National Audit Office: EHIF to agree with deficient medical institutions ({{contentCtrl.commentsTotal}})

Health Insurance Fund (Haigekassa) office.
Health Insurance Fund (Haigekassa) office. Source: Siim Lõvi /ERR

According to the report of the National Audit Office, the EHIF (Estonian Health Insurance Fund) was not able to ensure the procurement conditions that the contracts are concluded with capable and appropriate medical institutions. The procurement could also be won by a medical institution which did not have suitable premises, equipment, or staff to provide medical services at that time.

The National Audit Office (NAO) audited six public procurements of the EHIF's specialist medical and nursing care services with a total cost of nearly € 215 million. However, in the case of healthcare, it is important to ensure the procurement results in contracts with compliant institutions, as patients' health is at stake. 

Although the EHIF had largely complied with the Public Procurement Act when organizing procurements in 2018, there were substantial deficiencies in the procurement conditions, which means that compliance with the requirements was not guaranteed. 

According to the audit, there were institutions that applied for a new activity license from the Health Board after winning the procurement and started to provide the service on the premises of the institution without a contract and doctors. 

One of the qualification conditions of the EHIF for the procurement was the existence of an activity license for the provision of health care services, which must ensure that the tenderer's premises, equipment, and other items that have to meet the requirements. However, the EHIF did not carry out any inspections. 

The processing and supervision of operating licenses is the task of the Health Board, but the audit revealed that the Board does not have an overview of whether institutions with a valid operating license actually comply with the requirements.

"As the activity licenses are for an indefinite period, the Health Board has not inspected many institutions providing health care services for a long time," said Mart Vain, the audit manager of the National Audit Office. 

Vain said before 2018, the authority did not always carry out on-site inspections when processing a new activity license, which resulted in uncertainty as to whether the data on-premises and equipment were correct. 

The National Audit Office also identified cases where it was unclear which service provider's activity license the tenderer had to have in order to participate in the procurement. Behind this, the National Audit Office found insufficient cooperation between the Health Insurance Fund and the Health Board in preparing procurements. 

Procurement conditions may have favored new service providers 

The EHIF had also included in the conditions of the tender documents which did not ensure equal treatment between tenderers and did not consider the continuity of the institutions in meeting the requirements. "The same number of points could be awarded to EHIF evaluators by an institution that had been in operation for three years and by an institution that had only provided services for a few months," Vain said. 

For example, an institution did not receive points in the evaluation if it had been instructed or complained about within three years, but no account was taken of whether the institution had existed for three years at all. Thus, the conditions may have favored less existing service providers. 

In the case of outpatient care, the conditions laid down a turnover requirement, but the turnover was not required to be earned for the commission of the specific profession or type of treatment offered but covered the commission of all health care services. The company can achieve a turnover of €4,000 in a short time and easily.  

The companies that blocked the medical history summary of each patient in the health information system received the same number of points in the procurement as those that submitted only two epicrises in total. Thus, they could or if they wished to be submitted immediately before the procurement in order to obtain points. The NAO found that the consistent submission of epicrises to the health information system is an important prerequisite for ensuring the quality of treatment. 

The EHIF did not establish a condition in the procurement that the number of health care workers must correspond to the number of treatment cases, which is why tenders that did not indicate the required number of doctors to provide the desired volume of services were also declared successful . 

For example, two institutions submitted a tender for the provision of outpatient psychiatric services corresponding to a workload of 2.5 doctors. However, the offer included one doctor from both institutions. One tenderer was awarded a contract corresponding to the workload of 1.5 doctors and the other one was of 2.5 doctors. 

In the opinion of the National Audit Office, in such a case there may be malfunctions in the provision of the service or there is a risk that doctors that will start working and whose competence may not meet the requirements 

However, according to the audit, the EHIF mostly complied with the Public Procurement Act. 

As a result of six public procurements organized in 2018, the EHIF concluded contracts with 102 health care providers, the estimated value of which from October 2018 to September 2021 will total almost € 215 million. 

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Editor: Katriin Eikin Sein

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