Filenews 2 March 2022
The effective treatment of abuses, with the aim of safeguarding the sustainability of the General Health System, is pursued by the action plan of the Health Insurance Organisation, the Organization said in a statement.
Heading towards the completion of three years of the GHS's operation, it is noted, its contribution is a given and is confirmed by the way it is embraced by the beneficiaries.
"The challenges, however, are still huge and continuous. The Health Insurance Organisation is daily called upon to supervise, identify and manage a huge number of providers, beneficiaries and requirements with the sole aim of providing health care services optimally," he added.
One of the major problems that undermine the viability of the GHS, it is mentioned, is none other than the exploitation of the System, by providers and beneficiaries, for their own benefit.
The abuses detected in recent times and resulting either from complaints or from the supervisory audits carried out by the HIO, it is stressed, must be addressed immediately and effectively through a collective effort of all stakeholders involved.
Recognizing the existence of the problem, it is said, the HIO proceeded with a series of measures, drawing up an action plan to tackle abuses.
The aim, he says, is "to drastically address the phenomena of abuse that burden and affect the sustainability of the General Health System".
"In every major social reform that is implemented, a period of adaptation is needed. All the more so when it comes to reforms that radically change habits of decades. The GHS implementation allowed for the first time citizens to have access to services and medicines that they had previously not been able to do. At the same time, providers had to adopt a different way of offering services using technology and acting within the ghs philosophy", he added.
The HIO's action plan
As stated in the announcement, exploitation and abuses do not affect the System, but the beneficiaries and providers themselves. It is noted that the strategy of the Health Insurance Organization for the confrontation of abuses does not focus only on the punishment of violations, but mainly on their prevention and detection.
It is important, it is noted, to make targeted moves that will educate providers and beneficiaries on their behaviour within the System.
The main pillars of the HIO's action plan are behavioural control / operation of providers contracted with the Organization, analysis of data and reinforcement of controls, creation of a culture for rational use of the System by beneficiaries and encouragement of beneficiaries to report abusive activities as well as organization, staffing, development and improvement of procedures.
Control of provider operation
Starting from the institution of the Personal Doctor (PD), it is mentioned, the first observation concerns the large number of referrals issued to the Special Doctors (OS).
More specifically, on average, about 40 referrals are issued to higher education institutions for every 100 visits, while in developed systems, with organized primary health, the rates of referrals to higher education institutions by PDs are much lower. To address the phenomenon, the HIO has implemented a qualitative evaluation of referrals issued by doctors and has taken measures when their issuance is not documented through the accurate recording of diagnoses/clinical notes.
Another problem found in the referrals is their issuance by phone, without any prior examination by the PD. Usually this is done under conditions of pressure from the beneficiaries, resulting in the issuance of unnecessary referrals. This practice, it is noted, affects the viability of the System and at the same time the role and operation of the PD. In addition, it also burdens the waiting lists of Specialists at the expense of beneficiaries who really need medical attention.
It is also noted that, with the renewal of the PD's contracts in June 2022, the OAY will proceed to the introduction of quality criteria in their remuneration, with the ultimate goal of a per capita fee of 70% and the remuneration based on quality criteria and performance indicators at a rate of 30%. The remuneration based on qualitative criteria will refer to the provision of specialized services, such as the management of chronic diseases, while the remuneration based on performance indicators will refer to the behavior of personal doctors in relation to the issuance of referrals.
For the Medical Specialists, the HIO states that it has already revised the lists of activities, including the severities of each activity, but also to use the capabilities of the IT System to detect and prevent cases of abuse or fraud. It has also drawn up separate budgets per specialty of Special Doctors, in specialties that cover more than 80% of the total activity of higher education institutions. Furthermore, it has implemented restrictions, guidelines and protocols for the submission/approval of requirements by service providers, the administration of medicines and the conduct of inpatient operations. In addition, the Adoption of a mandatory annual tax clearance for GHS providers is being studied by the Organization.
Implementation of Protocols
With a view to consolidating the tools and mechanisms for the promotion of Evidence-Based and Cost-Effective health services within the GHS framework and contributing in this way to the qualitative upgrading of the services it offers within the framework of existing legislation, the Organization says that it has begun to cooperate with the British Organization NICE and the trainings include the transfer of knowledge about the procedures development-adaptation of protocols, quality and efficiency indicators and support in the involvement of stakeholders in the adaptation processes.
Analyze data and strengthen controls
As mentioned, a major chapter included in the HIO's strategic plan concerns the analysis of data to strengthen the controls available to the Agency to ensure the quality of services and at the same time combat abuses.
Among other things, the Agency carries out audits on providers, which arise after research and data analysis in the IT System.
To date, he says, dozens of doctors have been investigated, whose investigation has led to recommendations and the imposition of administrative fines.
In addition, the data analysis has led the HIO to suspend the contract of four specialists, a clinical laboratory, a pharmacy, a personal doctor, a health professional, as well as the termination of the contract of 1 specialist doctor, 2 personal doctors and 2 laboratories. It is noted that the Organization is currently investigating the suspension of contracts of 10 other contracted providers. At the same time, audits have identified hundreds of activity requirements that the Agency rejected. It is noted that more than 1,000,000 claims are received per month from providers.
Create a culture of beneficiaries
It is reported that the Agency has received several complaints from PDs, who say that they are under pressure from beneficiaries to issue referrals. Otherwise, the beneficiaries threaten to be removed from the list of each PD, he says.
For this purpose, it is noted, a change will be made to the IT System regarding the period of time that a beneficiary can change PD, as well as the obligation to state the reasons why it is deleted from the list of a PD.
At the same time, it is planned in 2022 to implement an integrated programme of information, communication and education of GHS beneficiaries, which, among other things, aims at creating a culture for the proper use of the System and the reduction of abuses, as well as information on the rights and obligations of beneficiaries and the importance of the role of the PD within the GHS. In addition, one of the main objectives of this programme is to educate/encourage beneficiaries to report abusive activities.
In addition to the handling of beneficiaries and providers, the Organization considers equally important its internal organization and development, as well as the strengthening of controls with the help of external consultants, so that it can adequately respond to the treatment of abuse.
CNA
