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© BO-EBM LIMITS OF INCENTIVES PRACTICAL EXAMPLES EHF GASTEIN 2005-10-05 DR. GOTTFRIED ENDEL
© BO-EBM 5.10.2005Dr Gottfried Endel2 LIMITS OF INCENTIVES CONFLICT OF INTEREST SYSTEM CONSIDERATIONS CORRUPTION and FRAUD in HEALTH CARE oDEFINITION oTYPES CORRUPTION and MARKET MECHANISM CONCLUSIONS
© BO-EBM 5.10.2005Dr Gottfried Endel3 CONFLICT OF INTEREST Accreditation for CME Sponsoring Due to EHFG I could not attend this meeting. The last meeting was on September 6.
© BO-EBM 5.10.2005Dr Gottfried Endel4 CONFLICT OF INTEREST Participation in sponsored CME activities Participation in a symposium to cardio- vascular prediction rules – sponsored by aunrestricted educational grant of a pharmaceutical company Got pharmaceutical samples for free
© BO-EBM 5.10.2005Dr Gottfried Endel5 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
© BO-EBM 5.10.2005Dr Gottfried Endel6 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
© BO-EBM 5.10.2005Dr Gottfried Endel7 SYSTEM CONSIDERATIONS benefit in kind VERSICHERTER insured person VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance Abrechnung, Antragstellung accounting, application Zahlung, Kontrolle payment, control VERTRAG Contract Beiträge, Selbstverwaltung contribution, self administration Leistungsgarantie, Krankenordnung performance guarantee,rules for insured persons Leistungen benefits Versicherungsnachweis evidence for insurance
© BO-EBM 5.10.2005Dr Gottfried Endel8 SYSTEM CONSIDERATIONS benefit in cash VERSICHERTER insured person VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance Antrag, Begründung, Unterlagen application, reasons, material of evidence Vergütung, Ablehnung(Bescheid) benefit in cash, Leistungen treatment Honorar payment
© BO-EBM 5.10.2005Dr Gottfried Endel9 SYSTEM CONSIDERATIONS application as principle VERSICHERTER insured person VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance Antragstellung, Begründung, Unterlagen application, reasons, materials of evidence Feststellungsverfahren, Kontrolle declaration procedure, control VERTRAG Contract Antragstellung, Begründung, Unterlagen application, reasons, materials of evidence Feststellungsverfahren, Bewilligung, Ablehnung(Bescheid) declaration procedure, Leistungen benefits Versicherungsnachweis evidence for insurance
© BO-EBM 5.10.2005Dr Gottfried Endel10 CORRUPTION in Health Care DEFINITION every 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.
© BO-EBM 5.10.2005Dr Gottfried Endel11 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)
© BO-EBM 5.10.2005Dr Gottfried Endel12 FRAUD in Health Care DEFINITION Simulation or claiming of services or requirements for services without fulfilling the claimed promises
© BO-EBM 5.10.2005Dr Gottfried Endel13 FRAUD in Health Care TYPES –Billing for services which were not delivered –Billing for services without meeting requirements Education Quality
© BO-EBM 5.10.2005Dr Gottfried Endel14 CORRUPTION and MARKET MECHANISM Market mechanisms in health care are suitable for –Freelancer –Small business Indicator of success –Profit –Loss
© BO-EBM 5.10.2005Dr Gottfried Endel15 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
© BO-EBM 5.10.2005Dr Gottfried Endel16 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?
© BO-EBM 5.10.2005Dr Gottfried Endel17 THANK YOU FOR YOUR ATTENTION
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