Summary Young TI Event - Corruption in Healthcare
Date : 28/06/2016
Corruption in healthcare can mean the difference between life and death. Although it is not often the case, corruption and fraud in the health sector can have grave consequences for patients and cause considerable financial losses for healthcare insurances and taxpayers.
Every country is affected by this phenomenon, although in different degrees. Belgium is not completely spared, with cases erupting once in a while.
For this edition of the Young TI chats, which also marks the first of a series on corruption in healthcare, we asked 2 speakers to share their professional experience in countering corruption in healthcare.
- Ms. Julie Bonhomme is Deputy Director Legal Affairs & Compliance at the European Federation of Pharmaceutical Industries and Associations (EFPIA).
- Mr. Paul Vincke is Managing Director at European Healthcare Fraud and Corruption Network (EHFCN) and Director of Staff at National Institute for Health and Disability Insurance (INAMI-RIZIV).
INTRODUCTORY REMARKS by Mathieu Maes, Board Member of Transparency International Belgium
Mathieu first spoke of his personal experience with corruption in healthcare: he was in South Korea where healthcare was not available to people with limited financial means. He was adopted by a Belgian family, which saved his life.
He then moved on to speak about the United Nations' 18 Sustainable Development Goals introduced in 2015. He explained that none of the goals could be achieved if corruption is not tackled as it is the common thread between all the issues that need to be corrected. For example, referring to goal n°13 "Good Health and Well-being", one cannot get fair conditions for health if corruption exists as it gets in the way of accessibility to healthcare.
For Julie Bonhomme, one of the way to fight corruption is to issue ethical rules and ensure that the rules are respected.
She works for EFPIA, which is an Europeanorganization which promotes the technological and economic development of the pharmaceutical industry in Europe, with the aim of improving human health worldwide. EFPIA is composed of 33 national organizations and 41 leading companies of the sector.
EFPIA is convinced that relationship between healthcare professionals and organisations is important in order to improve treatments for patients, in an effort to try and put codes and guidelines in place to meet the highest ethical standards to ensure the best possible care. Through the EFPIA, the industry commits "to working towards greater transparency, accountability and ethical behaviour ".
The key ethical principles of the EFPIA are the following:
- keep patient at the heart of their work
- act with integrity and respect
- support independent decision making
- are transparent about what they do.
The EFPIA bases their work on the EU Directive 2001/83 as well as national laws. They have then developed 3 codes which regulate practices in the healthcare sector. They set general standards, which shall then be adopted as such at the national levels or toughened. Member countries are then in charge of their implementation and enforcement. The industry then needs to follow the regulations in place in the country they wish to do business in.
HCP Code - Code on the Promotion of Prescription-only Medicines to, and Interactions with, Healthcare Professionals.
This code regulates the relationships between the industry and healthcare professionals (HCP). The code intends to ensure the transparency of promotion, as well as regulates the spending on events & hospitality for conferences and congresses for example, donations & grants as well as on medical samples.
This code also prohibits gifts as they could be interpreted as bribery. As Ms. Bonhomme, "if a physician needs a pen, he can buy a pen, he doesn't need to get one as a gift from the industry". Nevertheless, informational and educational material and items of medical utility has been introduced in the Code, as long as they are inexpensive and are for the benefit of the patient. PO Code - EFPIA Code of Practice on Relationships between the Pharmaceutical Industry and Patient Organisations
This code regulates the relations between the industry and patient organisations.
It prohibits the promotion of prescription-only medicines. Promotion of medicine is then limited to healthcare professionals. It also requests pharmaceutical industry to disclose the financial and non-financial support provided to patient organisations. Disclosure Code
This code demands all of the industry to disclose all their "Transfers of Value" given to HCPs and HCOs at least on their websites. Some countries have developed their own platform where all the information is centralized at the national level. The aim is to "secure the integrity of the decision and encourage a consistent disclosure approach".
This is applicable to all EU member states as well as Switzerland, Turkey, Norway, Russia, Serbia and Ukraine.
Regarding the enforcement of the Codes, the member associations are in charge of it. Verifying the concrete applicability of ethical rules is probably the most important step in fighting fraud and corruption in the healthcare sector.
Paul Vincke started by making a declaration of non-conflict of interest. Indeed, he works for the EHFCN and is a civil servant at INAMI, the Belgian federal health insurer. But INAMI is a founding member of EHFCN, which is a membership-based non for profit NGO which helps its members to be more efficient and effective in their work.
All members of EHFCN must have a department dealing with fraud and corruption. Members include INAMI in Belgium, Assurance Maladie in France, Nederlandse Zorgautoriteit in the Netherlands, the Ministries of Health of Serbia and Poland… As well as TI international!
When talking about fraud and corruption in healthcare, it is important to take the reputational factor into consideration as it can make or break a career, a firm, etc.
Corruption and fraud in healthcare has been considered too big to tackle for a long time until the 2008 financial crisis where the need to cut expenses forced health care organisations to address the issue as it was causing an important loss of revenues.
There are many examples about fraud and corruption in healthcare, some bigger than others, most staying under the radar.
Examples include a scandal in Romania caused by a disinfectant that had been diluted by the manufacturer in order to increase its profit.
The second example given by Paul Vincke was that of Italian doctors from the "clinic of horrors" (Santa Rita clinic in Milan), where unnecessary procedures were carried for financial gain. The chief of the hospital was sentenced to 15 years of prison.
Faced by a number of cases which have emerged since 2008, the European Commission's DG Home commissioned a report on corruption in healthcare which was released in 2013. The report was based on interviews and outlined 86 corruption cases. A follow up is expected for the second half of 2016.
In addition to corruption and fraud, "waste" also needs to be tackled in the healthcare sector. It is defined as "healthcare spending that can be eliminated without reducing the quality of care". This also allows for savings as well as is in the tax payers' and the patients' interests.
Reducing waste involves reducing inappropriate and low value care, which can be done by reducing overconsumption, which happens when doctors over prescribe.
Overconsumption can sometimes be done out of self interest and personal gain.
A case in Belgium clearly outlines this type of fraudulent practice: a surgeon was always working with the same knee brace company which charged the health insurer twice instead of once, in return for a part of the profit made. The case was exposed thanks to the people who took over the company involved in this illegal business.
Although the company owner has been charged, the surgeon still runs freely.
Paul Vincke insisted on the risk of conflict of interest which happens to be a root cause of corruption in the healthcare sector. He suggests that accountability and integrity management should be implemented everywhere, but especially in hospitals, as proven effectively in hospitals in Italy which have put in place such mechanisms.
Question: How to tackle corruption when gov officials are involved?
Answer: Just like doctors, government officials sign codes of conduct whereby they declare that they will work deontological.
Julie Bonhomme also reminded the importance of following EFPIA codes where government officials are in the scope and Paul Vincke stressed the importance of enforcement mechanisms.
Both agreed that government officials were seldom involved in corruption cases in Belgium, but that it was certainly the case in other European countries, especially in Eastern Europe.
Q: Is giving a box of chocolate to your doctor considered as a gift?
A: Yes, and there should be zero tolerance towards that kind of practice, Paul Vincke reminded us. A person in the audience reminded that this was a common practice in certain countries, especially in dire times where scarce resources can be as valuable as large sums of money.
Q: How to regulate off the market medicine?
A: In many countries, especially outside of the EU where healthcare accessibility is difficult, many people buy medicines online for the reason that they are cheaper or illegal in their countries. This of course raises concerns as such sensitive products can be dangerous for patients as they could be counterfeits.
A: There has been a big controversy following the pharmaceutical industry's campaign against under the counter drugs, said Mathieu Maes. This campaign has, however, been rejected by the delegates at the General Assembly of the European Healthcare Fraud & Corruption Network, as the campaign was deemed as "playing the game of the pharmaceutical industry" and further increasing their monopoly on healthcare products.
Q: What about the problem of monopoly, notably in regards to medical instruments that companies know patients cannot live without? What about the prices of certain instruments, like wheelchairs which cost a fortune, and which prices are high because the industry knows patients' will be reimbursed by their health insurance?
A: Both speakers reminded the audience that developing new medicine and medical instruments are expensive. Paul Vinckealso agreed that overconsumption and monopoly can indeed be an issue in some cases, and the industry largely benefit from the lack of competition.
Click on "download" at the bottom of the page to download the speakers' presentations.
This discussion was the first one on the topic of corruption in healthcare.
Another #YoungTIchat will take place in October. Please let us know which specific aspect of the issue you would like to see covered by fill in this form.
Thank you to our speakers, Julie Bonhomme and Paul Vincke for sharing their expertise on the issue.
And thank you to everyone who joined the discussion.
We hope to see you all at the next #YoungTIchat in September!
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