EH online: Ms Martiny, ten years ago, Transparency Deutschland e.V. prepared the first report on the German healthcare system. What were the key issues then?
Anke Martiny: At the time we drafted the first report the first cases of misdemeanour and fraud by physicians, health insurers and patients were made public. Transparency therefore decided to have a closer look at the German healthcare system whose structure is very complicated and complex. In our federal system the federal states assume certain control functions and they delegated the task of organising the healthcare system to statutory bodies such as the statutory health insurers, physicians’ associations, etc. which are all self-controlled. This set-up makes the system corruption- and fraud-prone.
EH online: Why is that so?
Martiny: Primarily, because of the system’s intransparency. A patient who is insured with a statutory health insurer has no means whatsoever to review the items the physician invoiced to the insurers. And even the insurers cannot tell which physician treated which patient for which disease since the individual physicians do not invoice the insurer, they invoice their physicians’ association. The association collects the invoices and forwards them. That makes fraud pretty easy such as unnecessary repeat-exams or exaggerated prescription of pharmaceuticals. Moreover, the internal structure of the different physicians’ organisations is merely pseudo-democratic as the directors support servile delegates which leads to a kind of “take-what-you-can-get mentality”. This changes only very slowly even though it is the physicians who finance their associations and the high directors’ salaries with their – mandatory - membership fees.
EH Online: In your most recent fourth report on the healthcare system you once again deplored the corruption- and fraud-prone structure. Did anything change in the past few years?
Martiny: Definitely. The most important change we triggered was a change in public awareness. Following the exposure of the invoicing fraud the health insurers established control bodies with the task to recover monies lost through fraud and corruption. Whistle-blowing systems were developed and in 2004, the federal government passed a law mandating the introduction of bodies to fight misdemeanour in the healthcare system. Under this law bi-annual reports have to be prepared and the first two reports were presented to the German parliament.
EH Online: Do you see further room for improvement ...
Martiny: .... certainly. Costs have to be reduced also in order to reduce fraud, squandering and corruption. Germany still maintains one of the most expensive healthcare systems, third to the US and Switzerland – but in international comparison the performance is only mediocre.
EH Online: Why do you think is that so?
Martiny: For example because Germany is the only country where pharmaceutical companies are entirely free to determine their prices. In all other countries prices for pharmaceuticals are regulated. Moreover 17 health ministries – one in each federal state and the federal ministry – do not facilitate the creation of transparent structures. Pharmaceutical companies still pay for the continuing professional training of physicians and they have a strong influence on the European Medicines Agency which is partially being funded from income generated by the authorisation of medicines. The pharmaceutical companies spend a lot of energy on pseudo-innovations while cutting budgets for useful research.
EH Online: In your report you do not deal with the influence of medical technology although this is a growing market in the healthcare system. Why?
Martiny: We assume that in the medical technology sector there is a similar degree of influence-taking than in the pharmaceuticals sector. But so far only isolated incidents were reported and dealt with by the insurers. If you systematically analysed the contract award practices in the medical technology sector I am sure you would find something. But to date there hast not been a substantial initial suspicion. But the medical technology sector of the major manufacturers has not yet been scrutinised. Maybe we are in for a surprise.
To read more, click TI: Corruption and fraud in the German healthcare system.