured in terms of days off work--also the greatest response to treatment. Also after post-hospital rehabilitative treatment clear, though not statistically significant, reductions in the number of days off work were observed. The most striking changes were seen when (only) total number of working days lost prior to the course of treatment was recorded: in the case of high pre-treatment figures for working days lost, a considerable decrease was subsequently observed, while in the case of low working days lost figures, a marked increase in days off occurred. With respect to some of the groups participating, the methodological approach we employed did not make it appear probable that (measured in terms of total working days lost) these groups were "more pathological". It must be pointed out that these results were obtained in relatively small groups; it was not possible to extend the investigation.

[Health resorts--dissatisfaction with health resorts]. / Kurwesen--Kurunwesen.

An efficient medical rehabilitation is an important part of a modern health care system. There should be no doubts about its necessity. The medical rehabilitative system in Germany however, as it is organized by the sick-insurances and the annuity-insurances, does not fulfil all the claims urgently required. Much criticism seems really correct: the missing scientific basis of rehabilitation, the poor flexibility around the administrative procedures of application and performance, which is inadequate to medical needs, the nearly total absence of any negative selective criteria on the one hand and the huge problems in finding out those persons badly needing rehabilitative measures on the other, and last not least the uncertainty regarding the real economic benefits of the total enterprise of rehabilitation as it is actually practised.