Combating Health Care Fraud and Abuse: Conceptualization and Prototyping Study of a Blockchain Antifraud Framework.

BACKGROUND: An estimated US $2.6 billion loss is attributed to health care fraud and abuse. With traditional health care claims verification and reimbursement, the health care provider submits a claim after rendering services to a patient, which is then verified and reimbursed by the payer. However, this process leaves out a critical stakeholder: the patient for whom the services are actually rendered. This lack of patient participation introduces a risk of fraud and abuse. Blockchain technology enables secure data management with transparency, which could mitigate this risk of health care fraud and abuse. OBJECTIVE: The aim of this study is to develop a framework using blockchain to record claims data and transactions in an immutable format and to enable the patient to act as a validating node to help detect and prevent health care fraud and abuse. METHODS: We developed a health care fraud and abuse blockchain technical framework and prototype using key blockchain tools and application layers including consensus algorithms, smart contracts, tokens, and governance based on digital identity on the Ethereum platform (Ethereum Foundation). RESULTS: Our technical framework maps to the claims adjudication process and focuses on Medicare claims, with the US Centers for Medicare and Medicaid Services (CMS) as the central authority. A prototype of the framework system was developed using the blockchain platform Ethereum (Ethereum Foundation), with its design features, workflow, smart contract functions, system architecture, and software implementation outlined. The software stack used to build the system consisted of a front-end user interface framework, a back-end processing server, and a blockchain network. React was used for the user interface framework, and NodeJS and an Express server were used for the back-end processing server; Solidity was the smart contract language used to interact with a local Ethereum blockchain network. CONCLUSIONS: The proposed framework and the initial prototype have the potential to improve the health care claims process by using blockchain technology for secure data storage and consensus mechanisms, which make the claims adjudication process more patient-centric for the purposes of identifying and preventing health care fraud and abuse. Future work will focus on the use of synthetic or historic CMS claims data to assess the real-world viability of the framework.

Quackery in Dental Practice in Nepal.

Quackery and fraud in dental practice, seen in many countries, is also rampant in Nepal, and they are unethical practices. There is a growing need for strict enforcement of government policy measures to eliminate quackery and fraudulent dental practice in Nepal. The government should mobilize all dental workforce (dental specialists, dentists, and dental auxiliaries) and aware of their responsibilities and limitations. This article presents a brief review showing some cases of malpractice in dentistry in Nepal.

Clinical trials and the origins of pharmaceutical fraud: Parke, Davis & Company, virtue epistemology, and the history of the fundamental antagonism.

This paper describes one possible origin point for fraudulent behavior within the American pharmaceutical industry. We argue that during the late nineteenth century therapeutic reformers sought to promote both laboratory science and increasingly systematized forms of clinical experiment as a new basis for therapeutic knowledge. This process was intertwined with a transformation in the ethical framework in which medical science took place, one in which monopoly status was replaced by clinical utility as the primary arbiter of pharmaceutical legitimacy. This new framework fundamentally altered the set of epistemic virtues-a phrase we draw from the philosophical field of virtue epistemology-considered necessary to conduct reliable scientific inquiry regarding drugs. In doing so, it also made possible new forms of fraud in which newly emergent epistemic virtues were violated. To make this argument, we focus on the efforts of Francis E. Stewart and George S. Davis of Parke, Davis & Company. Therapeutic reformers within the pharmaceutical industry, such as Stewart and Davis, were an important part of the broader normative and epistemic transformation we describe in that they sought to promote laboratory science and systematized clinical trials toward the twin goals of improving pharmaceutical science and promoting their own commercial interests. Yet, as we suggest, Parke, Davis & Company also serves as an example of a company that violated the very norms that Stewart and Davis helped introduce. We thus seek to describe one possible origin point for the widespread fraudulent practices that now characterize the pharmaceutical industry. We also seek to describe an origin point for why we conceptualize such practices as fraudulent in the first place.

Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches.

Background: As called for by the Sustainable Development Goals, governments, development partners and civil society are working on anti-corruption, transparency and accountability approaches to control corruption and advance Universal Health Coverage.Objectives: The objective of this review is to summarize concepts, frameworks, and approaches used to identify corruption risks and consequences of corruption on health systems and outcomes. We also inventory interventions to fight corruption and increase transparency and accountability.Methods: We performed a critical review based on a systematic search of literature in PubMed and Web of Science and reviewed background papers and presentations from two international technical meetings on the topic of anti-corruption and health. We identified concepts, frameworks and approaches and summarized updated evidence of types and causes corruption in the health sector.Results: Corruption, or the abuse of power for private gain, in health systems includes bribes and kickbacks, embezzlement, fraud, political influence/nepotism and informal payments, among other behaviors. Drivers of corruption include individual and systems level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems. We identify six typologies and frameworks that model relationships influencing the scope and seriousness of corruption, and show how anti-corruption strategies such as transparency, accountability, and civic participation can affect corruption risk. Little research exists on the effectiveness of anti-corruption measures; however, interventions such as community monitoring and insurance fraud control programs show promise.Conclusions: Corruption undermines the capacity of health systems to contribute to better health, economic growth and development. Interventions and resources on prevention and control of corruption are essential components of health system strengthening for Universal Health Coverage.

The risk of corruption in public pharmaceutical procurement: how anti-corruption, transparency and accountability measures may reduce this risk.

Background: The goal of the public procurement of pharmaceuticals is to purchase sufficient quantities of high-quality pharmaceuticals at cost-effective prices for a given population. This goal can be undercut if corruption infiltrates the procurement process. Good procurement practices can help mitigate the risks of corruption and support equitable access to affordable and high-quality medicines.Objectives: This paper aims to 1) examine manifestations of corruption in the pharmaceutical procurement process and key factors behind them, and 2) identify how to design and implement effective anti-corruption, transparency and accountability mechanisms within this process.Methods: This paper was informed by a narrative literature review from 1996 to the present. The search focused on publications that addressed the issue of pharmaceutical procurement and governance and corruption issues. Our search included peer-reviewed literature, books, grey literature such as working papers, reports published by international organizations and donor agencies, and some media articles. Some documents used in this paper were already known to the authors.Results: Procurement is highly vulnerable to corruption particularly in the health sector. What is more, corruption in the procurement process does not appear to be limited to any one level of government or type of health system. The better integration of accountability, transparency and anti-corruption mechanisms in the procurement process is needed to reduce the risk of corruption.Conclusions: Lessons learned suggest that anti-corruption, transparency and accountability mechanisms in the pharmaceutical procurement process, such as open contracting and integrity pacts are helpful towards reducing the risk of corruption.

Promoting anti-corruption, transparency and accountability in the recruitment and promotion of health workers to safeguard health outcomes.

Background: Human Resources for Health are a core building block of a health system, playing a crucial role in improving health outcomes. While the existing literature has examined various forms of corruption that affect the health sector, few articles have examined the role and impact of corruption in the recruitment and promotion of health-workers.Objectives: This study reviews the role of corrupt practices such as nepotism, bribery and sextortion in health-worker recruitment and promotion and their implications for health systems.Methods: The study is based on an interdisciplinary non-systematic review of peer-reviewed journal articles in the public health/medicine and political science literature, complemented with the 'grey' literature such as technical reports and working papers.Results: Political and personal ties, rather than merit are often factors in the recruitment and promotion of health-workers in many countries. This results in the employment or promotion of poorly qualified or unsuitable workers, with negative implications for health outcomes.Conclusion: Corrupt practices in health-worker recruitment and promotion 'set the tone' for other forms of corruption such as absenteeism, embezzlement, theft and bid-rigging to flourish, as those recruited corruptly can collude for nefarious purposes. On the other hand, merit-based recruitment is important for curbing corruption. Corrupt recruitment practices have deleterious effects on health-worker motivation and retention, quality and competency, citizens' trust in health services and health outcomes. Whereas international law and policy such as the United Nations Convention Against Corruption and the WHO Handbook on Monitoring and Evaluation of Human Resources for Health state that recruitment of public officers and health workers respectively should be done in a transparent and accountable manner, more research is needed to inform policies on merit-based recruitment.

Recalibrating the anti-corruption, transparency, and accountability formula to advance public health.

Policy-makers, implementing organizations, and funders of global health programs aim to improve health care services and health outcomes through specific projects or systemic change. To mitigate the risk of corruption and its harmful effects on those initiatives, health programs often use multiple anti-corruption mechanisms, including codes of conduct, documentation and reporting requirements, and trainings. Unfortunately, the introduction of anti-corruption mechanisms tends to occur without an explicit consideration of how each mechanism will affect health services and health outcomes. This may overlook potentially more effective approaches. In addition, it may result in the introduction of too many controls (thereby stymying service delivery) and a focus on financial or procurement-related issues (at the expense of service delivery objectives). We argue that anti-corruption efforts in health programs can be more effective if they prioritize addressing issues according to their likelihood and level of harm to key program objectives. Recalibrating the anti-corruption formula in this way will require: (i) extending responsibility and ownership over anti-corruption from subject experts to public health and health system specialists, and (ii) enabling those specialists to apply the Fraud Risk Assessment methodology to develop tailored anti-corruption mechanisms. We fill a documented gap in guidance on how to develop anti-corruption mechanisms by walking through the seven analytical steps of the Fraud Risk Assessment methodology as applicable to health programs. We then outline best practices for any anti-corruption mechanism, including a focus on quality health delivery; the alignment of actors' incentives around the advancement of health objectives; and being minimally corruptible by design.

Anti-corruption, Transparency and Accountability: Case Study of Healthcare in the Arab Countries.

Background: The Arab states suffer from high levels of corruption. The UNDP's team there developed an approach to tackle corruption and enhance transparency and accountability in healthcare as part of its broader efforts to support the Sustainable Development Goals. This work evolved into a proper tool, the Conceptual Framework for Corruption Risk Assessment at Sectoral Level (hereafter 'Framework'), with implementation guides that enable tailoring to sector and country context.Objectives: This article documents the development of the Framework, its methodology and observed added value.Methods: Qualitative methods were utilized comprising desk research, field experience, stakeholder outreach, and focus group observation and documentation. It was most appropriate because the objective was to develop a methodology with specific characteristics.Results: The new approach uses anti-corruption as an explicit entry point to governance reforms. It articulates a structured evidence-based method to apply risk management methodology - tailored to the specificities of corruption as a risk - in healthcare whereby assessment and mitigation are (a) within institutions (b) focused on decision points and (c) around transactions while bringing together health and anti-corruption communities towards designing measurable results-oriented reforms.Conclusions: The Framework may be effective in driving concrete governance reform efforts that demonstrably reduce corruption by means of creating a common language and agenda among different stakeholders, changing the mindset towards reform, and developing targeted solutions with higher return on investment. As such, it may be capable of generating observable and sustainable progress towards healthcare reform.

[Scientific misconduct: A major threat for medical research]. / Fraude scientifique : une menace majeure pour la recherche médicale.

Scientific misconduct (fabrication, falsification, and plagiarism) and detrimental research practices (selective reporting of data, inappropriate citation practice, ghostwriting) are admitted respectively by 2 % and 33 % of researchers. The consequences of scientific misconduct and detrimental research practices are disastrous, both for the doctors, who are the most affected researchers in view of the number of retracted articles, and for the patients, victims of false information that may have health consequences. In order to fight against the causes (promotion of doctors and allocation of resources to clinical wards and laboratories on purely quantitative research criteria, lack of training in scientific integrity in medical studies, heterogenous quality of reviewing, legal impunity), there are legislative, academic, technological and editorial solutions, but radical and urgent cultural change is needed first.

Ethical Issues in Physician Billing Under Fee-For-Service Plans.

Medical ethics has become an important and recognized component of physician training. There is one area, however, in which medical students receive little guidance. There is practically no discussion of the financial aspects of medical practice. My objective in this paper is to initiate a discussion about the moral dimension of physician billing practices. I argue that physicians should expand their conception of professional responsibility in order to recognize that their moral obligations toward patients include a commitment to honest and forthright billing practices. I argue that physicians should aspire to a standard of clinical accuracy-not legal adequacy-in describing their activities. More generally, physicians should strive to promote an integrity-based professional culture, first and foremost by stigmatizing rather than celebrating creative billing practices, as well as condemning the misguided sense of solidarity that currently makes it taboo for physicians to criticize each other on this score.

The American Health Care System Is Broken. Part 7: How Can We Fix It?

Previous articles have outlined the many problems that confront America in trying to humanely and efficiently deliver health care to our citizens.  First among these is that health care is unaffordable for too many. This final article describes how to expand coverage to all Americans and identifies many specific areas in which changes can be made to both improve care and lower costs.  There are many ways to reduce the cost of medications, to improve hospital care while lowering costs, to eliminate "surprise" medical bills, and to cut down fraud and waste.  The socioeconomic factors that contribute heavily to our poor health outcomes must be addressed.

For a honest Maghreb care system. Systematic Review of the International Literature on Corruption in the Health care System.

INTRODUCTION: Corruption in the health care system is a universal phenomenon, putting at risk the health of populations. The purpose of this work was to synthesize the international literature on corruption in the health sector. METHODS: This is a systematic review of literature dealing with articles on health corruption practices, published between July 2008 and June 2018, via two search engines: PubMed and Google Scholar. The extracted data were narratively summarized in three major areas: defining the concept of corruption in health, its typology / manifestations and anti-corruption interventions. RESULTS: A total of 23 articles were selected for final analysis. The articles that defined health corruption shared two key aspects: "abuse of power" and "benefit". The main types of corruption were "abuse of therapeutic indication", followed by "bribes" and "falsification". The anti-corruption interventions were synthesized into seven types: creation of an independent multi-interventional agency, support for scientific research, law enforcement, awareness raising, detection, reporting and institutional commitment. CONCLUSION: Based on the use of power, corruption in health is a complex phenomenon whose struggle requires a specific and contextualized strategy integrating information, detection and punishment.

Predatory Open-Access Publishing in Anesthesiology.

Predatory publishing is an exploitative fraudulent open-access publishing model that applies charges under the pretense of legitimate publishing operations without actually providing the editorial services associated with legitimate journals. The aim of this study was to analyze this phenomenon in the field of anesthesiology and related specialties (intensive care, critical and respiratory medicine, pain medicine, and emergency care). Two authors independently surveyed a freely accessible, constantly updated version of the original Beall lists of potential, possible, or probable predatory publishers and standalone journals. We identified 212 journals from 83 publishers, and the total number of published articles was 12,871. The reported location of most publishers was in the United States. In 43% of cases (37/84), the reported location was judged as "unreliable" after being checked using the 3-dimensional view in Google Maps. Six journals were indexed in PubMed. Although 6 journals were declared to be indexed in the Directory of Open Access Journals, none were actually registered. The median article processing charge was 634.5 US dollars (interquartile range, 275-1005 US dollars). Several journals reported false indexing/registration in the Committee on Publication Ethics and International Committee of Medical Journal Editors registries and Google Scholar. Only 32% (67/212) reported the name of the editor-in-chief. Rules for ethics/scientific misconduct were reported in only 24% of cases (50/212). In conclusion, potential or probable predatory open-access publishers and journals are widely present in the broad field of anesthesiology and related specialties. Researchers should carefully check journals' reported information, including location, editorial board, indexing, and rules for ethics when submitting their manuscripts to open-access journals.

Is multi-level marketing of nutrition supplements a legal and an ethical practice?

BACKGROUND: Multi-level marketing (MLM) of nutrition products has experienced dramatic growth in recent decades. 'Wellness' is the second most popular niche in the MLM industry and represents 35% of sales among all the products in 2016. This category includes dietary supplements, weight management and sports nutrition products. The aim of this paper is to analyse whether this practice is legal and ethical. METHODS: An analysis of available documentary information about the legal aspects of Multi-level marketing business was performed. Ethical reflexion was based on the "principlism" approach. RESULTS: We argue that, while being a controversial business model, MLM is not fraudulent from a legal point of view. However, it is an unethical strategy obviating all the principles of beneficence, nonmaleficence and autonomy. What is at stake is the possible economic scam and the potential harm those products could cause due to unproven efficacy, exceeding daily nutrient requirements and potential toxicity. The sale of dietary and nutrition supplements products by physicians and dieticians presents a conflict of interests that can undermine the primary obligation of physicians to serve the interests of their patients before their own. CONCLUSION: While considering that MLM of dietary supplements and other nutrition products are a legal business strategy, we affirm that it is an unethical practice. MLM products that have nutritional value or promoted as remedies may be unnecessary and intended for conditions that are unsuitable for self-prescription as well.

["Integrity" in the healthcare system : Recognize and avoid risks: on dealing with the Association of Statutory Health Insurance Physicians and the public prosecutors office]. / "Lauterkeit" im Gesundheitswesen : Risiken erkennen und vermeiden: zum Umgang mit Kassenärztlicher Vereinigung und Staatsanwaltschaft.

BACKGROUND: This article describes the introduction of the law to combat corruption in the healthcare system. OBJECTIVE: The effects of the introduced penal regulations on the delivery of medical services is critically scrutinized and the associated procedures as well as indications for the course of action are presented. RESULTS: Knowledge of the relevant regulations and types of procedure is decisive for the penal, social legislative and professional conduct risk minimization.

Ethical aspects in medical publishing in Belgium.

Medical publishing has become a pivotal aspect of all stages of career development in medicine in Belgium. Publication pressure is therefore present from the stage of the medical student to the level of the head of an academic medical service. This pressure represents a real danger to commit scientific misconduct, ranging from minor missteps to severe fraud. Recent surveys have shown that scientific misconduct and publication fraud represent an important problem in medical publishing, more than in other scientific fields, also in Belgium. Several factors may explain the increased risk of scientific misconduct in medical publishing. Recent national and international initiatives have emerged in order to better understand the problem of scientific misconduct and to optimize ethics in medical publishing. They aim to increase integrity and transparency at all levels of medical research and publishing, starting at the beginning of a career in medical school. The current review describes the ethical difficulties in medical publishing in Belgium, and offers possible solutions.