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LIMITS OF INCENTIVESPRACTICAL EXAMPLES

EHF GASTEIN 2005-10-05DR. GOTTFRIED ENDEL

5.10.2005 Dr Gottfried Endel 2

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LIMITS OF INCENTIVES

• CONFLICT OF INTEREST

• SYSTEM CONSIDERATIONS

• „CORRUPTION“ and FRAUD in HEALTH CARE

o DEFINITION

o TYPES

• „CORRUPTION“ and MARKET MECHANISM

• CONCLUSIONS

5.10.2005 Dr Gottfried Endel 3

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CONFLICT OF INTEREST

•Accreditation for CME •SponsoringDue to EHFG I could not attend this meeting. The last meeting was on September 6.

5.10.2005 Dr Gottfried Endel 4

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CONFLICT OF INTEREST

• Participation in sponsored CME activities

• Participation in a symposium to cardio-vascular prediction rules – sponsored by a „unrestricted educational grant“ of a pharmaceutical company

• Got pharmaceutical samples for free

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SYSTEM CONSIDERATIONS

• Role of health professional– Freelancer– Small business– Trustee of the

health care system / the health insurance

• Role of patient

– Contractor – Buyer– Client, patient,

beneficiary

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SYSTEM CONSIDERATIONS

The Paradox of the Rational Patient and The Ethical Physician

http://www.mism.com

An INTERNET forum established by Michael F. Quinn M.D. to examine MEDICAL DECISION THEORY, the APPLIED MATHEMATICS of DIAGNOSIS and the MATHEMATICAL PRINCIPLES of SCIENTIFIC MEDICINE

5.10.2005 Dr Gottfried Endel 7

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SYSTEM CONSIDERATIONSbenefit in kind

VERSICHERTERinsured person

VERTRAGSPARTNERcontracting party

SOZIALVERSICHERUNGsocial insurance

Abrechnung, Antragstellungaccounting, application

Zahlung, Kontrollepayment, control

VERTRAG Contract

Beiträge, Selbstverwaltung

contribution, self administration

Leistungsgarantie, Krankenordnung

performance guarantee,rules for insured persons

Leist

unge

n

bene

fits

Versic

heru

ngsn

achw

eis

evide

nce

for i

nsur

ance

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SYSTEM CONSIDERATIONSbenefit in cash

VERSICHERTERinsured person

VERTRAGSPARTNERcontracting party

SOZIALVERSICHERUNGsocial insurance

Antrag, Begründung, Unterlagen

application, reasons, material of evidence

Vergütung, Ablehnung(Bescheid)

benefit in cash,

Leist

unge

n

treat

men

t

Honor

ar

paym

ent

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SYSTEM CONSIDERATIONSapplication as principle

VERSICHERTERinsured person

VERTRAGSPARTNERcontracting party

SOZIALVERSICHERUNGsocial insurance

Antragstellung, Begründung, Unterlagenapplication, reasons, materials of evidence

Feststellungsverfahren, Kontrolledeclaration procedure, control

VERTRAG Contract

Antragstellung, Begründung, Unterlagen

application, reasons, materials of evidence

Feststellungsverfahren, Bewilligung, Ablehnung(Bescheid)

declaration procedure,

Leist

unge

n

bene

fits

Versic

heru

ngsn

achw

ei

sev

idenc

e fo

r ins

uran

ce

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„CORRUPTION“ in Health Care

• DEFINITIONevery decision

about the necessity of services

or acces to services

which brings favour / profit for the decision maker and/or the beneficiary

and

is not undoubtly based on medical evidence.

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„CORRUPTION“ in Health Care

• Examples:– Patients

• Gain benefits without insurance (family members who are not co-insured, foreign visitors)

• Misuse of services (sick leave, pharmaceuticals for first aid kits on travels)

– Health professionals• Informal payments connected with waiting lists • Payments for referral (hearing aids, laboratory)

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FRAUD in Health Care

• DEFINITIONSimulation or claiming

of services or requirements for services

without fulfilling the claimed promises

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FRAUD in Health Care

• TYPES– Billing for services which were not

delivered– Billing for services without meeting

requirements • Education• Quality

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„CORRUPTION“ and MARKET MECHANISM

• Market mechanisms in health care are suitable for – Freelancer– Small business

• Indicator of success– Profit– Loss

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„CORRUPTION“ and MARKET MECHANISM

Market mechanism in health care lead to corruption and fraud

– In social insurance systems– National health systems

Where health professionals are

Trustees of the health care system / the health insurance

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CONCLUSIONS

We need:

• Transparency – What is the role of the health professional?– Where are money and benefits going?– Where are conflicts of interest?– Which information or service provider

benefits from a decision?

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THANK YOU FOR YOUR ATTENTION