-
.
- Ελληνικά
The effective treatment of abuses, in order to safeguard the sustainability of the General Health System is the objective of the Health Insurance Agency's action plan, the Health Insurance Agency said in a statement.
As we approach the three-year anniversary of the GHS, it notes, its contribution is a given and is confirmed by the way beneficiaries have embraced it.
"The challenges, however, remain immense and ongoing. Every day, the Health Insurance Agency is required to supervise, identify and manage a huge number of providers, beneficiaries and claims with the sole objective of providing optimal health care services," it adds.
One of the major problems undermining the sustainability of the GHS, it says, is none other than the exploitation of the System, by providers and beneficiaries, for their own benefit.
The abuses that have been detected lately, resulting either from complaints or from the supervisory audits carried out by the OAI, it is stressed, must be addressed immediately and effectively through the collective effort of all stakeholders.
Acknowledging the existence of the problem, it is stated, OAI has taken a series of measures, drawing up an action plan to address the abuses.
The aim, it is said, is "to drastically address the abuses that burden and affect the sustainability of the General Health System."
"Every major social reform that is implemented needs a period of adjustment. All the more so when it comes to reforms that fundamentally change decades-old habits. The implementation of the GHS has allowed citizens for the first time to have access to services and medicines they previously could not afford. At the same time, providers had to adopt a different way of offering services using technology and acting within the GHS philosophy," it added.
The OAS action plan
As stated in the statement, exploitation and abuses do not hurt the System, but the beneficiaries and providers themselves. It is noted that the Health Insurance Agency's strategy to address abuses is not only focused on punishing violations, but mainly on preventing and detecting them.
It is important, it is noted, to make targeted moves that will educate providers and beneficiaries on how to behave within the System.
The main pillars of the OAI's action plan are monitoring the behaviour/operation of providers contracted with the Agency, analysing data and strengthening controls, creating a culture for rational use of the System by beneficiaries and encouraging beneficiaries to report abusive activities, as well as organising, staffing, developing and improving processes.
Audit of providers' operations
Starting from the institution of Personal Physician (PI), it is mentioned that the first observation concerns the large number of referrals issued to Specialist Physicians (SPs).
More specifically, on average, about 40 referrals to PIs are issued for every 100 visits, whereas in developed systems, with organised primary health care, the rates of referrals to PIs from PIs are much lower. To address this phenomenon, OAI has implemented quality assessment of referrals issued by physicians and has taken action when their issuance is not documented through accurate recording of diagnoses/clinical notes.
Another problem identified with referrals is their issuance over the phone without prior review by the PI. This is usually done under pressure from 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 functioning of the PI. Moreover, it also burdens the waiting lists of Specialists at the expense of beneficiaries who really need medical care.
It is also noted that, with the renewal of the PIs' contracts in June 2022, the OAY will proceed to introduce quality criteria in their remuneration, with the ultimate goal of per capita remuneration at 70% and remuneration based on quality criteria and performance indicators at 30%. Remuneration based on quality criteria will relate to the provision of specialised services, such as the management of chronic conditions, while remuneration based on performance indicators will relate to the behaviour of personal physicians in relation to the issuing of referrals.
For Specialists, the OAI reports that it has already undertaken a review of the lists of activities, including the weights of each activity, and the use of the capabilities of the IT system to identify and prevent cases of abuse or fraud. It has also established separate budgets per specialty of Specialists, in specialties that cover more than 80% of the total activity of PIs. Further, it has implemented restrictions, guidelines and protocols for submission/approval of claims by service providers, administering drugs and performing inpatient procedures. In addition, the Agency is considering the adoption of mandatory annual tax clearance for providers participating in the GIS.
Implementation of Protocols
With a view to consolidating the tools and mechanisms for the promotion of scientifically based (Evidence-Based) and cost-effective (Cost-Effective) health services within the framework of the GHS and contributing in this way to the qualitative upgrading of the services offered within the framework of the existing legislation, the Agency says that it has started working with the British NICE Agency and the trainings include knowledge transfer on the development-adaptation processes of protocols, quality and efficiency indicators and support in engaging stakeholders in the adaptation processes.
Data analysis and strengthening controls
As mentioned, a major chapter included in the OAH's strategic plan is on data analysis to strengthen the controls the Agency has in place to ensure quality of services while combating abuse.
Among other things, the Agency conducts audits of providers, which are derived from research and analysis of data in the IT system.
To date, he says, dozens of physicians have been investigated, the investigation of which has led to recommendations and the imposition of administrative fines.
In addition, data analysis has led the OAI to suspend the contracts of four specialists, a clinical laboratory, a pharmacy, a personal physician, a health professional, and to terminate the contracts of 1 specialist, 2 personal physicians and 2 laboratories. It should be noted that the Agency is currently investigating the suspension of the contracts of 10 other contracted providers. In addition, audits have identified hundreds of activity claims that the Agency has denied. It is noted that over 1,000,000 claims are received from providers per month.
Creating a beneficiary culture
It is reported that the Agency has received several complaints from PIs, who report receiving pressure from beneficiaries to issue referrals.
To this end, it is noted, there will be a change in the IT system with regard to the period of time that a beneficiary can change PI, as well as the obligation to state the reasons for being removed from the list of a PI.
At the same time, the implementation of a comprehensive information, communication and education programme for beneficiaries of the GIS is planned in 2022, which, among other things, aims to create 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 PI within the GIS. 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 Agency considers equally important its internal organisation and development, as well as the strengthening of controls with the help of external consultants, in order to be able to adequately respond to abuse.
Contents of this article including associated images are belongs Cyprus Times
Views & opinions expressed are those of the author and/or Cyprus Times
Source
