EUROPEAN HEALTHCARE FRAUD AND CORRUPTION NETWORK Working together for a better healthcare

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EUROPEAN HEALTHCARE FRAUD AND CORRUPTION
NETWORK- Working together for a better
healthcare -

• Paul Vincke
• President EHFCN
• Edinburgh 17 November 2008

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CONTENT

• Healthcare in Europe source or solution ?
• What is at stake ?
• The scale of the problem
• The nature of the problem
• Background to the EHFCN
• EHFCN vision and mission
• Two basic strategies
• 3 Pillar approach
• The holistic approach
• The comprehensive approach
• EHFCN tools
• EHFCN and NHS Scotland Counter Fraud Services

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The Healthcare System
Patients
Payments and re-imbursements
Services and payments
Gouvernement regulator
Payers
Providers
Payments and services
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Healthcare systems throughout history

• The Shemasko model (former Soviet Union)
• Provision of healthcare through policlinics that
  combine the role of a hospital outpatients
  department with that of a general medical
  practice serving populations of several thousand.
  
• The Beveridge model (Cuba, Great-Britain, Spain,
  Scandinavia and New Zealand)
• Provision and financing of healthcare by the
  government through tax payments. (low cost per
  capita because of government control) Most
  clinics are owned by the governmentvery focused
  choice high reimbursement rate
• The Bismarck model (Belgium, France, The
  Netherlands, Germany Japan, Switzerland)
• Provision of healthcare via an insurance system
  (insurers are mutual funds) financed by employers
  and employees mainly through payroll
  deductionwide spread general choice lower
  reimbursement rate
• The National health insurance model (Canada,
  Taiwan, South Korea)
• Mixture of the Beveridge and Bismarck model it
  uses private-sector providers, but payment comes
  from a government-run insurance program that
  every citizen pays into.
• The Out-of-pocket model (Africa, India, China,
  South America)
• Provision of healthcare ... if you have the
  money the rich get medical care, the poor
• stay sick or die.

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Classification of healthcare systems
Voluntary
Developed countries
Provider
Provision
Healthcare
Limited choice
In-kind services
Bismarck
Beveridge
Free choice
Re-imbursement
Payer
Statutory
Social services
Developing countries
Insu rance
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WHAT IS AT STAKE ?

• Annual healthcare spending across Europe totals
  approximately one trillion Euro (
  1,000,000,000,000)
• Between 3 and 8 of GDPs are spent on healthcare
  in European countries
• Healthcare spending outstrips economic growth in
  many western countries
• Higher public expectations
• Ageing of population
• Higher spending on pharmaceuticals
• Rapid advances in medical technologies

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The scale of the problem in Europe

• Fraud and corruption take a big bite out of funds
  earmarked for healthcare
• European risk measurement exercises estimate
  losses of billions of
• No country nor healthcare system is safeguarded
• Fraud and corruption take many forms, ranging
  from bill padding, phantom patients, ID fraud,
  counterfeit drugs to bribes, kickbacks and
  siphoning of funds

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The nature of the problem

• Examples of healthcare fraud and corruption
• Patients
• Medical professionals
• Hospitals
• Staff and managers
• Companies supplying services, drugs and equipment
• Fraud and corruption have created a black market
  in counterfeit drugs, killing thousands every
  year
• The World Health Organisation (WHO) estimates
  that 10 of all drugs sold in Europe are
  counterfeit
• Up to 60 of the drugs sold on the Internet are
  fake

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Proving fraud and corruption in healthcare is
difficult

• No common definition of fraud and corruption
• Invisible and hidden forces
• The burden of proof lies with the investigator
• The line between abuse and honest mistake is
  frequently blurred
• Information on Healthcare is not transparent
• This encourages impunity

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THREAT TO SOCIETY

• Fraud and corruption deprive people of needed
  medical care and lead to human suffering and
  worsening diseases
• Fraud and corruption eat away at the publics
  trust in the medical community
• Fraud and corruption undermine the publics
  confidence in authorities competence to handle
  public funds

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Why is healthcare fraud- and corruption-
susceptible?

• The medical profession is self-regulative in
  return for assuming professional responsibility
  in the best interest of the patient
• Involvement of high amounts of public money
• Specific mix of
• Uncertainty of the market
• Asymmetric information
• Large numbers of dispersed actors
• Less transparency
• Less accountability

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Does fraud and corruption vary across health
systems ?

• Particular institutional structures of health
  systems may make particular forms of fraud and
  corruption more or less attractive
• Reflexion of the society in which is operated
• Rule of law
• Transparency
• Trust
• Accountability
• Integrity

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• No healthcare system is immune to fraud and
  corruption
• A correct appropriation of public and private
  healthcare resources is vital

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BACKGROUND TO THE EHFCN

• Established in 2004 by six founding organizations
  to coordinate and advance efforts to counter
  healthcare fraud and corruption in Europe
• Only European organization of its kind
• Today, members number over 30 public and private
  healthcare organizations across Europe
• In aggregate, these 30 entities provide
  healthcare services to over 430 million people
  in Europe
• Austria, Belgium, England ,Scotland ,Wales,
  France, Germany, Iceland, Lithuania, Luxembourg,
  Malta, Norway, Poland, N-Ireland,Slovenia,
  Spain, Sweden, The Netherlands, Turkey, Portugal

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EHFCN VISION AND MISSION

• Vision Statement
• Improve healthcare systems in Europe by reducing
• losses caused by fraud and corruption
• Mission Statement
• Support members in their fight against FC
• Create anti-fraud culture
• Act as deterrent
• Use effective prevention
• Use detection systems to identify FC
• Investigate FC cases professionally
• Impose appropriate sanctions
• Seek financial redress

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• Efforts to address corruption and fraud need
  the application of two basic strategies
  "discipline" "values"
• "Discipline approach" (top-down)?
• Legislative reform establishes laws against
  corruption and fraud with adequate punitive
  consequence for violating the laws
• Prevents corrupt and fraudulent practices through
  fear of punishment
• "Values approach" (bottom-up)?
• Promotes institutional integrity through
  promotion of moral values and ethical principles
• Motivates ethical conduct of public servants

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3 Pillar Approach in combating
fraud and corruption

• ? ? ?
• Prevention Education Repression

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The Holistic Approach

• EHFCNs role is to promote
• The developing of a real anti-fraud culture
  across Europe
• . . . and to help members
• create a strong deterrent effect
• prevent fraud where it is not deterred
• detect fraud where it is not prevented
• investigate every suspicion of fraud objectively
  and fairly
• apply appropriate sanctions where fraud is found
• recover losses

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The Comprehensive Approach
ANTI-FRAUD CULTURE DETERRENCE PREVENTION
CREATE A PROFESSIONAL STRUCTURE TO IMPLEMENT THE
STRATEGY
MEASURE FRAUD LOSSES ACCURATELY
DEVELOP AN INTEGRATED STRATEGY AND BUSINESS
PROCESS
DEVELOP AN INTEGRATED STRATEGY AND BUSINESS
PROCESS
CREATE A PROFESSIONAL STRUCTURE TO IMPLEMENT THE
STRATEGY
USE THE STRUCTURE TO TAKE A RANGE OF ACTION
USE THE STRUCTURE TO TAKE A RANGE OF ACTION
DELIVER REDUCED LOSSES
DELIVER REDUCED LOSSES
DETECTION INVESTIGATION SANCTIONS REDRESS
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EHFCN TOOLS

• The EHFCN furthermore offers workshops and makes
  practical tools available to its members for
  fighting fraud and corruption
• Manual of Guidance
• Interactive Website
• Risk measurement techniques
• Fraud detection - data mining
• Raising of fraud awareness
• Promote Staff exchanges
• Legal arrangements
• Propriety checks
• Training
• Annual Conference

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EHFCN and NHS Scotland Counter Fraud Services

• Where is added value ?
• Expertise in fraud and corruption issues in
  healthcare
• Facts and figures
• Risk assessment methodologies
• Projects on cross border issues (counterfeit
  drugs, healthcare tourism)
• Expert Training
• Fraud and Corruption warnings
• Staff exchanges
• Training

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THERE IS NO TIME TO WASTELETS WORK TOGETHER AND
TAKE THE FIGHT TO NEW HIGHTS THE POTENTIAL FOR
LOST RESOURCES IS TOO GREAT TO IGNORE

• CONTACT EHFCN AT
• enquiries_at_ehfcn.org
• OR CALL 32 2 739 7982
• www.ehfcn.org