Between consistency and flexibility

Abstract

Based on the provisions of SGB V, evidence-based medicine (EBM) forms the basis for the work of the Federal Joint Committee (G-BA) and the Institute for Quality and Efficiency in Health Care (IQWiG) in their medical assessments and decisions on the specification of care content such as disease management programmes (DMP) and the services to be financed by the statutory health insurance (SHI). The evaluation of available evidence is thus directly linked to pricing, reimbursement and also to care management. Greater flexibility in dealing with the evidence requirements has been exercised in the past, but without consistency and certainly also when a lowering of the requirement level led to a financial advantage for the statutory health insurance (SHI). At the same time, there are also examples in which the clinical relevance of an intervention was so obvious that the G-BA used its room for manoeuvre in the interests of healthcare.