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Revi­si­on of the KVG: pro­po­sal to amend Art. 56 and 84 KVG – infor­ma­ti­on for insu­red per­sons by the basic insurer

In the cur­rent busi­ness on the “Amend­ment of the KVG con­cer­ning cost con­tain­ment mea­su­res – Packa­ge 2” (Busi­ness No. 22.062), the Natio­nal Coun­cil will dis­cuss a num­ber of adjust­ments to the KVG in the 2023 fall ses­si­on (Sep­tem­ber 11 – 29) (cf. the Mes­sa­ge from 7 Sep­tem­ber 2022).

On August 31, 2023, the majo­ri­ty of the Natio­nal Council’s Com­mit­tee for Social Secu­ri­ty and Health (SGK‑N) made an inte­re­st­ing pro­po­sal for the atten­ti­on of the NR in con­nec­tion with the effi­ci­en­cy requi­re­ment (Art. 56 KVG) (cf. the Flag 2023 III N1 D).

Art. 56 shall be repla­ced by a new para­graph 1bis be supplemented:

1bis In order to ensu­re the mea­su­res pur­su­ant to para­graph 1 [“The ser­vice pro­vi­der must limit its ser­vices to the ext­ent that is in the inte­rest of the insu­red per­son and neces­sa­ry for the pur­po­se of tre­at­ment.”], the insu­r­ers may allow the per­sons insu­red with them to inform indi­vi­du­al­ly about the ser­vices they recei­ve, about mea­su­res to pre­vent ill­nesses and about offers aimed at impro­ving the effi­ci­en­cy and coor­di­na­ti­on of the pro­vi­si­on of medi­cal ser­vices, and, with their con­sent, the Ser­vice pro­vi­ders Pro­vi­de infor­ma­ti­on on the bene­fits recei­ved by the insured.

Accor­din­gly, also Art. 84 KVG (pro­ce­s­sing of per­so­nal data) must be sup­ple­men­ted (“The bodies ent­ru­sted with the imple­men­ta­ti­on, con­trol or super­vi­si­on of the imple­men­ta­ti­on of this Act or the KVAG are aut­ho­ri­zed to pro­cess or have pro­ce­s­sed the per­so­nal data, inclu­ding data requi­ring spe­cial pro­tec­tion and per­so­na­li­ty pro­files, that they need in order to per­form the tasks assi­gned to them under this Act or the KVAG, name­ly to: […]”):

j. mea­su­res in accordance with Artic­le 56 para­graph 1bis and to pro­vi­de cor­re­spon­ding information.

This would pro­vi­de the legal basis for health insu­r­ers in the man­da­to­ry sec­tor (OKP) to pro­cess per­so­nal and non-per­so­nal data in order to To advi­se basic insu­red per­sons. Via Art. 84 lit. j KVG, the acqui­si­ti­on of data from sup­ple­men­ta­ry insu­rance would also be per­mit­ted, becau­se the acqui­si­ti­on of per­so­nal data is also pro­ce­s­sing; it would the­r­e­fo­re also be pos­si­ble to link such data (but only in one direc­tion, i.e. not also a dis­clo­sure of OKP data to sup­ple­men­ta­ry insu­rance) – at least as long as no pro­fil­ing takes place (becau­se a for­mal legal basis would be requi­red for this).

It is a long-stan­ding con­cern of health insu­r­ers to be allo­wed to use data to advi­se insu­reds and influence their beha­vi­or. It can cla­im to take into account the real situa­ti­on, name­ly the fact that basic insu­r­ers have more and qua­li­ta­tively bet­ter data at their dis­po­sal than is gene­ral­ly the case for ser­vice pro­vi­ders (Lerbs), espe­ci­al­ly sin­ce data from seve­ral Lerbs con­ver­ge at the health insurer. The fact that health insu­r­ers have an inte­rest in redu­cing ser­vices is not a pro­blem, but rather part of the solu­ti­on, espe­ci­al­ly sin­ce the actu­al gate­kee­pers – the Lerbs – are assu­med to have a ten­den­cy to be inte­re­sted in expan­ding volu­mes. Sin­ce too much tre­at­ment can be just as harmful as no tre­at­ment or the wrong tre­at­ment, some balan­cing of inte­rests in health care is not wrong. It will be up to regu­la­tors to ensu­re that health insu­r­ers use oppor­tu­ni­ties for the bene­fit of impro­ving the health of the insu­red and not to save costs as an end in itself.

Cf. also the Artic­le in the Aar­gau­er Zei­tung from Sep­tem­ber 11, 2023 “Brea­king a taboo: Hels­a­na boss wants to relax data pro­tec­tion – and inter­ve­ne in pati­ent tre­at­ment” (paywall).

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