The history of/eliminating fraud and abuse in health care

Eliminating Fraud and Abuse in Health Care
Name
Institution

Abstract
The demand for health care is growing at an exponential rate, but access is controlled by willingness and ability to pay, cost and availability of the care, which creates an opportunity for both fraud and abuse. This is based on the understanding that health care fraud and abuse are unethical practices that increase costs by benefiting the perpetrators who benefit from the subject transaction while having an adverse effect on the other stakeholders who did not participate in the transaction. It has been noted that fraud and abuse are caused by competition, need to improve market position, local cultures, and the need to protect local investments by engaging in quid pro quo trade. Given that fraud and abuse have a negative impact on health care access and costs, not to mention being unethical practices, it is understandable that these practices should be curtailed. The unethical practices should be curtailed through greater oversight, inclusion, and control. In addition, they should be addressed by setting up clear rules on acceptable conduct, better policing, and stiffer penalties for the perpetrators of the corrupt practices. Overall, the incentive for fraud and abuse should be reduced through sanctions and audits so as to improve health care access and costs.

Eliminating Fraud and Abuse in Health Care
Introduction
The demand for medical care is growing at an exponential rate and is dependent on the observed need and utility of health care services as noted in population-based statistics.

In spite of the snowballing demand for health care, access is managed by the willingness and ability to pay, costs, and availability of the care thereby creating an opportunity for both fraud and abuse to occur (Getzen, 2013). It is based on this awareness that medical audits becomes pertinent and influence access to health care services since it is noted that accountability for use of resources ensures that most of them are used in the right way. Still, there is the aspect of institutional (industry) related factors that are often overlooked but affect access to health care through fraud and abuse related factors. These include individuals’ propensity for fraud, absence of well elucidated codes of conduct, and absence of oversight (Tietelbaim & Wilensky, 2013). In this respect, health care structures present an opportunity for fraud and abuse with the current paper evaluating these opportunities and proposing appropriate strategies for addressing them.
Concept of Fraud and Abuse in Health care
It is acknowledged that cases of fraud and abuse have an adverse effect on health care services delivery and access, explained on the basis of introducing unethical practices and increasing health care costs for most persons. With such increased cases and incidences, patients are likely to suffer since they are placed in an unfamiliar environment where the irregular practices increase their cash burden without guaranteeing high quality access. It then becomes a question of who or how much rather than what is the need (Feldman, 2011).
In the same vein, it is accepted that fraud and abuse are terms that can define as the sale of public services and goods for personal gain. This is equivalent to corruption by the persons put in charge of the public resources with their intention being to have personal gain. It must be noted that the law plays an important role as a protector of all stakeholders who include patients and medical personnel. Whereas a host of factors may affect health care quality, there is no doubt that both fraud and abuse affect health care access (Patel & Rushefsky, 2015). While fraud is beneficial to the particular stakeholders who benefits from the subject transaction (such as a patient receiving preferential treatment and a nurse being paid to offer the preferential treatment), there is likely to be an adverse general effect of making it difficult for other patients to access medical care. This is seen when those who meet the publicly set criteria are overlooked in place of their counterparts who do not meet the set criteria but can offer some advantage to the individual who determines which person receives care and how (Feldman, 2011).
Causes of Fraud and Abuse in Health care
According to the existing literature, greater oversight, inclusion, and control should reduce the incidence of fraud and abuse in health care delivery. That is because these measures improve industry competitiveness and efficiency while encouraging good norms, values, and governance. This is, regrettably, a mainly unfeasible deduction that fails to contemplate the subjective nature of medical facilities and their strategic relationship with the public. To survive in a competitive environment, medical facilities must take advantage of their opportunities. These environment-specific advantages are required to overcome the bottlenecks that could exist within that environment. This means, therefore, that there are certain opportunities that the management of medical facilities must have for them to be successful, and these opportunities must be sufficient to defeat the challenges experienced in tackling the competitive environment (Harris, 2015).
In an ideal world, the assets owned by a medical facility would be marketing and managerial capacity and skills, and advanced technologies that allow it to venture into a competitive environment. Because of the implications of the decision to offer public services, health care facilities will find that they are motivated to protect their investments by adapting to the local market, such as offering bribes to acquire permits. This is the start of appreciating the fraud and abuse undertaken by health care stakeholders in competitive environments (Emanuel, 2014).
Although it has long been recognized that the costs and uncertainty that are brought about by fraud and abuse deter stakeholders, there is a consensus that not all stakeholders will be resistant to such practices and there is a need to contemplate the subjective reactions of some stakeholders when assessing fraud and abuse in health care. There is indeed substantial proof that there are health care facilities and personnel who quite willingly participate in the quid pro quo trade to expand their interests and horizons. This is the reason why there is a need to consider the distinguishing qualities of health care facilities and stakeholders so as to define their strategic plans in relations to the public and the effects that the strategies will have on their fraud and abuse (Teitelbaum & Wilensky, 2013).
There is confirmation from political economists that fraud and abuse are caused by the lack of competition and scarcity of resources, which would generally mean that it is prevalent in areas with weaker governance structures. To secure their position in these environments, the medical facilities and stakeholders may find that they have to offer bribes to regulatory officials and indeed do so to secure and maintain their position within the industry. This is coupled with new medical technologies, capital-intensive nature of the industry, and differentiation. In addition, they use the corrupt structures afforded by fraud and abuse to influence and collude with other stakeholders to improve market position (Teitelbaum & Wilensky, 2013).
Addressing Fraud and Abuse in Health Care
It is acknowledged that fraud and abuse in health care must be addressed. This would entail avoiding the attitude of characterizing health care as fraudulent and abusive since perpetrating such practices enables them. This would include instances when the local culture is not well understood or even contentious and complicated. That is because failing to understand the local culture for doing business creates an opportunity for corruption as a way of compensating for shortcomings by buying or selling entry (Feldstein, 2011; Yoder-Wise, 2013).
An example of this is seen in the numerous cases of physicians who were influenced by their colleagues to file false insurance reimbursement claims as a normal way of doing business. The result of this is that insurance companies are forced to pay out a lot of money and increase their premiums to cover the costs thereby increasing the financial burden on the public. The situation is worsened when participating medical personnel is identified and prosecuted thereby reducing the number or practicing medical personnel and placing a greater strain on the scarce medical resources (Feldstein, 2011; Yoder-Wise, 2013).
Yet another instance can be seen in the case of physicians and pharmacists receiving kickbacks from pharmaceutical companies to recommend their products while ignoring others that may be more advantageous. Addressing this concern would require clear rules on acceptable conduct, better policing, and stiffer penalties for the perpetrators of the corrupt practices. In essence, there will be a lower incentive to take part in abuse or fraudulent activities since there is the threat of sanctions hanging and audits. It is noteworthy that the law prohibits giving out anything of value, and not just money, for the purpose of influencing health care access (Feldman, 2011; Getzen, 2013).
Conclusion
One must accept that the increasing demand for health care is creating an opportunity for fraud and abuse through the patient-related, physician-related and institutional-related factors that affect demand for health care. In addition, one must acknowledge that fraud and abuse introduce unethical practices and increase health care costs. This occurs through the subjective nature of medical facilities and their strategic relationship with the public. In fact, there is substantial proof that there are health care facilities and personnel who quite willingly participate in the quid pro quo trade to expand their interests and horizons. Addressing fraud and abuse concerns would best occur through setting up clear rules on acceptable conduct, better policing, and stiffer penalties for the perpetrators of the corrupt practices to act as deterrents. Therefore, health care structures present an opportunity for fraud and abuse that can be addressed through institutional changes.

References
Emanuel, E. (2014). Reinventing American Health Care: How the Affordable Care Act will improve our terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error prone system. New York, NY: Public Affairs Publications.
Feldman, A. (2011). Understanding Health Care Reform: Bridging the gap between myth and reality. Boca Raton, FL: CRC Press.
Feldstein, P. (2011). Health Care Economics. Boston, MA: Cengage Learning.
Getzen, T. (2013). Health Economics and Financing (5th ed.). Hoboken, NJ: John Wiley & Sons.
Harris, M. (2015). Handbook of Home Health Care Administration (6th ed.). Burlington, MA: Jones & Bartlett Learning.
Patel, K. & Rushefsky, M. (2015). Healthcare Politics and Policy in America (4th ed.). New York: Routledge.
Teitelbaum, J. & Wilensky, S. (2013). Essentials of Health Policy and Law (2nd ed.). Sunbury, MA: Jones & Bartlett Learning.
Yoder-Wise, P. (2013). Leading and Managing in Nursing (5th ed.). Amsterdam: Elsevier Health Sciences.