In the case of abuse in healthcare, several concepts are lumped together: lack of integrity, fraud, corruption. Not even in response to parliamentary questions about the Isala case does Minister Helder distinguish between fraud and corruption. However, these expressions do not have the same meaning.
Fraud in the healthcare system concerns misuse of insurance funds. For example, a health care provider declares a service that was not provided and aims to obtain a financial advantage at the expense of the patient or health insurance. Health insurance and NZa have instruments to combat fraud. Fraud can also lead to criminal prosecution or an administrative fine.
In cases of corruption, people working for health care providers are offered (or asked for) bribes to do or not do certain things in return. This is at the expense of the care provider and ultimately also of the quality of and access to care. Corruption on the part of health services affects the relationship of trust between the patient and the doctor. The patient assumes that the health nurse makes a decision based on her professional assessment. When the material assessment is mixed with business or personal considerations, it affects the treatment relationship. The letter from Heart Patients Netherlands mentions this.
In addition to fraud and corruption, the importance of integrity in the health care system is emphasized. Integrity is a broader concept than fraud or corruption. Successive cabinets have announced the Ethical Business Conduct Bill for health care providers, but it is not yet very clear what it will contain.
Is the healthcare system at risk? Is FIOD rightly aware of it? This is what experts think (see recommendations and the FD article). They point to the complexity of the healthcare system, the large number of actors involved in transactions, information asymmetry between doctor, patient, insurer and healthcare institution, the hospital’s lack of insight into the specialist’s activities., the large financial interests and the imperfect and globalized market for medicine and medical equipment.
Codes of Conduct
The health sector also recognizes the risks themselves. Therefore, there are rules of conduct and codes that aim to promote integrity. For example, there is a code of conduct for pharmaceutical advertising that aims to promote responsible cooperation between the pharmaceutical industry and those who prescribe or dispense. Also of great importance is the Medical Devices Code of Conduct (GMH), which contains detailed rules on the prevention of undue influence and, by extension, rules on documentation of interactions between healthcare personnel and suppliers. This also includes internal reporting obligations and external registers such as the Health Transparency Register. There are also security measures within institutions in the form of rules of conduct or reporting obligations.
Despite all the laws, codes and rules of conduct, there will always be those who break the law. FIOD is hoping that tipsters can start a criminal investigation. These tips may, for example, relate to questioning certain suppliers or procurement processes.
However, before FIOD is tipped off, the health institutions could also do everything necessary themselves. The health institutions would therefore be wise to ensure that tipsters are free to report possible abuse internally. This can already prevent unnecessary attention from the investigating authorities.
Reporting must make sense. This requires an accessible, effective internal procedure for such reporting persons. Even more important is the knowledge and resources to actually investigate such reports. Where necessary, health institutions must also implement improvements and tackle abuse. Above all, it requires a culture that makes it possible to create and follow up on the reports efficiently. It is a management responsibility.
Care institutions naturally want to prevent the FIOD’s and the prosecution’s criminal investigation from being necessary. This requires first of all (if not yet) awareness of the aforementioned general corruption risks and knowledge of the rules that apply to prevent them. Such awareness then leads to knowledge of the specific processes in which these risks manifest and sufficiently robust procedures to manage these risks, for example when dealing with suppliers. The documentation and transparency obligations from GMH are an important basis in this regard. This enables the healthcare institutions to prevent errors and partially repair them themselves. Of course, everyone involved in vulnerable processes must be aware of this. This prevents corruption and saves the healthcare system from damage caused by criminal investigations.
Hopefully the investigation at Isala and the announcement from FIOD to the health institutions is therefore a warning – and not the start of a trend.
Through: Vincent de Bruijnlawyer at AKD Benelux Advokater