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LIMITS OF INCENTIVES PRACTICAL EXAMPLES

LIMITS OF INCENTIVES PRACTICAL EXAMPLES. EHF GASTEIN 2005-10-05 DR. GOTTFRIED ENDEL. LIMITS OF INCENTIVES. CONFLICT OF INTEREST SYSTEM CONSIDERATIONS „CORRUPTION“ and FRAUD in HEALTH CARE DEFINITION TYPES „CORRUPTION“ and MARKET MECHANISM CONCLUSIONS. CONFLICT OF INTEREST.

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LIMITS OF INCENTIVES PRACTICAL EXAMPLES

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  1. LIMITS OF INCENTIVESPRACTICAL EXAMPLES EHF GASTEIN 2005-10-05 DR. GOTTFRIED ENDEL

  2. LIMITS OF INCENTIVES • CONFLICT OF INTEREST • SYSTEM CONSIDERATIONS • „CORRUPTION“ and FRAUD in HEALTH CARE • DEFINITION • TYPES • „CORRUPTION“ and MARKET MECHANISM • CONCLUSIONS Dr Gottfried Endel

  3. CONFLICT OF INTEREST • Accreditation for CME • Sponsoring • Due to EHFG I could not attend this meeting. The last meeting was on September 6. Dr Gottfried Endel

  4. 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 Dr Gottfried Endel

  5. SYSTEM CONSIDERATIONS • Role of patient • Contractor • Buyer • Client, patient, beneficiary • Role of health professional • Freelancer • Small business • Trustee of the health care system / the health insurance Dr Gottfried Endel

  6. 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 Dr Gottfried Endel

  7. SYSTEM CONSIDERATIONS benefit in kind VERSICHERTER insured person Leistungsgarantie, Krankenordnung performance guarantee,rules for insured persons Leistungen benefits Versicherungsnachweis evidence for insurance Beiträge, Selbstverwaltung contribution, self administration Abrechnung, Antragstellung accounting, application VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance VERTRAG Contract Zahlung, Kontrolle payment, control Dr Gottfried Endel

  8. SYSTEM CONSIDERATIONS benefit in cash VERSICHERTER insured person Vergütung, Ablehnung(Bescheid) benefit in cash, Leistungen treatment Antrag, Begründung, Unterlagen application, reasons, material of evidence Honorar payment VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance Dr Gottfried Endel

  9. SYSTEM CONSIDERATIONS application as principle VERSICHERTER insured person Feststellungsverfahren, Bewilligung, Ablehnung(Bescheid) declaration procedure, Leistungen benefits Versicherungsnachweis evidence for insurance Antragstellung, Begründung, Unterlagen application, reasons, materials of evidence Antragstellung, Begründung, Unterlagen application, reasons, materials of evidence VERTRAGSPARTNER contracting party SOZIALVERSICHERUNG social insurance VERTRAG Contract Feststellungsverfahren, Kontrolle declaration procedure, control Dr Gottfried Endel

  10. „CORRUPTION“ in Health Care • DEFINITION every decision about thenecessity 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. Dr Gottfried Endel

  11. „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) Dr Gottfried Endel

  12. FRAUD in Health Care • DEFINITION Simulation or claiming of services or requirements for services without fulfilling the claimed promises Dr Gottfried Endel

  13. FRAUD in Health Care • TYPES • Billing for services which were not delivered • Billing for services without meeting requirements • Education • Quality Dr Gottfried Endel

  14. „CORRUPTION“ and MARKET MECHANISM • Market mechanisms in health care are suitable for • Freelancer • Small business • Indicator of success • Profit • Loss Dr Gottfried Endel

  15. „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 Dr Gottfried Endel

  16. 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? Dr Gottfried Endel

  17. THANK YOU FOR YOUR ATTENTION Dr Gottfried Endel

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