Putting the quality of medical reports to the test

With the revision of the ATSG, the Federal Council set up the Federal Commission for Quality Assurance in Medical Assessment EKQMB on 1 January 2022. As the name suggests, the commission is tasked with ensuring the quality of medical assessments in social insurance procedures (BBI 2017 2535, 2683). An initial high-profile recommendation by the commission led to the Federal Social Insurance Office ending its collaboration with the PMEDA AG assessment centre (FSIO media release dated 4 October 2023: No further orders from the IV for the PMEDA assessment centre).

In January 2024, the Commission has now published a catalogue of quality indicators for the assessment of medical reports. These are intended to enable a more reliable and efficient medical assessment, promote compliance with minimum standards and ethical guidelines in the assessment process and thus increase transparency in the assessment process(Roman Schleifer, Markus Braun, Michael Liebrenz, Medizinische Begutachtung: Qualität anhand von Indikatoren messen, Soziale Sicherheit CHSS; on the quality indicators). These are measuring instruments that serve to monitor and evaluate the quality of medical assessments. They can provide indications of the quality of the expert opinion. At the same time, the reports should be comparable.

These are the quality indicators:

1. Processing times must not be too long

2. The duration of the examination interview must be appropriate to the complexity of the case

3. Basic ethical principles of the assessment discussion: A respectful and fair process must be guaranteed

4. Comprehensible justification of discrepancies with previous reports

5. Consideration of resources, burdens and functional limitations during the assessment

6. The expert judgement of consistency and plausibility must be comprehensibly justified.

Although intended as measuring instruments - as such, the indicators are not quality criteria - they can be a helpful aid for legal practitioners when assessing medical reports. Any anomalies in one of the indicators must prompt an in-depth examination of the expert opinion. In the current case law of the Federal Supreme Court, indicators 4 to 6 are already used when assessing the probative value of an expert opinion. Indicators 1 to 3, on the other hand, do not play a role. Rather, the Federal Supreme Court reiterated that the duration of the exploratory interview does not in itself speak against the quality of an expert opinion (see judgement of the Federal Supreme Court of 29 March 2010, 8C_942/2009, E. 5.2). In practice, there are examples of psychiatric exploratory interviews lasting less than one hour. The duration is correctly set in relation to the complexity of the insurance case. It is to be hoped that the duration of the exploratory interview will be taken more into account again and that a closer look will be taken at short exploratory interviews. Long processing times were also not previously an indicator that was taken into account when assessing an expert opinion. However, personal experience shows that many experts have to be reminded several times before the expert report is completed. This is despite the already very long clarification times - proceedings lasting several years are the rule today. Delays in this process can reduce the acceptance of the expert opinion from the outset. However, this indicator also serves the goal of a simple and quick procedure, which was pursued by the most recent revision of the IVG (further development of disability insurance). In previous practice, a respectful and fair procedure during the assessment was only of marginal importance. Clients often report disrespectful behaviour on the part of the assessors. Numerous reports in newspapers and journals also bear witness to this. The fact that this aspect is now to serve as an indicator of the quality of the assessment is therefore to be welcomed. It represents a paradigm shift towards a clarification procedure in which the person is not just perceived as a national insurance number, but as an individual again. This should further promote the acceptance of an assessment.

The EKQMB's projects to date demonstrate a high level of motivation to actually improve the quality of the assessment. However, it should not be forgotten that the ECQMB can only issue recommendations (cf. Art. 7 ATSV). This greatly relativises the importance of the commission. The President of the ECQMB and a number of voices from legal practice and academia are therefore calling for the Commission not only to be able to make recommendations, but also to lay down obligations. In view of the desolate situation regarding the quality of expert opinions, this is also necessary: To date, there is no adequate scientific basis to answer the question of the quality of expert opinions in Switzerland. Studies published by the University Hospital of Basel revealed that there is a high degree of variation in the assessment of fitness for work between individual experts (RELY studies: https://www.unispital-basel.ch/dam/jcr:a3605f93-aad4-4997-9d82-c02cf6891200/RELY_Public-Results_Web_2019_07_03-RK.pdf). Whether and to what degree an incapacity for work is certified depends to a large extent on the expert and not on the health impairment or the individual circumstances of the insured person. It therefore depends on who assesses you. This unequal treatment can no longer be tolerated. The EKQMB has already launched various projects to remedy this shortcoming. Its findings are particularly valuable because they are based on a scientific and methodical approach. The proposals of the ECQMB must therefore not merely be recommendations. They must be binding for the experts if they are not to remain ineffective. Otherwise, the quality of the expert reports is unlikely to change.