A pharmacoepidemiological approach to investigating inappropriate physician prescribing in a managed care setting in Israel (original) (raw)
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Prescription Fraud: Characteristics, Consequences, and Influences
Journal of Drug Issues, 1997
This research examines the characteristics, consequences, and potential factors impacting the prevalence of prescription fraud committed by pharmacy employees. Using standard thematic content analysis, 292 cases prosecuted by Medicaid Fraud Control Units throughout the nation are analyzed. Preliminary results reveal that certain kinds of fraud (generic substitution, short-counting, and filling prescriptions without a refill) are committed more regularly, or at least detected more readily than other kinds of fraud. Most of the prosecutions involved pharmacists accused of fraud and many of the offenses were committed in groups. Implications for future research and policy are provided.
Medications prescribing pattern toward insured patients
Saudi Pharmaceutical Journal, 2014
Background and Objective: The rising costs of health care continue to make health insurance important for many countries. Health insurance may cover different aspects of health care in Saudi Arabia including the prescribed drugs. Physicians usually have different personal attitudes toward insured and uninsured patients. This study is to investigate the prescribing behavior of physicians to those groups of patients in the private setting. Design and Setting: A prospective study was conducted during the period between October 2011 and January 2012, in three Saudi private hospitals. Method: Prescriptions for insured and uninsured patients were randomly selected and analyzed. Data regarding diagnosis, age, gender, co-morbidity, number of items and the total cost of the medication in Saudi Riyals (SR) were collected through a chart review form. Results: Three thousand sixty six patients' prescriptions were included in this study, 34.7% of them were females. 273 patients (75.2%) were insured while 90 were not. 24.8% were patients who paid cash. Majority (57.6%) of the patients were with diabetes plus hypertension and other co-morbidity. 20.7% of patients were taking three medications or less, while 67.8% were taking 4-10 and 11.6% were taking more than 10 medications. Analysis of differences showed that, patients who were insured have a higher number of prescribed medications (p 6 0.001), and a higher total price of prescription than those who were paying cash only (p 6 0.001). In a more confirmatory step, all uninsured patients (n = 90) were closely matched in the age, gender, diagnosis and hospital with similar 90 insured patients. Results of this matching process confirmed the above findings.
Fraud in the American Health Care System Takes on Many Forms
An Insider’s View of How Violations are Uncovered and What Happens as a Result The number of schemes to defraud health care insurance are as varied as the services and care providers in the health care field. The opportunities to defraud the system are numerous. As a public service, the Inspector General of HHS publishes a semi-annual report. This report is available online at www.oig.hhs.gov and provides information about recent findings in audits by the Office of Audit Services (OAS), reports of inspections, short-term studies and evaluations conducted by the HHS, Inspector General’s Office of Evaluation and Inspection (OEI). Also disclosed are the outcomes of recent concluded investigations, prosecutions, and settlements by the Office of Investigations, the U.S. attorney, and the OCIG. In addition, the Inspector General publishes the OIG annual work plan, which sets forth the focus of the year in working to identify potential fraud or its intent to review certain areas. For example, the plan lists the focus on elements of Medicare hospitals, Medicare home health, Medicare nursing homes, Medicare physician and other health professionals, Medicare managed care, laboratory services, medical equipment and supplies, Medicare drug reimbursement, end stage renal disease, Medicaid/State Children’s Health Insurance Program, Medicare contractor operations. This document is available to providers, health care insurers, and other interested parties. A Semi-annual Report is provided to congress and highlights the reports, audits and criminal and civil actions concluded in the previous six months. These are easily found at the OIFG website at www.oig.hhs.gov. A major concern has been fraud schemes by pharmaceutical manufacturers and distributors. In the past two years, investigations and prosecutions have led to the recovery of more than $2 billion.
Investigating Physicians\u27 Compliance with Drug Prescription Notifications
2011
The objective of this study was to investigate physicians\u27 compliance with recommendations for drug substitutes embedded within an electronic medical record, to assess factors affecting compliance, and to evaluate associated cost savings. An exploratory study of all physicians in all clinics operated by a large health maintenance organization (HMO) was conducted using a transparent computerized agent that collected 1.21 million prescriptions prescribed by 647 physicians. Compliance with HMO recommendations for substitute drugs reached a 70 percent rate. Substitute type, whether generic or therapeutic, was found to be the most significant factor affecting compliance, with physician workload and age second and third in effect magnitude, respectively. Compliance was found to be non-automatic and selective, following a thoughtful cognitive process. The HMO realized at least a 4 percent reduction in costs for prescribed drugs as a result of compliance with substitute recommendations. ...
How Does Use of a Prescription Monitoring Program Change Medical Practice?
Pain Medicine, 2012
Objectives. The objectives of this study were to test for differences in prescription monitoring program (PMP) use between two states, Connecticut (CT) and Rhode Island (RI), with a different PMP accessibility; to explore use of PMP reports in clinical practice; and to examine associations between PMP use and clinician's responses to suspected diversion or "doctor shopping" (i.e., multiple prescriptions from multiple providers). Design, Setting, Subjects. From March to August 2011, anonymous surveys were emailed to providers licensed to prescribe Schedule II medications in CT (N = 16,924) and RI (N = 5,567). Outcome Measures. PMP use, use of patient reports in clinical practice, responses to suspected doctor shopping, or diversion. Results. Responses from 1,385 prescribers were received: 998 in CT and 375 in RI. PMP use was greater in CT, where an electronic PMP is available (43.9% vs 16.3%, c 2 = 85.2, P < 0.0001). PMP patient reports were used to screen for drug abuse (36.2% CT vs 10.0% RI, c 2 = 60.9, P < 0.0001) and detect doctor shopping (43.9% CT vs 18.5% RI, c 2 = 68.3, P < 0.0001). Adjusting for potential confounders, responses by PMP users to suspicious medication use behavior were more likely to entail clinical response (i.e., refer to another provider odds ratio, OR, 1.75 [95% confidence interval, CI, 1.10, 2.80]; screen for drug abuse OR 1.93 [1.39, 2.68]; revisit pain/treatment agreement OR 1.97 [1.45, 2.67]; conduct urine screen OR 1.82 [1.29, 2.57]; refer to substance abuse treatment OR 1.30 [0.96, 1.75]) rather than legal intervention (OR 0.45 [0.21, 0.94]) or inaction (OR 0.09 [0.01, 0.70]). Conclusions. Prescribers' use of an electronic PMP may influence medical practice, especially opioid abuse detection, and is associated with clinical responses to suspected doctor shopping or diversion.
Potential Fraud in The Primary Healthcare
Jurnal Medicoeticolegal dan Manajemen Rumah Sakit
This study discusses of potential fraud at the primary healthcare. Fraud is more often associated with secondary healthcare, namely hospitals, so that fraud in primary healthcare rarely supervises. Premi of JKN around 38.5 trillion and estimating the potential fraud of around 5% will disappear 1.8 trillion per year. This research used qualitative methods with phenomenological design, as the data are collected using in-depth interview and observation techniques. The number of respondents in this research were 3 public healthcare and 2 private healthcare in X regency. The results showed potential fraud in primary healthcare related to human resources (HR), management of health service, leadership policies, management of capitation funds and operational audits. Penelitian ini membahas potensi fraud pada fasilitas kesehatan tingkat pertama (FKTP). Fraud lebih sering di kaitkan dengan fasilitas kesehatan tingkat lanjut (FKTL) yaitu rumah sakit, sehingga fraud di FKTP jarang ada yang mengawasi. Premi BPJS kesehatan sekitar 38.5 triliun dan diperkirakan potensi terjadinya fraud sekitar 5% maka akan hilang sebesar 1.8 triliun per tahun. Penelitian ini menggunakan metode kualitatif dengan desain fenomenologis, pengumpulan data menggunakan wawancara mendalam. Responden penelitian adalah 3 kepala puskesmas dan 2 kepala klinik swasta di kabupaten X. Hasil penelitian menunjukan potensi fraud pada FKTP bekaitan dengan sumber daya manusia (SDM), manajemen pelayanan kesehatan, kebijakan kepemimpinan, pengelolaan dana kapitasi dan audit operasional.
Eastern Mediterranean Health Journal/Eastern Mediterranean health journal, 2024
Background: Pharmaceutical companies invest greatly in promotional gifts to influence prescription of medications by physicians, yet there is limited published information evaluating its impact on healthcare. Aim: This study aimed to assess the beliefs and practices of physicians in Lebanon regarding promotional gifts and their interactions with representatives of pharmaceutical companies. Methods: This cross-sectional study was conducted between December 2019 and January 2020 through an email-based questionnaire sent to 5936 physicians of different specialties registered in the Lebanese Order of Physicians. Assessment was done using a validated tool and data analysis was conducted using SPSS version 26.0. Results: Of the 268 respondents, 188 (70.4%) reported that physicians in Lebanon accepted gifts from representatives of pharmaceutical companies. Most of the physicians (31.7%) interacted with company representatives more than once a week. Medication samples (251 respondents) and stationary items (222 respondents) were the most common gifts accepted by physicians who admitted accepting gifts. Overall, 225 (84.9%) respondents believed that prescriptions by physicians in Lebanon were influenced by the gifts. Only 74 (40.0%) of those who accepted gifts from pharmaceutical companies believed that it was unethical, and around half did not know if the Lebanese Code of Medical Ethics allowed them to accept gifts from pharmaceutical companies. Conclusion: Although physicians in Lebanon were aware of the effect that gifts from pharmaceutical companies could have on their prescription behaviours, many of them still accepted the gifts. This study provides evidence to policymakers for decision-making regarding ethical guidance on interactions between physicians and pharmaceutical companies in Lebanon.
Health Care Fraud: Physicians as
2016
White collar crimes are characterized by “deceit, con-cealment, or violation of trust and are not dependent upon the application or threat of physical force or violence. Such acts are committed by individuals and organizations to obtain personal or business advan-tage ” (Ref. 1, p 3). Health care fraud is a form of white collar crime that may be committed by health care providers, consumers, companies providing medical supplies or services, and health care organi-zations. There is a trend toward increased participa-tion by organized crime groups in complex health care fraud schemes.2 There are many different types of illegal and unethical schemes that constitute health care fraud. The common types of fraud com-mitted by physicians include billing for services that