EHFCN Annual Conference 2011
The 8th EHFCN Annual Conference called for improved cooperation in fighting fraud and corruption in healthcare and social security
Around 125 participants from 15 countries representing Ministries of Health and of Social security, sickness funds, unemployment funds, academics, healthcare providers and industry met in Krakow on 6-7 October to share experience and best practice related to the fight against fraud and corruption in the two sectors. Over 25 experts have agreed to share their knowledge facing both the theoretical and practical aspects of fraud and corruption in various spheres of the healthcare and social security sectors. The conference was also a call upon decision makers to devote more attention to thes
e phenomena and to deploy more means to eradicate them.
Over the last couple of years it became clear that the phenomenon of “Social Fraud” and how to effectively counter it, showed remarkable resemblance and overlap with the healthcare fraud. Identity fraud and issues related to undeclared work for example are generating considerable losses in social security as well as in healthcare. And although healthcare and social security systems are different throughout the European Member States, internationally common practices such as tax evasion, moonlighting and illegal contracting, prevent important amounts from being collected on one hand whereas over-billing, fake sick leaves and the like represent heavy losses in benefits on the other. These important amounts are indispensable for the sustainability of both healthcare and social security systems.
In line with a Thomson Reuters report on waste in healthcare, estimates are that approximately 30% of healthcare money is being “wasted” in the US (administrative inefficiencies, overconsumption, lack of care coordination, fraud and error). In Europe waste in healthcare would as a consequence represent an amount of 300 billion euro. Add to that the estimated losses as a result of undeclared work only (240 billion or 2 % of the European GDP) and we are talking about more than 500 billion euro lost annually in healthcare and social security systems in Europe.
Money lost to social and healthcare fraud takes huge proportion. In 2010, EHFCN estimated that 56 billion euro were lost annually to healthcare fraud and error in the European Union (1). According to the French Ministry of Social Affairs and Employment, social fraud detected in 2010 reached more than 457 million euro(twice as much as in 2006), of which the biggest amounts concerned the healthcare insurance (156 million), the Social Security Central Agency (ACOSS – 186 million) and family allocations (90 million) (2). Money is not only lost to healthcare fraud and corruption; more money is lost to waste, which in the healthcare sector for example, is due to over-prescription, medical errors malpractice and lack of quality in health services. To date it is still difficult to evaluate the total losses due to waste across the European Union. Some studies in the US indicate that the annual cost of measurable medical errors that harmed patients in the US in 2008 amounted to 17.1 billion dollars (3). In 2009 another study estimated that the total loss to fraud, error, overconsumption and inefficiencies in the US reached 700 billion dollars (4).
Paul Vincke, President of EHFCN, said “In the context of the financial crisis which hits Europe and the world it is high time to recognise, assess and reduce this economic burden which drains unacceptable amounts of money from public resources. We call on decision makers at national and at European level to devote more attention and to give more means to eradicate this phenomenon”.
Day 1: The first day of the Conference started with Mr. Mariusz Kujawski's presentation regarding the role of the Central Anti-Corruption Bureau in combating criminal offences in the healthcare system in Poland.
The first Session concentrated on Fraud in healthcare and social security in the European Union.
The session presented different theoretical and practical aspects of fraud and corruption in various spheres of the healthcare and social security sectors from Poland, UK and The Netherlands. An overview of the current research into the social distribution of welfare, the relationship between the economy and the welfare state, and the organisation of social security, analyzing the various risks related to fraud within this context and the impact on economy was also presented.
The Social Insurance Institution (ZUS) in Poland presented the internal and external risks faced in various spheres such as in financial asset management (where risks are linked for example to infrastructure, credit, investment); in the benefit sphere (where risks are linked for example to false documents and false information which give right to undue benefits), and in the income sphere (where risks are related fro example to understatements, non-payment of insurance contributions or errors in insurance documents).
Fraud is not a victimless crime, it is often well organised and systematic, and it affects everyone in the UK either directly or indirectly. Public sector fraud accounts for €24.5 billion, of which Welfare Fraud amounts to €1.7 billion. The strategic importance to tackle fraud, ensuring correctness and reducing customer error was highlighted.
The social security system in the Netherlands is seen as an important asset within Dutch society. Its quality can only be maintained when deliberate abuses are absent. Its quality can only be maintained when deliberate abuses are absent. The Dutch government gives priority to fraud prevention and detection. The wishes of the government are laid down in policy guidelines and programmes.
Panelists included:
Jozef Pacolet, HIVA, Catholic University of Leuven, Belgium
Miroslawa Boryczka, ZUS (Social Insurance Institution), Poland
Dave White, JobCentre Plus, Department for Work and Pensions, UK
Miranda Vermeulen, UWV, Netherlands
The second session of the day highlighted some of the Network's cooperation and focus of interest.
The Council of Europe representative highlighted a number of key recommendations included in the ‘Recommendation on Good Governance in Health Systems' and reviewed the necessary steps to implement the guidelines that are contained in the appendix to the recommendation. These steps refer to a systemic strategy which foresees enforcing mechanisms, provisions for professional investigation, sanctions, and compensation. They should be coupled with education and training of healthcare professionals, and do not go without good monitoring and assessment.
Informal payments in CEE countries showeda review of the empirical studies on informal patient payments which have been carried out in Poland over the past two decades. The types, scope, and levels of informal payments, as well as opinions on informal payments, are analysed
In recent years the German Government made significant legislative and regulatory changes in combating healthcare fraud. In 2007 section 128 Social Code Five has been introduced, generally prohibiting the provision and acceptance of any kind of benefits with respect to hospitals, physicians and other care providers. Under this section, service providers, physicians and pharmacists are prohibited from granting special benefits for care provided.
The analysis of the Belgian international money transfers (income and expenses), coordinated and managed by the Administrative Commission for the Coordination of Social Security Systems in Europe (CASSTM), showed that the complex procedures and the big number of stakeholders involved hinder a correct payment of the amounts due within the imposed delay.
In times of economic constraints it is more and more difficult to physically meet and perhaps not always necessary. Sharing of resources, information and tools in an efficient and dynamic way by using cloud computing may be the answer for the current and future Network.
Panelists included:
Stanisława Golinowska, Uniwersytet Jagiellonski Collegium Medicum, Poland
Thomas Bade, Management Consultant to the healthcare and health insurance industry, Germany
Didier Verbeke, Federal Public Service (FPS) Social Security, Belgium
The third session consistedof two informative breakout sessions:
A – Waste in healthcare
As we know, money is lost to healthcare fraud and corruption every year. But more money is lost to inefficiency due to over-prescription, medical errors and malpractice, lack of quality in health services. This break-out session will look at the overall problem of money lost and how this situation is exacerbated due to the financial crisis. The topic is (finally) getting more attention; WHO experts for example just issued a study which identified cost-effective measures for non-communicable diseases (NCD) that can help turn the tide and reduce the economic burden for low- and middle-income countries.
Panelists included:
Paul Garassus, BAQIMEHP / European Union of Private Hospitals (UEHP), France
Susanne Weinbrenner, German Agency for Quality in Medicine (AQuMed / AEZQ), Germany
Roy Poses, Brown University, Rhode Island, USA
B – Fraud Management in Social Security
In this interactive workshop four leaders from social welfare and healthcare agencies discussed strategies and solutions in place today that are addressing and reducing fraudulent activity. With current austerity measures, cutbacks, and financial scandals arousing public ire, public-sector agencies in many countries face growing pressure to detect and investigate fraud, enforce compliance and reduce the amount of money being lost. The challenge is that most government agencies were conceived, organised and staffed to deliver services rather than to police, investigate and penalise citizens. In addition, most legacy information systems were not developed with fraud detection in mind or aren't capable of dealing with the high-tech practices used by today's criminals.
Panelists included:
Margaret Worsfold, NHSScotland Counter Fraud Sservices (CFS)
Tony Ellis, IBM (ex-London Borough of Brent), UK
Dariusz Śpiewak, Social Insurance Institution (ZUS), Poland
Marek Ujejski, National Health Fund (NFZ), Poland
Hammou Messatfa, IBM, France: Session moderator
Day 2: Are Analytics Needed in the Fight Against Health Care Fraud?
In the second day of the conference the role of analytics was debated and particularly how analytics can help organizations towards building a comprehensive fraud detection and prevention strategy by intelligently filtering data assets to allow organizations to focus investigation on cases with a higher chance of fraud or malpractice. The CNAMTS Department of dispute settlement and the fight against fraud (DCCRF) from France uses two ways to detect fraud; the first uses database queries and has been fully implemented in the last years, the other one uses datamining and is currently being experimented at regional level for daily allowances and at national level for other specific cases. An overview and examples for both methods were given. The example provided by INAMI-RIZIV, Belgium gave an overview of the methods used to identify prescribers and patients and to reach outliers, i.e. those who prescribed an expensive class of antibiotics inappropriately.
As corruption knows no borders, affects all countries and sectors of society and cannot be remedied with traditional educational methods alone, IACA's vision is to tackle this global phenomenon with a new and holistic approach which is international, inter-disciplinary, intersectoral and integrative. Mr. Grabenweger's presentation covered how IACA provides know-how and expertise from various academic and non-academic fields, how their holistic curricula address a wide range of disciplines and cater to all sectors of society and to various regions in the world.
Panelists included:
Georg-Florian Grabenweger, IACA, Austria
Kamil Kondracki, National Health Fund, Poland
Ross Kaplan, SAS Institute, USA
Hans Nagels, INAMI-RIZIV, Belgium
Although healthcare and social security systems are different throughout the member states, fraud processes share similarities and strategies. Methods to counter them are generically and technically speaking the same for both sectors. Some of the most important frauds involve both sectors. An example is identity fraud which gives access to undue unemployment and healthcare benefits.
“This is why the focus of the conference was not only on the fight against fraud in healthcare but on the fight against fraud in social security as well”, Paul Vincke added. “We hope the conference delivered practical output and tools to protect the fundamental values of our social security and healthcare systems. We also hope it inspired people from both sectors to join forces. It is only by joining forces that we can hope to curb losses and improve counter fraud strategies and expertise within our respective countries and across Europe.”
During the 8th Annual Conference held in Krakow EHFCN signed a Memorandum of Understanding with the Healthcare Forensic Management Unit (HFMU/South Africa) and the Health Insurers Counter Fraud Group (HICFG/UK). The purpose of the MoU is to provide framework support for improved awareness and share of research and information: Further information can be found at www.ehfcn.org.
EFHCN also took this opportunity to confer its third Excellence Awards to “Doctors Against Corruption”, Serbia, and to Dr. Pierre Fender, Director of dispute settlement and the fight against fraud for the French National Health Insurance Fund for Salaried Workers (CNAMTS).
References
(1) Gee J, Button M, Brooks G; The financial cost of healthcare fraud; University of Portsmouth, MacIntyre Hudson, EHFCN, 2010.
(2) Portail de la Sécurité Sociale ; http://www.securite-sociale.fr/institutions/fraudes/fraude.htm, accessed 3/10/2011
(3)Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz, Shreve J; Health Aff April 2011 vol. 30 no. 4 596-603
(4) Kelley R: White paper – Where can 700 billion in waste be cut annually from the U.S. healthcare system? Thomson Reuters, 2009
Further information can be found HERE