Jo De Cock - CEO NIHDI

04-02-2016 - OECD Paris

OECD Joint Network of Senior Budget and Health Officials: The Belgian Experience

HEALTH CARE FRAUD: NOT A NEW PROBLEM

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HEALTH CARE FRAUD: BUT MORE AND MORE AWARENESS

Many findings of wasteful use of

resources have been reported in the

empirical literature, inter alia:

i) sub-optimal setups for delivery of

care;

ii) inefficient provision of acute

hospital care;

iii) fraud and corruption in health care

systems;

iv) a sub-optimal mix of preventative

versus curative care

HEALTH CARE FRAUD: BUT MORE AND MORE AWARENESS

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HEALTH CARE FRAUD: BUT MORE AND MORE AWARENESS

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SUSTAINABILITY OF HEALTH CARE SYSTEMS: WHAT’S THE RIGHT WAY ?

• Investing less resources ?

• Developing additional funding mechanisms ?

• Reducing waste, increasing value ?

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WASTE

“ Waste is any activity in a process that consumes

resources without adding value ”

- Taiichi Ohno, Toyota

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HEALTH CARE FRAUD: TYPES

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Source: THORNTON, e.a., Categorizing and Describing

the Types of Fraud in Healthcare, 2015

FRAUD AND ABUSE: A PICTURE OF A BROAD LANDSCAPE

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Source: EHFCN

FINANCIAL IMPACT

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COMBATING FRAUD

A essential element for good governance health

systems:

• Rules

• Tools

• Manpower

• Cooperation

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THE BELGIAN EXPERIENCE: MAIN TRENDS

• From incidental, anecdotal interventions to

strategic, robust and integrated approach

• From exclusive top down strategy to active and

responsible partnerships

• From a vision unilateraly based on criminal law to

a multidimensional policy

• From primitive datasets to more sophisicated

databases, datalinkage and datamining

• From national dimension to international

cooperation

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THE BELGIAN EXPERIENCE: GENERAL FEATURES

- Primary control: sickness funds; second line: NIHDI

- Specific department of medical evaluation and control of NIHDI,

organised on a multidisciplinary basis and associated in establishing

legislation

- Triple mission

• Information for providers (e.g. ‘infobox’)

• Control: reality and conformity checks as well as

overconsumption (not easy!)

• Evaluation (feedback mirror for providers and impact analysis)

- Yearly ‘ICE’ program

- Research and investigation capacity (direct access to claims data

and medical files)

- Fast and efficient procedures (e.g. suspension payments),

specialised jurisdictions

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ANTI

FRAUD/CORRUPTION

CULTURE

DETERRENCE

PREVENTION

DETECTION

INVESTIGATION

SANCTIONS

REDRESS

PROBLEM

STRATEGY

STRUCTURE

ACTION

DELIVERY

Progressive, sustained and

integrated approach

Copyright Jim Gee 2009

PROGRESSIVE, SUSTAINED AND INTEGRATED APPROACH

1. Prevention

- Definition benefits to be reimbursed, including

reimbursement conditions, pricing and tarriff setting

- Information (individual, professional groups,

academia, media, ...)

- Professional education and peer review

- Benchmarking and mirroring

- Feedback (individual; groupwise)

- Call to account providers

- Monitoring individual providers

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PROGRESSIVE, SUSTAINED AND INTEGRATED APPROACH

2. Investigation

- Evaluate allegations or suspicions

- Conduct background checks and collect data

- Look to additional evidence: interview witnesses,

access to relevant medical files, ...

- Interview primary subject

- Make final report

- Decide what action to take: warning, settlement,

administrative sanction, recuperation or referral

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PROGRESSIVE, SUSTAINED AND INTEGRATED APPROACH

3. Enforcement

- Recuperation and claw back

- Sanctions:

• Administrative sanction

• Suspend payments; third payer billing; impose

prior authorisation; suspend license to practice;

• Referral to criminal law jurisdiction

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THE BELGIAN EXPERIENCE: CONCRETE EXAMPLES

- Introduction unique barcode pharmaceuticals

- Billing in emergency units

- Assessment autonomy patients in home care

- Repetitive protective dental care

- Upcoding CT scans rock bones / Carpal tunnel

treatment

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THE BELGIAN EXPERIENCE: NEW DEVELOPMENTS

- Creation of interdepartemental unit appropriate

care (e.g. low back surgery; medical imaging; ...)

- SLA with departement justice

- Project on data mining methodology

- Transparancy for patients in case of electronic

third payer billing; compulsory use of eHealth

identification

- Review financial incentives

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COMBATING FRAUD AND ABUSE: CRITICAL SUCCESSFACTORS

- Prevention (awareness, information, clear and fraud

tested legislation, ...)

- Deterrence: sufficient investigation and prosecuting

capacity (quantity and quality)

- Structured approach based on risk analysis

(“not only lucky shots”)

- Tailored and fast interventions and appropriate

sanctions and claw back procedures

- Cooperation with different stakeholders (justice;

providers; patients; ...)

- Data availability

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A BIG CHALLENGE: HOW TO REDUCE INAPPROPRIATE AND LOW VALUE CARE ?

A BIG CHALLENGE: HOW TO REDUCE INAPPROPRIATE AND LOW VALUE CARE ?

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Source: Colla C., NEJM, October 2014, 1280

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A BIG CHALLENGE: HOW TO REDUCE INAPPROPRIATE AND LOW VALUE CARE ?

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A BIG CHALLENGE: HOW TO REDUCE INAPPROPRIATE AND LOW VALUE CARE ?

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A BIG CHALLENGE: HOW TO REDUCE INAPPROPRIATE AND LOW VALUE CARE ?

POSSIBILITIES OF INTERNATIONAL COOPERATION

EHFCN

- Not for profit organisation (NIHDI cofounder and hosting

secretariat)

- Established in 2005

- Network of governmental authorities, health insurers,

counter fraud investigation units

- 12 European memberstates involved

Quid OECD ?

- Stimulate good practices

- Support and align data standardisation

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EHFCN

HTTPS://EHFCN-POWERHOUSE.ORG/

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THANK YOU FOR YOUR ATTENTION !

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