The United States health care system is among the most extensive and the most prone to fraud and misappropriations. The health system includes public and private practitioners, insurance plans, medical corporations, and treatment facilities. The United States health care system receives 15.2% of the gross national product, from which 3 to 10% is lost through medical fraud (Rosoff et al., 2020). The United States loses hundreds of millions in the health care system making medical crime one of the highest white-collar crimes in the country. Considering the sensitivity of the health sector, medical crimes have severe consequences on the life and safety of the citizens. The extent of public risk due to medical crimes exceeds medical ethics and includes legal interventions. Medical crimes are crimes against humanity since failure to deliver services and misappropriation of health benefits risks the life of many desperate patients whose trusts were on the health officers. Medical crimes can take many forms and can be either commission or omission of duty in public service. The most common form of medical crimes includes the sale of equipment, theft, homecare and hospital frauds, health care insurance fraud, abuses of nursing homes, fertility, and research fraud. Medical crimes betray public trust as they defy humanity and the code of ethics in public health.
There are numerous cases involving theft, misappropriation of property, and fraud in the US health care system. According to the United States Sentencing Commission (2020), more than 76,538 health care cases were recorded in the US Sentencing Commission. Out of the recorded cases, more than 5,707 involved theft, property misappropriation, and fraud. The commission notes that though healthcare fraud cases have decreased by 10.3% from 2015 to 2019, medical crimes are common and becoming fatal (the United States Sentencing Commission, 2020). The healthcare cases in 2019 had significant effects on the delivery and quality of healthcare in the US. The commission noted that the average cost of the medical crimes was $1,188,178, while more than 23.9% and 15.4% of the cases involved amounts greater than $3,500,000 and less or equal to $150,000 respectively (United States Sentencing Commission, 2020). Most of the healthcare frauds were identified in Southern Florida, South and Northern Texas, Eastern Michigan, and Missouri. Based on the findings of the commission, this vice is deep-rooted in the health care system.
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Equipment sale is rampant under the Medicare health program where items are sold after delivery or fail to be delivered after procurement swindles. Some of the most sold equipment are seat lift chairs, oxygen concentrators, and home dialysis machines (Rosoff et al., 2020). The most significant crimes happen in the procurement processes since Medicare fails to do due diligence to verify the legitimacy of suppliers through documentation (Rosoff et al., 2020). As a result, Medicare often pays for products that were never delivered, and the taxpayers' money ends up with scammers in the procurement processes. Rosoff et al. (2020) note that the United States lost approximately $700 million between 2006 and 2007 in procurement frauds. Overpricing of medical items is also a rampant medical crime in the United States. For example, Medicare paid $900 for a flimsy foam with a market price of approximately $28 and $500 for a radio shack with a market price of $50 (Rosoff et al., 2020). Therefore, most of the medical crimes are based on the mismanagement of resources in the health sector.
Moreover, inappropriate allocation of medical resources has been a costly practice in the United States health care system. There have been cases where abled people have been allocated wheelchairs and scooters by doctors who get a bribe to sign the certificates of disability. Later, the beneficiaries of the inappropriate allocation sell the items and share the profits with the perpetrators of the crime. One of the most common allocation frauds involved Dr. Anant Mauskar, who prescribed motorized wheelchairs to abled people with the intention of getting $200 from each allocation (Rosoff et al., 2020). From the wheelchair allocation scheme, Dr. Mauskar pocketed $1.4million from Medicare. To curb the rising medical frauds through equipment sales, the United States government initiated the Center for Medicare & Medicaid Services (CMS) and HHS agency to review the medical equipment supply chain. Similarly, the Department of Health and Human Services and the Department of Justice formed the Medicare fraud strike force to investigate and prosecute Medicare frauds. Regardless of the proactive measures to curb equipment sales in Medicare, the vice is deep-rooted and far from over.
Home care fraud is a new form of medical crime that involves people who prefer to recover from home to minimize medical expenses and people who wish to spend their last days at home. As Rosoff et al. (2020), home-based care is among the fastest-growing industry in the United States and, as expected, has drawn the attention of many fraudsters in the health care sector. The government initiated Medicare and Medicaid with a special mandate to extend insurance programs to the elderly and people living below the poverty line to ensure equity in access to quality medical care. However, more than $2billion from the insurance programs is lost annually in medical crimes in home-based care (Rosoff et al., 2020). Medical organizations that supply services to patients at home have been identified to overcharge products and access payments from the insurance programs. Interestingly, patients in home-based care services have been involved in joint home care frauds. Medical companies conspire with the patients to hire uncertified medical aides, after which the companies get payments from Medicaid and share with the patients (Rosoff et al., 2020). Billions of shillings have been lost as the government pays for services that were never delivered to home-based care patients. According to Miller (2012), 91 healthcare officials were involved in homecare fraud where they billed more than US$230 million to Medicare. Therefore, homecare fraud is another avenue used to facilitate medical crimes.
Hospital frauds are the most common medical crimes since hospital costs constitute the largest expenditure in the United States health care system. In many cases, hospitals have been accused of billing patients for services that were never offered or charging multiple times for a single service. Besides, healthcare givers have been known to complicate simple treatment procedures to maximize the amount paid by insurance companies for the procedures (Rosoff et al., 2020). Furthermore, hospitals have been shifting costs where patients are attracted by the reasonable prices displayed, after which the hospital offers ancillary services that drastically raise the hospital bill (Rosoff et al., 2020). Besides, medical frauds in psychiatric hospitals have been in existent for many years, intending to maximize the amounts paid by the lessening psychiatric patients. Crimes in psychiatric hospitals include hospitalizing patients until their insurance covers run out, false diagnoses, overcharging, unnecessary treatment procedures, and corruption in hospital admissions (Rosoff et al., 2020). Besides, psychiatrists offer money to counselors to refer patients to their treatment centers. According to Miller (2012), 91 health care officials, including physicians and nurses, were arrested for community mental health care fraud where they had billed more than $100 million to Medicare. Though hospital frauds are the most rampant and directly linked to the patients, they are difficult to identify, investigate, and prosecute since they involve individual patients and individual heal care officers.
Furthermore, self-referrals constitute a significant influence in the rising cost of medical care in the US. According to Rosoff et al. (2020), self-referrals happen when healthcare givers send patients for further treatment procedures and services in centers or companies where they have financial interests. Primarily, self-referrals are meant to increase incomes for healthcare providers. Therefore, doctors and nurses often invest in pharmacies, clinics, and laboratories to refer patients for inessential services to raise their incomes. According to a 1989 study in the United States, healthcare givers who had invested in laboratories had a 45% more chance of referring patients for further tests than those who did not (Rosoff et al., 2020). In addition, the United States Department of Health And Human Services estimates that more than 25% of the medical laboratories in the United States are owned by doctors for self-referrals. Self-referrals show a conflict of interest where medical practitioners provide substandard services to warrant referrals to their health centers for further treatment and services.
Medicare and Medicaid fraud accounts for billions of dollars lost in the healthcare system in the United States. The initial idea when forming the Medicare and Medicaid programs in 1965 was to subsidize medical care for the aged and the poor. The biggest frauds have been in kidney dialysis treatment, where hospitals use cheaper and potentially harmful dialysis equipment to cut costs (Rosoff et al., 2020). Furthermore, reports have revealed that Medicare has been losing millions annually on ambulance services that were never required. Medicare has been losing resources on non-emergency transportation of patients or payments for ambulance services that were not offered. Ambulance companies have been found guilty of backdating trips or billing Medicare for transportation done in personal vehicles. Miller (2012) exemplifies that ambulance transportation fraud accounted for approximately $49 million of the total medical bills in a single case in October 2011. According to the Government Accounting Office (GAO), Medicare loses a minimum of 10% of its expenditure through medical fraud (Rosoff et al., 2020). As Rosoff et al. (2020) discuss, doctors can defraud Medicare systems through overcharges, retainers, and waivers. Overcharges occur when patients sign treatment documents with overpriced services, while retainers occur when doctors coerce patients to pay for services not covered by Medicare. Furthermore, waives happen when doctors are granted by the patients to bill Medicare directly, after which the patients are required to pay for fees that Medicare would otherwise shoulder. Frauds in Medicaid are often considered more extensive than Medicare frauds considering the bias and prejudice by some healthcare givers on impoverished patients. Medicaid fraud happens when health officers are allowed to continue practicing even after being proven to be unfit for public service.
Fertility fraud is a less-discussed crime, although it is a common form of medical crime in the United States. Couples with conception problems face unaccountable challenges since they are more vulnerable out of desperation. As Rosoff et al. (2020) states, fertility frauds result from the rapid advancements in technology and knowledge that surpasses ethics and legal confines. Doctors have been accused of unethical practices such as inaccurate fertility tests and misinformation that often lead to stress and depression. The first documented fertility fraud involved Cecil Jacobson, who inseminated women with his sperms instead of using the donors' (Rosoff et al., 2020). Assisted reproduction has been a vital ground for fraud as the process is often overpriced and unmonitored. Fake medical procedures have been common and have attracted criminals who have never been to medical schools. The desperation in many fertility patients makes them prone to abuse since most are willing to offer large sums of money to get fertility help.
Research frauds are pretty uncommon but fatal when they occur. In research frauds, researchers lie about their experiments to achieve financial benefits or occupational recognition. Rosoff et al. (2020) record a research fraud involving Dr. Stephen Breuning, who falsified his findings in his research on the use of Ritalin as a treatment therapy for children with the hyperactive condition. According to the National Institute of Mental Health (NIMH), Breuning misled a third of all scholarly literature concerning the treatment of hyperactive children. Though research frauds are income-based, the research-based medical environment where researches are shared can cause severe effects. Doctors share information and discoveries that are quickly adopted in patient care after being proved to be effective. Therefore, false information about a health procedure during the development or verification processes can lead to severe side effects and adverse health effects on the victims. Research frauds override the basic research ethics that mandate that every research be grounded on safety and public benefit.
Medical crimes are common in nursing homes where elders and the disabled reside for long-term care. According to Rosoff et al. (2020), as of 2007, the United States had approximately 1.7 million disabled and elderly individuals residing in nursing homes. Many nursing homes are profit-oriented, and therefore, quality of care is usually not the primary consideration. Organizations have been rushing to buy nursing homes, refurbishing them, and selling them for a higher price since the United States government initiated Medicare and Medicaid programs for the elderly. Though the nursing homes industry is a multi-million industry, the quality of the working environment and care given to the elderly and the disabled is below the recommended standard in many centers. Rosoff et al. (2020) affirm that healthcare workers in many nursing homes are among the lowest-paid health care providers in the US. The elderly are among the most vulnerable part of the American population since they are helpless and significantly dependent. Rosoff et al. (2020) illustrate medical fraud in nursing homes by quoting a case where a nursing assistant stole critical information from her elderly patients and used it to apply credit card services and charge more than $8600. Besides, the elderly and the disabled are prone to physical abuse where they are either beaten or punished. Hawes and Kimbell (2010) explain that patients in nursing homes in the United States experience sexual mishandling, physical abuse, psychological torture, and sometimes death. Moreover, the “Is Grandma Drowsy or Is She Drugged?” report found out that healthcare givers in many nursing homes give their patients strong sedatives and psychotropic drugs to keep them docile and minimize the resources and labor required to care for them (Rosoff et al., 2020). The provision of minimal care for the elderly and the disabled helps nursing homes to maximize profits at the expense of needy Americans in need of their help.
Medical malpractices and negligence also qualify as white-collar crimes according to the classification by Herbert Edelhertz. Herbert defined white-collar crimes as an abuse of trust by a professional by violating their responsibility to the client and the employer (Cliff & Desilets, 2014). Medical malpractice and negligence betray the patients' trust in the health care providers who are perceived to be in a noble profession. Oyabode (2013) argues that disabling illnesses due to medical malpractices and negligence have significant effects on care costs for individuals and the country. According to the Institute of Medicine (IOM) report, medical errors and negligence costs between $17 to 29 billion per year globally (Oyabode, 2013). Medical malpractices can be clinical errors such as misdiagnosis and medication errors. Also, medical malpractices can include nondrug events such as technical complications and infection mismanagement. Though medical malpractices result from negligence, some are caused by duty stresses, depression, work overload, and experience. Though medical crimes may be extensive and difficult to curb, the government should enact more strategies to minimize crime degrees to mitigate the adverse effects on health delivery and quality.
In conclusion, medical crimes are white-collar crimes since they betray public confidence and trust in the medical care providers. Medical crimes have been declining since 2015 thanks to the strict measures enacted by the government and healthcare stakeholders; however, the war against medical fraud is far from over. Equipment sale and graft in the procurement of hospital assets have involved multi-million fraud cases where Medicare pays for products that are never delivered. Inappropriate allocation of medical resources later commercialized by fraudulent doctors and patients has been rampant in the United States. Besides, home care fraud happens when patients recovering at homes pay more for substandard or overpriced products. Moreover, hospital frauds that include overcharging and cost-shifting have been the most extensive since they involve individuals. Furthermore, self-referrals where doctors and nurses refer patients to their investments such as clinics, labs, and chemists have depicted the insatiability for income ad profits. Self-referral leads to more requests for further tests and treatment procedures and hence higher medical costs. Medicare and Medicaid frauds involve incorrect billing for services that were either delivered partly or were not delivered. Ambulance transport frauds are common where abled patients are offered emergency ambulance services, after which the bill is sent to Medicare and Medicaid. Fertility frauds are also common where couples with fertility challenges are exploited due to their vulnerability and desperation. Though research frauds and rare, they are often fatal as many healthcare practitioners can adopt the researched procedures, thus risking the health of many people. Crimes in nursing homes such as medical manipulation, physical and emotional abuse are medical crimes against the elderly and the disabled. Lastly, medical malpractices and negligence are medical crimes since they betray the medical ethics and the acceptable code of conduct in patient health care.
References
Cliff, G. & Desilets, C. (2014). White-collar crime: What it is and where it's going. Notre Dame Journal of Law, Ethics, and Public Policy , 481. http://scholarship.law.nd.edu/ndjlepp/vol28/iss2/3
Hawes, C., Kimbell, A, M. (2010). Detecting, Addressing and Preventing Elder Abuse in Residential Care Facilities . Grant Number: 2005-IJ-CX-0054. 229299 https://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf
Miller, A. (2012). White coats and white-collar crime . Canadian Medical Association Journal, 185 (1), E19–E20 . https://doi.org/10.1503/cmaj.109-4346
Oyebode, F. (2013). Clinical errors and medical negligence . Medical Principles and Practice, 22 (4), 323–333 . https://doi.org/10.1159/000346296
Rosoff, S, M., Pontell, H, N., Tillman, R. (2020). Profit Without Honor: White Collar-Crime & The Looting of America . Pearson.
United States Sentencing Commission (2020). Health Care Fraud. https://www.ussc.gov/research/quick-facts/health-care-fraud
