German pain doctors are complaining that the application and approvals process for insurance reimbursement is too complicated – and in response have just launched a trial program in Hamburg to expedite the same
There is a saying aus Deutschland that complaining (about anything) is a national pastime. This is even more true when talking about domestic bureaucracy. That and the weather are the two top peeves of Germans, generally.
A lot of this complaining occurs about things that cannot be changed, or do not seem possible to change easily. When it comes to cannabis approvals specifically, however, it is getting increasingly clear that the current system is unworkable and as a result must be changed, simply because it is too complex, costly, and takes too much time.
That awareness at this point is thankfully not just limited to patients.
The good news, in fact, is that awareness of the need to change the status quo is rapidly taking hold in several places in Germany right now, a country where recreational cannabis reform is now clearly in the cards if not on a set schedule. Even national politicians are saying publicly that cannabis patients are caught in a terrible bind right now.
Pain Doctors Take the Initiative
In a new and very positive development, however, that complaint has now begun to infiltrate the public statements of specialist doctors on the front lines of this discussion from the bureaucratic side. Last week, in a highly revealing (if not positive) online press conference, reported in a leading German medical journal, Aerzeblatt.de, Johannes Horlemann, President of the German Society for Pain Medicine (DGS), has called for the process of approvals to be changed – and expedited.
To that end, the DGS has just concluded a select contract with AOK – one of the largest statutory insurers in the country, on a state level in Rheinland/Hamburg – to roll out a new kind of approvals process. This will be used by the North Rhine Association of Statutory Health Insurance Physicians going forward.
Here is the great news. The therapy decision will lie exclusively with the attending physician – not with the insurers or regional health approvals agency.
To apply, doctors must complete a 20-hour training course.
This is a huge development, even though limited to one state and one insurer for now.
What Faces Patients Now
According to the most recent German government figures (from BfArM), there are about 46,000 German cannabis patients who receive compensated medical cannabis (in other words are publicly insured). This figure is about a quarter of what has been widely reported in the industry press to date. Of 70,000 applications for compensation, two-thirds have been approved – although many analysts believe the refusal rate is closer to 50%. The delta between these patients and what is being reported as total patients (which is as much as 130,000) could be a combination of faulty accounting, difficulties in tracking longer-term patients vs written prescriptions, and, albeit a fairly minimal number, the private paying community. Keep in mind that anyone who pays for their cannabis out of pocket is facing costs of between 600-1,000 euros a month, plus the doctor’s visit.
For those who must rely on reimbursement to get their medicine, simply because they cannot afford the alternative, the average processing time for the application takes about five weeks -but that is only when things go well. In a contested situation, which is the norm, such approvals can take months (or years). This is why so many patients are finding ways to sue their insurer.
Per Horlemann, “This treatment of seriously ill people is inhumane,” he said.
Norbert Schürmann, the VP of DGS added that “processing times also depend on the respective health insurance company, the medical service of the health insurance companies and the clerk.” He added that the health insurance funds do not have to make priority decisions based on the severity of a patient’s illness. There is no accelerated track.
Tragically, this situation remains almost uncovered in the industry press for one reason. The largest cannabis firms who are either in or want to be in this market, want the numbers to be as high as possible – but so far have committed few resources to create an effective lobby to change the status quo. Not to mention have a vested interest in keeping the costs as high as possible to make their margins.
How Could Patient Suffering Be Alleviated?
While the DGS believes that oral therapies are more cost-effective than flowers because of their half life and ability to control dosing, this call for a revised approval process from specialist doctors is a very positive sign – particularly coming several months before the German government is expected to unveil draft recreational cannabis reform legislation.
Here is why.
The legislation to create a recreational cannabis market could well also move medical cannabis from a drug of last resort into a more normalized medicine class. This would mean that instead of normally having to go through specialist doctors, even though it is not currently required, regular practitioners would feel safer in prescribing the drug. And further, like other generics medications, patients could obtain direct, unapproved prescriptions that they could redeem at local pharmacies for five euro (or less). Just like other normalized, bulk purchased pharmaceutical products.
Beyond this? There is a realization, even at the federal political level in Germany that the current system is failing patients – and further that it cannot be easily tweaked because it is in place to help keep overall drug costs low. This is one of the strongest reasons so far for creating a separate home grow allowance for patients who receive a doctor’s approval for cannabis consumption. Not to mention creating at least one drug class, even if it is a generic form of cannabinoid extract like dronabinol or lower cost GMP flowers – that would be accessible via this route.
One thing is for sure. When pain specialists talk openly about how much of a pain the procedure to get medical cannabis is and are further motivated to create a change in said procedure, this makes an impact, if not a splash.
Even in a system where such bureaucratic hurdles have been created either by design or default.