Health Care Systems: Misuse, Abuse & Predatory Fraud Controls (1 of 3)

Health care is an integral part of a nation’s critical infrastructure (CI). It is the largest public cash dispensing sector in the United States and Canadian economies. Ten times that of defense. Health care services delivery is an extraordinarily complex system. Within this context, conversation on misuse, abuse and predation (fraud) controls must be broken down into smaller ecosystems to make sense of the issues and to deploy effective counter measures.

Definition: Ecosystems are, “living organisms in conjunction with nonliving components of their environment interacting with the system.”  

This is the first of three blog posts addressing human cheating and predatory practices causing financial harms to health care systems.

The United States spends in excess of 17.3% of GDP on health care. It is a complicated vertical system of public and private sector plans. People falling between the cracks end up uninsured. The result can be physically, emotionally and financially  catastrophic for families.

Far and way, the United States has the most expensive per capita health care spending in the world. In his book, “A License to steal: How Fraud Bleeds America’s Health Care System”, Harvard University’s Malcolm K. Sparrow explored health care delivery system’s defenses against predatory attacks and made recommendations on fraud specific controls that are for most part ignored.

Canada spends in excess of 10.53 % of GDP on health care benefits and services. The Canadian system is more horizontal; with basic care for everyone meeting status and residency requirements. It is topped up by private plans for unregulated services, Some costs are also absorbed by the property and casualty insurance industry in the case of injury related accidents. Although Sparrow’s work was introduced at a conference held by former Canadian Health Care Anti-Fraud Association, it pretty much goes unheeded by the health care industry’s replacement, the Canadian Life and Health Insurance Association.

Increasingly larger portions of provincial budgets is fueling subtle deregulation of formerly paid for public services in Canada. In Chronic Condition; What Canada’s Health Care System Needs to Be Dragged Into the 21st Century”, Jeffrey Simpson explores the options with a growing problem the Canadian system faces; including cuts to “nonessential” services, tax increases, various types of privatization, and finding savings within health care itself.

The next post in this series explores inside-the-system financial harms and controls. The third in this series looks out outside-the-system financial harms and controls. The distinction between these two types of harms and controls is too often poorly defined.

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