Pharmacy waste, fraud, and abuse in health care reform

Carpenter, Laura A.; Edgar, Zachary; Dang, Christopher

doi:10.1331/japha.2011.10168

Cited by 3 publications

(2 citation statements)

References 2 publications

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“…[29] Due to ACA, total pharmaceutical coverage increased and copayment decreased. [33,35] Medicaid-paid prescription increased by 19 percent in expansion states in compare to states that did not expand the coverage, more over the ACA reduced Opioids Prescription to Medicaid enrollees. [30,36] The prescription assistance programs (PAPs) is still important to cover prescription drug costs for eligible patients.…”

Section: Discussionmentioning

confidence: 99%

Public perception of the United States’ Affordable Care Act

Molla

Bacon-Baguley²,

DeVuyst-Miller³

et al. 2019

IJH

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Background/Objective: Implementation of the Affordable Care Act (ACA) in the US has given opportunity to obtain health insurance for thousands who were previously uninsured. Many believe that the ACA is an improvement over previous insurance, while others view it as making health care more costly. The purpose of this study was to survey individuals regarding knowledge and perceptions of the ACA.Methods: Researchers in public health, physician assistant studies, pharmacy and medical education developed a survey to assess the impact of the ACA. The survey included demographic questions and statements which assessed ACA support, and perspectives of the ACA’s impact on pharmaceutical and medical coverage and personal out of pocket costs. A convenience sampling was used to recruit participants at a public venue in an urban setting.Results: Demographics of the 179 surveyed include: median age 31 years; 84% Caucasian; 37% married; 58% completed a minimum of four years of college; and 45% with income exceeding $50,000. 13 (7%) were uninsured before the ACA, and 8 (4%) after. 130 (73%) had prescription coverage before the ACA with 107 (60%) reported no change in coverage, 22 (12%) better coverage, and 21 (12%) less coverage after the ACA. An association for ACA support was found based on political affiliation with more Democrats than Republicans supporting the ACA (p < .001). 71 (71%) who support the ACA, reported insurance did not improved after the ACA.Conclusions: These findings identify that in a sample of upper middle class individuals, a majority support the ACA despite a lack of improvement in their own insurance indicating that personal sacrifice for the general population is occurring.

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Section: Discussionmentioning

confidence: 99%

Public perception of the United States’ Affordable Care Act

Molla

Bacon-Baguley²,

DeVuyst-Miller³

et al. 2019

IJH

View full text Add to dashboard Cite

show abstract

“…Moral hazard behaviors such as fraud, waste, and abuse in the medical insurance market have caused a major financial impact on the development of health care causes worldwide ( 7 ). Global Health Care Anti-Fraud Network estimated that $260 billion, ~6% of global health care spending is lost due to fraud each year ( 8 ).…”

Section: Introductionmentioning

confidence: 99%

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China

Qin

Liu

et al. 2022

Front. Public Health

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ObjectiveThe huge loss of health insurance funds has been a topic of concern around the world. This study aims to explore the network of moral hazard activities and the attribution mechanisms that lead to the loss of medical insurance funds.MethodsData were derived from 314 typical cases of medical insurance moral hazards reported on Chinese government official websites. Social network analysis (SNA) was utilized to visualize the network structure of the moral hazard activities, and crisp-set qualitative comparative analysis (cs/QCA) was conducted to identify conditional configurations leading to funding loss in cases.ResultsIn the moral hazard activity network of medical insurance funds, more than 50% of immoral behaviors mainly occur in medical service institutions. Designated private hospitals (degree centrality = 33, closeness centrality = 0.851) and primary medical institutions (degree centrality = 30, closeness centrality = 0.857) are the main offenders that lead to the core problem of medical insurance fraud (degree centrality = 50, eigenvector centrality = 1). Designated public hospitals (degree centrality = 27, closeness centrality = 0.865) are main contributor to another important problem that illegal medical charges (degree centrality = 26, closeness centrality = 0.593). Non-medical insurance items swap medical insurance items (degree centrality = 28), forged medical records (degree centrality = 25), false hospitalization (degree centrality = 24), and overtreatment (degree centrality = 23) are important immoral nodes. According to the results of cs/QCA, low-economic pressure, low informatization, insufficient policy intervention, and organization such as public medical institutions, were the high-risk conditional configuration of opportunism; and high-economic pressure, insufficient policy intervention, and organizations, such as public medical institutions and high violation rates, were the high-risk conditional configuration of risky adventurism (solution coverage = 31.03%, solution consistency = 90%).ConclusionThere are various types of moral hazard activities in medical insurance, which constitute a complex network of behaviors. Most moral hazard activities happen in medical institutions. Opportunism lack of regulatory technology and risky adventurism with economic pressure are two types causing high loss of funds, and the cases of high loss mainly occur before the government implemented intervention. The government should strengthen the regulatory intervention and improve the level of informatization for monitoring the moral hazard of medical insurance funds, especially in areas with low economic development and high incident rates, and focus on monitoring the behaviors of major medical services providers.

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Exploring corruption in the South African health sector

Rispel

Jager

Fonn

2015

Health Policy Plan.

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Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.

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Pharmacy waste, fraud, and abuse in health care reform

Cited by 3 publications

References 2 publications

Public perception of the United States’ Affordable Care Act

Public perception of the United States’ Affordable Care Act

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China

Exploring corruption in the South African health sector

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