177. The main mechanisms used to ensure the availability of economic justification for the project include: device management reviews, audits and claims, and monitoring subscriptions, and inspections of clinical, screening and the main categories of claims service providers. Most of interventional procedures and reviews the relevant control and are today manually, a method is not only costly in time and human resources, but it is also likely that efficient in terms of costs with respect to returns. It will be the implementation of the Information Management System modern and efficient point of payment from doing these activities more effective manner. The main objectives with respect to sub-optimal use of resources and include the following: organized fraud and illegal acts of service providers and users, and behaviors of exaggerating the health services offered by service providers to maximize their income, which, poor medical practices. There are also other potential benefits, such as improving administrative efficiency and monitor adherence to the payment of contributions.
178. project investments – occur once fully implemented – impact on all areas that cause problems, as we discussed earlier. It is unrealistic in any case expect to solve all the problems completely, because many countries still enjoy much greater expertise in monitoring spending on health services suffer from these problems, albeit to a lesser degree.
a thousand. Manipulation, fraud and poor distribution of resources so the caller
179. There are different forms of manipulation, fraud and behaviors illegal ranging from business affect the entire system and colludes in which several members of both sides and users of service providers for the purpose of financial gain or get other benefits from the system and practices fraudulent service providers at the individual level in the range but it frequently is limited. It is also likely that there will be other types such as these behaviors, but the evidence of the practice of manipulation and fraud are not easily identifiable.
180. General Authority for Health Insurance has been able to present through revisions and manual checks computational claims submitted her from revealing the behavior of manipulation and fraud, such as claims for non-medical items. Despite the absence of further evidence methodology at the level of manipulation and fraud in Egypt for lack of a good system to provide management information, refer evidence from countries like the United States where there is also a fragmented health financing system to a large extent – that manipulation and fraud level in the billing It may range from 3 per cent to 10 per cent of total health care expenditures. In countries that have anti-manipulation and fraud programs are less developed significantly and information systems of lower quality and management, although it is the structure of health insurance by the regulations may vary but there are – beyond any doubt – manipulation and fraud and then poor distribution of financial resources, and perhaps they were approaching the level of the maximum estimated at 10 per cent.
181. The environment lacks a system for the management of claims electronically means that the anti-manipulation and fraud is one of the things that beset by problems, however, such a system along with the basic programs to combat manipulation and fraud should occur, an effective impact, since they may Ihbtan nearly 25 per cent manipulation of existing activities. And therefore making it difficult to confirm until the introduction of such electronic systems. Assuming that the potential for fraud percentage is 10 per cent of total health care expenditures, the resulting combination of claims management systems and software anti-manipulation and fraud, case work with them after three years, for example, for providing 2.5 per cent of total health care expenditures, or about 123 million dollars a year.
B. Exaggerating the health services offered by service providers to maximize their income by
182. percentage of service providers will actively looking for ways to manipulate their payment in excess of the entry system, based on the current and future nature of this system. Of course, this is to be expected, but if they are not combat it could lead to higher costs and then departs from that complies with best practices. It is difficult to assess the extent of these activities in Egypt because of the lack of data, but it is logical to assume that these activities may represent 10 per cent of total expenditure.
183. If our means to control such activities are in close and systematic monitoring of the process to take advantage of services and identify the emergence of behaviors are not acceptable, and then modifying the regulations and rules of repayment to curb these activities. We must make some effort in both operating and management information system, which will be provided through this project and the process of institutional capacity, which coincides with the work by the Egyptian government to Atsidia of this issue building. It is expected that this type of behavior that is resistant to change, but it is necessary to work to reduce these behaviors by about 20 per cent – the equivalent of 2 percent of total health care costs, or about $ 98 million annually.
Jim. Bad medical practices
184. The measure of good medical practice is extremely difficult for a number of reasons, including the disparity in the identification of best practices. The assessment of the health care technology – a special field to analyze the quality of health care, and the field to develop a standard policy for health care – is applied to a growing application in the OECD countries in the economic field. However, this assessment literally requires access to high quality data, which will be strengthened when developing project investments place of execution. Regardless of the lack of evidence in the beginning on the occurrence of medical errors in Egypt, it would be reasonable to conclude that 20 per cent at least a portion of all health costs related to medical treatments is not the best practice.
185. Judging by the evidence available at the international level on clinical practices and ways to address the glitches it is reasonable to assume that the combination of the information that will be provided through this project and the process of institutional capacity building and the development of programs that will be carried out by the Egyptian government system – will lead to reduce the financial impact of bad practices by 10 per cent, representing 2 per cent of total health care costs, or approximately $ 98 million annually.
D. Increase administrative efficiency
186. Evidence derived from different health care systems indicate that the administrative costs of health care can be high. For example, select a percentage of estimated administrative costs in the health system in the United States at 30 per cent. And it operates the fragmented nature of the system of the United States and the Egyptian regime – both – to pay these costs to increase as a result of what was happening in the past from economies of scale and duplication management systems. On the other hand, show evidence derived from systems with more compact purchasing systems bodies there are administrative costs that the general system of between 10 per cent and 12 per cent, much less than the fragmented systems.
187. The replacement of claims management system is based on the paper more efficient electronic system will lead to a significant reduction in cost per transaction – ideally less than one US dollar per claim. In addition, the introduction of links to service providers to enable them to file claims electronically to reduce the rate of rejection of claims, which is associated in the habit cost increase for the service provider to the point of payment will result.
188. difficult to determine line numbers for transaction costs and rates based on claims rejected because of the current system based on the use of paper documents and the organizational structure of the General Authority for Health Insurance that lead Doreen: hand payment service provider. However, it is possible to compare a new push anti-organized with or without use of management information system. At the international level, often the cost of processing paper claims is $ 7 per claim in exchange for almost one dollar to demand processed electronically. It is also reasonable to assume that the applicability of the relative difference in costs over Egypt. While acknowledging that the expected volume of claims outpatient clinics in Egypt is 460 million claims a year, it is clear that even then reduce the cost per transaction to US $ 1 will lead to the provision of US $ 460 million annually.
189. At a time when the potential savings in the administrative aspects associated with using a single purchaser of services is equipped with modern technologies trained cadre of managers and administrators – is a big saving and whatever, there are many factors that may limit the ability to achieve this administrative savings, such as the complexities involved in implementing the program organizational restructuring of this magnitude. Therefore, a very conservative estimate of the savings in the administrative aspects ranging from 1 per cent to 2 per cent of the total spending on health care services, or about US $ 73 million annually.
190. The new entity will be Almtkvlh to pay the health insurance system – enhanced development project costs of health systems – in a position to face the issues of accountability and transparency very important connection with the financing of health services and provide them in Egypt. But the project will contribute specifically to build the capacity of management and technical capacity Alehioatin in this side with the continuation of reduced administrative costs.
191. The following table summarizes the combined effects of these benefits on the total expenditure on health care in the year.
A summary of the effects of the project
The problem effectiveness of the program estimate the total impact
Manipulation and fraud 10% 25% 2.5%
Overstate the cost of services to maximize income 10% 20% 2%
Bad practices 20% 10% 2%
Administrative efficiency 10% 10% 1%
GDP at the national level of 7.5%
US $ 370 million a year
Total project (in the three pilot provinces) of US $ 111 million a year
Note: World Bank staff estimates based on international and national evidence.
192. based on the total annual revenue of US $ 370 million a year above the national coverage and health care spending estimates. It may also have been an analysis of the total annual revenues are also the three pilot provinces which will run Health Insurance Systems Development Project. Based on current data on the level of health care expenditures in the three provinces where the project is implemented as a share of total spending on health care, and in the light of the evidence shows that per capita health care spending in this higher than the national average provinces, any conservative estimate will explain that