limits of incentives practical examples
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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
5.10.2005 Dr Gottfried Endel 5
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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
5.10.2005 Dr Gottfried Endel 6
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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
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5.10.2005 Dr Gottfried Endel 8
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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
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treat
men
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Honor
ar
paym
ent
5.10.2005 Dr Gottfried Endel 9
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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
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achw
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sev
idenc
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r ins
uran
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5.10.2005 Dr Gottfried Endel 10
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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.
5.10.2005 Dr Gottfried Endel 11
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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)
5.10.2005 Dr Gottfried Endel 12
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FRAUD in Health Care
• DEFINITIONSimulation or claiming
of services or requirements for services
without fulfilling the claimed promises
5.10.2005 Dr Gottfried Endel 13
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FRAUD in Health Care
• TYPES– Billing for services which were not
delivered– Billing for services without meeting
requirements • Education• Quality
5.10.2005 Dr Gottfried Endel 14
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„CORRUPTION“ and MARKET MECHANISM
• Market mechanisms in health care are suitable for – Freelancer– Small business
• Indicator of success– Profit– Loss
5.10.2005 Dr Gottfried Endel 15
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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
5.10.2005 Dr Gottfried Endel 16
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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?
5.10.2005 Dr Gottfried Endel 17
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THANK YOU FOR YOUR ATTENTION
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