Academic journal article Bulletin of the World Health Organization

Mobilizing the Honest Majority to Fight Health-Sector Fraud

Academic journal article Bulletin of the World Health Organization

Mobilizing the Honest Majority to Fight Health-Sector Fraud

Article excerpt

[ILLUSTRATION OMITTED]

Jim Gee has more than 25 years of operational, policy and strategic experience as a counter fraud-specialist. From 1990 to 1998, he worked in counter fraud for local government in the United Kingdom (UK). In 1998, he headed the country's National Health Service (NHS) Counter Fraud Service and, in 2003, became chief executive of the NHS Counter Fraud and Security Management Service. In 2005, he became director-general of the new European Healthcare Fraud and Corruption Network and helped to develop the United Kingdom's first cross-economy counter-fraud strategy. He is currently director of Fraud Economics Ltd.

At a time when the global financial crisis is squeezing government budgets, Jim Gee says that the argument for fighting fraud in health systems has never been stronger.

Q: Why is it important to define fraud?

A: Sometimes 'fraud' is used as a catch-all for all kinds of undesirable behaviour. However, fraud is only one problem among several. And different problems need different solutions. It's very important to be clear what fraud is and what it isn't. Fraud is something that people find very difficult to talk about; they imagine it's perpetrated by a much wider group than it is. When you explain to people what it is, many more people feel that they can support you. In civil law in the United Kingdom and other European countries, fraud is when someone knowingly obtains resources to which they are not entitled. Using a common definition makes it easier to work together and compare statistics on losses.

Q: How can you measure success in reducing losses due to fraud?

A: We undertook eleven fraud-loss measurement exercises across the NHS budget and then re-measured the reduced losses in each. Our work reduced losses by up to 60% and delivered 811 million [pounds sterling] worth of financial benefits between 1998 and 2006. And now that's been followed up in nine other countries, where there have been 57 fraud-loss measurement exercises in 43 organizations. These are statistically valid, highly accurate exercises that show the total cost of fraud. Two showed losses of less than 3% of expenditure, five of over 8% and 50 of 3-8%.

Q: Is the financial crisis and the prospect of tighter government budgets driving the trend towards fraud prevention in the health sector?

A: Yes, but not as widely as I would like. Health-care systems are losing, on the basis of available evidence to date, between 3% and 8% of their expenditure to fraud. That's an enormous amount across Europe and beyond, but we have shown that these losses can be massively reduced. The benefits to patients of professional work to measure and reduce fraud losses are manifest.

Q: What are the main forms of health sector fraud?

A: In all the countries where I have worked, I have found that there are four main areas of fraud that are usually found: fraud by patients; by clinical professionals (often claiming for work they haven't done); by managers and staff misusing their position or authority; and fraud by companies and contractors supplying goods and services (a major area there is around the pricing of drugs).

Q: What personal experiences led to your campaigning approach?

A: It always seemed to me that fraud involved the irrational allocation of resources on the basis of greed, rather than the rational allocation of resources on the basis of need. When the NHS celebrated its 50th anniversary in 1998, nothing had been done to stop fraud and corruption since it was founded. I was the first person appointed to deal with this issue. I was given three staff and a budget of 210 000 [pounds sterling] a year (US$ 290 000 at exchange rates on 10 March 2009) to stop fraud across an organization of 1.2 million employees with a budget of 40 billion [pounds sterling] (US$ 55.2 billion). We built the NHS Counter Fraud Service into one of 250 staff and a budget of 20 million [pounds sterling] by delivering a financial return of 12 to I on the cost of our work. …

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