How to control medical fraud epidemic
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The first is that local governments may see the issue as largely one of shifting resources from one pocket of the government (medical insurance) to another (public hospitals). That would be a mistaken view partly because the frauds of course will raise the out-of-pocket payments that citizens have to make and partly because fraud reduces the amount of healthcare that could otherwise take place.
The second reason is the embarrassment factor. Generally, public agencies across the world are not keen to concede that 5 or even 10 percent of the money they spend is fraudulent.
Third, fraud measurement, prevention and investigation all costs a lot of staff and money and many local governments don't have the resources to invest up-front in tackling the problem.
But looking at these issues as opportunities throws a different light on the situation. Undertaking fraud loss measurement exercises gives local leaders the chance to show they are addressing the issue and finding solutions. In the United Kingdom, the National Health Service Counter Fraud Service reduced the amount of fraud losses by up to 40 percent in just two years.
Knowing the extent of fraud also provides justification for providing more resources to fight it. Best of all, reduced losses and recoveries of stolen funds can be channeled back directly into the fight against fraud. In the UK, we calculated that we had saved or recovered 12 for every 1 we spent. In the United States, officials claim an even higher benefit cost ratio of 15:1.
In terms of how to tackle fraud, a combination of strategies is required to be adjusted to the particular context of a country's health system. The World Health Organization annual report of 2010 identifies 10 ways of making health resources go further and many of them include addressing aspects of fraud and corruption such as tackling inappropriate and over-prescription of medicines and services, promoting greater use of generic drugs and tackling counterfeit and substandard drugs.
The general thrust of public hospital reform program, from reducing the reliance on income from sale of pharmaceuticals and increasing budget support and introducing performance related pay for doctors to developing clinical pathways to curb unnecessary services and charges shows great promise. But these changes are likely to have a long-term impact only if they are made systematically and resources are made available to monitor and fight fraud on a long-term institutional basis.
Most importantly, the vast and honest majority of medical system staff members and the wider public need to be educated and mobilized to tackle the issue. Staff members at all levels should understand what fraud is and how they can report and be taken seriously without fear of retribution. The public, whose pockets are being picked, need to be told that being involved in frauds like lending their insurance cards may have costly implications for them and their families when they most need help. We have to recognize that the fight against fraud is a fight for our future.
Grayson Clarke is resident fund management expert with the EU-China Social Security Reform Project, and Jim Gee is the chair of the Centre for Counter Fraud Services at the University of Portsmouth and director of counter fraud services for PKF UK Ltd.
