What is the future of osteopathic medicine



1 FUTURE OF OSTEOPATHY IN GERMANY Sectoral alternative practitioner license for osteopathy as a solution? JANUARY 1 Medotrain

2 Contents Foreword Everything is one but not everyone agrees Sectoral alternative practitioner license Definitions of osteopathy Position of the German Medical Association on osteopathic procedures and manual medicine (German Medical Association, 2014) Still's definition of osteopathy In addition to the final examination analogous to the BAO examination as Sectoral alternative practitioners check for delimitation: osteopathic science

3 Published by Medotrain Verlag, Leibnizstr. 9, Kornwestheim Contact: Printing: Digitaldruck Stetter, Ludwigsburg Publisher and author: Michael Kothe MSc.Ost. DO. Cover design: Michael Kothe Lectorate: Susanne Kothe Any use of extracts without the consent of Medotrain (M. Kothe) is inadmissible and punishable. This applies in particular to copying, microfilming and saving and processing in electronic media. 1st edition: Kornwestheim, February 2016 Printed in Germany ISBN:

4 Foreword What actually ensures quality in osteopathy? Title? No. A good framework that enables a smooth process in practice. Like a body on a car. So that the engine can perform at its best. To ensure that the interaction between the engine and the body / chassis works well, there is a regular technical inspection by the TÜV. For the same reason, there are quality management systems in industry that run according to certain standards. Practices in the medical field also do this as an obligation. We osteopaths, as not yet recognized, should adapt to the system in this area so that acceptance increases! 3

5 1. Everything is one but not everyone agrees Andrew Taylor Still initially found access to the entire body through the bones. Today an osteopath also works intensively with other tissues. Initially, osteopathy was only available in the United States. We can now find osteopathy in many other countries around the world, as well as in Germany. In the beginning, osteopathy was developed by A.T. Still defined. Today the German Medical Association and the courts in Germany define osteopathy. At first, Still had treated infectious diseases. Today osteopaths are denied this competence and even forbidden. In the beginning, acute trauma patients came to the osteopaths. Today the practices are so full that the osteopaths hardly find time to treat a patient acutely. Is that the evolution of osteopathy? Is osteopathy controlled by others than osteopaths? Most professional associations in Germany spend more time, money and energy regulating osteopathy internally than finally establishing it as a separate profession. What is the point in dividing osteopathy even further into infant osteopathy, geriatric osteopathy and sports osteopathy? The increasing fragmentation with its many other certificates definitely does not ensure a uniform overall impression for the patient / end user! What kind of external image emerges when lecturers in osteopathy say in class: If you understand even 10 percent of what I am saying, then that's fine.? How should these listening osteopaths approach their patients and doctors with this knowledge and the explanations and explain osteopathy to them? If osteopathy is so aloof and unclear, how is it supposed to open up to patients and doctors? Does osteopathy even represent a platform for egomaniac self-promoters? Where is the teaching assignment? 4th

6 If a professional association's statute states that you are committed to professional recognition, why do you tolerate osteopaths in your ranks, even at high management levels, who knowingly and deliberately illegally account for osteopathy as billing fraud for physiotherapy services? Propagate this even publicly? Why can the professional associations not give a legally correct and meaningful answer to questions about accounting? Isn't that a very important point for a professional representative? Why do several leaders of the osteopathic professional policy not manage to forego power in favor of osteopathy? Perhaps the answers to these admittedly very provocative questions are quite simple. These questions are based on facts (personal experience). The solutions are also based on personal experience and common sense. I don't want to come across as know-it-all here, but I still want to offer possible solutions from my point of view. I would very much like those responsible to sit down at the table, put the ego behind and act objectively and result-oriented. Unfortunately, I especially miss the factual, result-oriented and acting. When osteopathy came to Germany about 3 decades ago, the majority of the physiotherapists were initially interested in this form of medicine. The physiotherapists were the physiotherapists in their younger years and consisted mostly of women. Often it was the doctors' wives who were supposed to do a little gymnastics with the patient. Only in the 80s and 90s due to the strong growth, for example manual therapy, did this profession offer more and more opportunities for men, including financial ones. The so-called better orthopedists, the manual therapists, who also liked to mess with orthopedists and other doctors, also come from this time. A constant dissatisfaction with the therapeutic performance in relation to the billing motivated to switch to osteopathy in addition to being able to provide even better professional help. Thus one was even closer to the doctor in terms of responsibility and knowledge and ability. Unfortunately, this conflict with doctors has remained with many. If I understood Still correctly, osteopathy saw itself as a supplement or continuation of medicine, not as a competitor! I was once denied the certification of a CMD advanced training course by an osteopathic association because I would impart osteopathic knowledge to dentists there. I was asked to include a little less osteopathy in the advertisement and the program. When I did this, the said association no longer wanted to certify the same advanced training because too little osteopathic knowledge would be imparted. How much idiocy do we need in the 5th

7 osteopathy to make contact with doctors as problematic as possible? They should understand osteopathy so that they can integrate it into their way of thinking and working. Osteopathy needs to be made public. It must be able to be explained and made understandable, also for doctors! Don't worry, the doctors who work with osteopathic techniques and believe that using a hammer will make an artist out of them will not harm osteopathy. We are freelancers. Not least because we have no standards and the diagnosis and therapy is the responsibility of everyone's creative, freelance art. We are artists - freelance. Art creates facts, can be proven. Man performs art without time pressure. Because pressure prevents creativity. Financial pressure also hampers creativity. It is the task of the responsible associations in terms of quality assurance, oh sorry I meant quality assurance! to ensure that every osteopath can produce his quality without pressure. If you add the investment costs to the living requirements (see cost calculation) with adequate, creative working hours, then an osteopath should not receive significantly less than 100 for one hour of his services to the patient! Merchants use this cost calculation to find out at what price a service / product can be offered. So that we do not fall into the tax trap and have to pay sales tax (this applies to fixed prices), we should use an osteopathic accounting schedule to invoice what we have done. Of course, in such a way that we name osteopathic diagnoses and know that osteopathy always means a whole. However, not every treatment is the same and it is best to name the structures that sought the path of freedom. The naming of dysfunctions is certainly a good way of not defining diseases and instead looking for the path to health and also naming it in the billing. In this context, it is very important to remember that osteopathy can be of benefit to many patients if it is affordable. This does not mean that we should set the price per treatment low, but rather that we should integrate this service into the healthcare system to cover partial costs. This ailing health system will not be able to fully finance the number of osteopathic treatments. With the number of citizens and the number of osteopaths, you don't have to study mathematics to know that it can't be financially viable. So if osteopathy is included in the statutory benefit catalog of the 6th

8 health insurances would be included and paid only if the price is correspondingly low or is regulated by co-payments by the patient. 1 sentence 2 SGB V: The insured are jointly responsible for their health; Through a health-conscious lifestyle, early participation in preventive health measures as well as active participation in medical treatment and rehabilitation, they should help to avoid the onset of illness and disability or to overcome their consequences. For this reason, those insured with the aid are expected to make additional payments! A low price leads to the fact that with this service no longer sufficient livelihood can be financed and is only possible if a spouse earns additional money (at least the price would no longer do justice to the training, i.e. investment) or you reduce time and thus increase the number of cycles so that the financial pressure is overcome and now the time pressure disrupts creativity. Not a desirable solution. We should therefore not rely on the current situation in which the statutory insurance companies are temporarily promoting osteopathy from other sources for marketing reasons. However, there is something positive about this situation. A grant is expressly given. This is exactly the way of the future for the supportive financing of osteopathy. We shouldn't advertise that, under certain conditions (scientific evidence), osteopathy will be completely covered by the statutory health insurance funds. This is not good for osteopathy! However, the current regulation regarding the regulation is total nonsense! According to the German Medical Association and some courts, osteopathy is considered a medicine in Germany. Now medicine cannot be prescribed and is also not required, since a medicine automatically contains a diagnosis. With this regulation, the insurance companies wanted to take into account the fact that most (approx. 94 percent) of the osteopaths working in Germany in the primary occupation are physiotherapists, and with a diagnosis, at least they cannot provide this service illegally. In return, they ask the doctor to issue a prescription for a medicine. But since this is not possible, the regulation is what? An expert opinion? However, this would be costly and subject to sales tax. Few doctors would be willing to do this. Especially since they often enough regard osteopathy as a competitor (unfortunately the behavior of many osteopaths still supports this picture). At this point you have to talk to the GKVs. If you were to pay the osteopathy explicitly on the basis of a direct first contact with the osteopath, that would be a promotion of the 7

9 External cultivation, as in Germany only a doctor or alternative practitioner is allowed to diagnose. With this fact one could now bring about a political solution. Preparing a specific change in the law, giving it strength by collecting signatures and supporting it with meaningful studies is certainly the right way to go. Unfortunately, the study situation is not sufficient. We often find insufficient numbers of cases and unrelated questions in the databases. One reason is too little money to fund these time-consuming and financial studies. As a rule, an osteopath has to support his family with his practice income. This means that there is no money left for study costs, loss of earnings or loss of leisure time and therefore no interest in carrying out large or technically and therefore financially expensive studies. Removing oneself from practice for a long time is bad for the image. A replacement costs money. Technical devices also cost money. So if you want to have good studies, the osteopathic public has to provide money and give it as a scholarship. 8th

10 2. Sectoral alternative practitioner license The alternative practitioner license is divisible, unlike the medical license granted to a doctor with a license to practice medicine. The Senate has already decided that the Heilpraktikergesetz contains neither the meaning nor the wording of a prohibition on the granting of a restricted permit. When the law came into force, there was no need for such a restriction. Since then, however, the job profiles in the medical professions have differentiated in ways that were unforeseeable at the time. The provisions of the pre-constitutional Heilpraktikergesetz must therefore be adapted to the current circumstances through interpretation in the light of the freedom of choice of occupation from Article 12, Paragraph 1 of the Basic Law. The Senate has already stated this for the field of psychotherapy; the considerations there are not limited to this, but apply in general. An unrestricted naturopathic permit with the result of a comprehensive knowledge check is not required to protect public health if an applicant wishes to practice medicine only in a definable area or only in a clearly defined form of therapy. In this case, it is sufficient to grant a permit limited to this area, as long as it is ensured that the person concerned knows and observes the limits of his ability. "(OVG Düsseldorf of June 13, 2012, 13 A 668/09) Three years later The Higher Regional Court (OLG) Düsseldorf ruled on September 8, 2015 (Az. I-20 U 236/13) that osteopathy may only be practiced by physiotherapists if they have the (unrestricted) alternative practitioner Düsseldorf any advertising with osteopathy has been forbidden with the argument that he is not allowed to practice osteopathy according to the Heilpraktikergesetz. This decision was confirmed in the next instance by the OLG Düsseldorf. The OLG states that osteopathy goes beyond the field of activity and training of physiotherapy and may only be exercised by persons with a non-medical practitioner license or by doctors, including the fact that the affected Physi otherapeut had undergone many years of osteopathic further training and worked on a medical prescription or prescription from a HP, according to the Düsseldorf Higher Regional Court, nothing would change this. In paragraph 19 of this judgment it says: There is no special legal regulation concerning osteopathy. 9

11 In paragraph 25: This ensures that the offer does not pose an indirect health risk because the patients were not prevented from visiting the doctor. From paragraph 26 it is described: It is rather the abstract danger that counts. A general statement for all osteopaths in Germany is not permissible, however, as it is justified in paragraph 33: As a purely individual decision, the case has neither fundamental significance within the meaning of 543 para. 2 No. 1 ZPO, the granting of a license to practice medicine The Naturopaths Act, limited to the field of chiropractic, may not be made dependent on a knowledge test if the applicant has a master's degree for a British chiropractic degree and corresponding professional experience. This was decided by the Frankfurt am Main Administrative Court with its judgment of (Az .: 4 K 2714/12). In 2009 the Federal Administrative Court (BVerwG 3 C 19.08) affirmed the right of a physiotherapist to be granted a non-medical practitioner license limited to the field of physiotherapy, subject to a successful, limited knowledge check. According to this, this review is subject to proportionality with regard to the required knowledge. Only skills that are related to the planned activity may be required. On the form of the review, e.g. orally or in writing, the court did not go any further. The check is the normal case here, but the competent authority must check in the context of the determination of the facts whether a check in individual cases is unnecessary on the basis of the certificates submitted. Even though this judgment is a case-by-case decision, it can be found in fundamental statements. It was confirmed again by the highest court that the naturopath permit is basically divisible. For certain professions in the health sector, this may result in the possibility of a restricted healing permit. In some federal states, as a result of the above-mentioned judgment, podiatrists were also allowed to check their knowledge to a limited extent for legal reasons. The Ministry of Social Affairs, Labor, Health and Demography of Rhineland-Palatinate sees the legal situation in exactly the same way and affirms a legal claim in the above sense to a limited review.In consultation with the Ministry for Social Affairs, Labor, Health and Demography of Rhineland-Palatinate and the State Office for Social Affairs, Youth and Care, this will take place for the first time from autumn 2013 in 10

12 Rhineland-Palatinate a review for alternative practitioners - restricted to the field of podiatry on the basis of the judgment for the sectoral alternative practitioners in physiotherapy (BVerwG 3 C 19.08). Basically, this restricted permission to practice medicine is granted if, within the scope of a review in accordance with the first implementing ordinance for the Heilpraktikergesetz, there are no indications that this poses a risk to public health. Due to state law (jurisdiction ordinance) in Rhineland-Palatinate, the health department in Mainz (today the health department of the Mainz-Bingen district administration) carries out the inspections according to the Heilpraktikergesetz. If proof of a corresponding post-qualification is provided, it is possible to issue the permit after checking the submitted documents without a personal knowledge check. This catalog of criteria compiles the essential training content that is to be conveyed in the context of post-qualification in order to meet the requirements for a decision based on the files. This catalog of criteria is therefore also suitable for developing corresponding curricula, which in Rhineland-Palatinate open up the possibility of granting permission according to the files. Recently, the occupational therapists have also achieved success. The judgment of the Administrative Court (VG) Karlsruhe gives occupational therapists the opportunity to obtain a sectoral alternative practitioner permit (judgment of, Az. 9 K 1519/13, published on). Thus there is currently the possibility in Germany of medicine in the sectors of - psychotherapy (since 1999) - physiotherapy (since 2009) - podiatry (since 2013) - occupational therapy (since 2015). The Higher Administrative Court of North Rhine-Westphalia has moved osteopathy in the direction of sectoral alternative practitioners with a judgment: 11

13 Efforts by osteopathic professional associations to standardize training or further education in osteopathy have so far not led to success in terms of uniform regulations. This has not been successful in the area of ​​health policy either, because, according to the findings of the Senate, the responsible working group for professions in the health sector of the highest state health authorities has not yet presented any viable, uniform (compromise) solutions for assessing medical professional activities in the field of osteopathy in connection with requests for a Physiotherapy has found a limited alternative practitioner license.Nevertheless, the assumption seems justified that the plaintiff's several years of further training in osteopathy will significantly expand her knowledge and skills in quantitative and qualitative terms and in relation to her independent and self-dependent work as a physiotherapist and in contrast to the necessary medical diagnosis and Activity has caused. (OVG North Rhine-Westphalia, judgment of, AZ: 13 A) On this decision, the Ministry for Health, Emancipation, Care and Age of the State of North Rhine-Westphalia is now building the following catalog of criteria for granting the restricted naturopathic license for physiotherapy. Here it says: According to the files, the alternative practitioner permit in the field of physiotherapy can be issued in the following exceptional cases without participating in a 60-hour post-qualification: A successfully completed osteopathy further education according to the regulation of further education and examination regulations in the field of osteopathy (WPO- Osteo) of the State of Hesse dated () in the respective version or another equivalent training and further education in the field of osteopathy. In North Rhine-Westphalia this means: Proof of equivalent training and further education, including is confirmed by the BAO certificate, helps the certificate holder without further examination, without further course attendance to the authorization of the sectoral alternative practitioner permit in physiotherapy. All that is required is to submit the application and provide the necessary documents. From a constitutional point of view (Article 12, Paragraph 1 of the Basic Law, alternatively from Article 2, Paragraph 1 of the Basic Law) 12