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- Ελληνικά
The Health Insurance Agency's action plan seeks to effectively address abuses,
As we approach the three-year anniversary of the GHS, its contribution is a given and is confirmed by the way beneficiaries embrace it. The challenges, however, remain enormous and ongoing. Every day, the Health Insurance Agency is called upon to oversee, identify and manage a huge number of providers, beneficiaries and claims with the sole aim of providing optimal health care services.
One of the major problems undermining the sustainability of the GIS is none other than the exploitation of the System, by providers and beneficiaries, for their own benefit. The abuses that have been identified recently, resulting either from complaints or from the supervisory audits carried out by OAI, must be addressed immediately and effectively through the collective effort of all stakeholders.
Recognizing the existence of the problem, OAI has taken a series of measures, drawing up an action plan to address the abuses. The aim 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 for the first time allowed citizens to have access to services and medicines that 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.
What we all need to realize is that exploitation and abuses do not hurt the System, but the beneficiaries and providers themselves.
The Health Insurance Agency's strategy to address abuses is not only focused on punishing violations, but primarily on preventing and detecting them. It is important to make targeted moves that will educate providers and beneficiaries as to their behavior within the System. The main pillars of the OAS action plan are. Behavioral/operational audit of providers contracted with the Agency.
2. Analysis of data and strengthening of controls.
3. Creating a culture of rational use of the System by beneficiaries and encouraging beneficiaries to report abusive activities.
4. Organization, staffing, development and improvement of procedures.
EPROVIDER OPERATIONS
- Personal Physicians
Starting from the institution of Personal Physician, the first observation concerns the large number of referrals issued to Specialists. 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 undermines 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. The Agency has repeatedly stressed the importance of the role of the PI for each beneficiary. It has also explained that the PI is, in addition to being each beneficiary's first point of contact with the GHS, the health professional who has the knowledge and experience to properly guide the beneficiary through the System.
It is also noted that, with the renewal of the PIs' contracts in June 2022, OAY will move to introduce quality criteria in their remuneration, with an end goal of 70% per capita remuneration and 30% remuneration based on quality criteria and performance indicators. 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.
- Specialists
The Agency 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 evidence-based and cost-effective health services within the framework of the GHS and thus contributing to the qualitative upgrading of the services offered within the framework of the existing legislation, the Agency has started to cooperate with the British NICE. The Agency has already organised a training workshop with NICE in December 2021. The aim of the collaboration with NICE is to develop expertise in the supporting mechanisms of the OAI and to establish working groups in collaboration with the medical community and patients to adapt protocols and guidelines in Cyprus. In particular, trainings include knowledge transfer on the processes of development-adaptation of protocols, quality and efficiency indicators and support in engaging stakeholders in the adaptation processes.
DATA ANALYSIS AND ENHANCEMENT OF CONTROLS
A major chapter included in the OIA's strategic plan is on data analysis to enhance the controls available to the Agency to ensure the quality of services while combating abuses.
Among other things, the Agency conducts audits of providers, which result from investigation and analysis of data in the IT system.
To date, dozens of physicians have been investigated, the investigation of which has led to recommendations, as well as 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 care 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 per month from providers.
BUILDING A CULTURE OF BENEFICIARIES
As noted above, the Agency has received several complaints from PIs who report being pressured by beneficiaries to issue referrals. Otherwise, beneficiaries threaten to be removed from the list of the PI in question. To this end, there will be a change in the IT system regarding the period of time that a beneficiary can change PIs, as well as the obligation to state the reasons for being removed from the list of a PI. At the same time, a comprehensive information, communication and education programme for beneficiaries of the GIS is planned to be implemented in 2022, which, among other things, aims to create a culture for the proper use of the System and reduce abuses, as well as to inform beneficiaries about their rights and obligations and the importance of the role of PIs within the GIS. In addition, one of the main objectives of this programme is also to educate/encourage beneficiaries to report abusive activities.
ORGANIZATION, STAFFING, DEVELOPMENT AND IMPROVEMENT OF PROCEDURES
In addition to dealing with beneficiaries and providers, the Agency considers equally important its internal organization 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.
As has been repeatedly emphasized, the GHS is a living System that is open to continuous improvement. The priority of the OAI is to monitor its evolution and intervene effectively, both to correct any distortions and to further improve the services provided.
The needs of the beneficiary and quality service are at the heart of the operation of the GIS, which remains purely person-centred. This social dimension of the reform is also the highest priority of the Health Insurance Organisation, aiming at lifelong equal and unhindered access to quality health care services for all citizens.
(MB/IC)
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