Fraud and Abuse in the Saudi Healthcare System: A Triangulation Analysis

Advantages and Challenges of Implementation and Strategies for Health Insurance in Saudi Arabia: A Systemic Review

The Saudi Vision 2030 emphasizes the need for health insurance in terms of both economic growth and lowering government healthcare costs. Recently, the Saudi Ministry of Health has requested the private sector to contribute more to health spending through alternative financing and delivery systems, specifically health insurance. The main purpose of this review is to systematically review the benefits and issues of the implementation approach for health insurance in Saudi Arabia. Three electronic databases were used to conduct the systematic search for articles published in 2018 or after as this is a recent review of the last 5 years articles. Articles were considered if they matched the following criteria: Saudi articles concentrating on health insurance in Saudi Arabia, with a particular emphasis on issues, problems, barriers, and challenges related to insurance in Saudi Arabia. Of the many references identified in the initial search, 13 studies were identified that met the inclusion criteria. The included studies clearly highlighted, explained the current financial methods of the healthcare system in Saudi Arabia, and evaluated Cooperative Health Insurance's potential contribution to the healthcare system's success in achieving the Saudi Vision 2030 goals, as well as the benefits and disadvantages of health insurance. This review exemplifies the need for implementation of health insurance in Saudi Arabia to improve economic growth, and to improve efficiency and quality of care. Many of the issues were identified in this review could be addressed by a strong healthcare infrastructure. The Council of Cooperative Health Insurance and Saudi Arabian Monetary Agency should keep monitoring medical services and collaborating toward enhancing Saudi Arabia's health insurance.

Incidence of moral hazards among health care providers in the implementation of social health insurance toward universal health coverage: evidence from rural province hospitals in Indonesia

Objective

To identify the incidence of moral hazards among health care providers and its determinant factors in the implementation of national health insurance in Indonesia.

Methods

Data were derived from 360 inpatient medical records from six types C public and private hospitals in an Indonesian rural province. These data were accumulated from inpatient medical records from four major disciplines: medicine, surgery, obstetrics and gynecology, and pediatrics. The dependent variable was provider moral hazards, which included indicators of up-coding, readmission, and unnecessary admission. The independent variables are Physicians' characteristics (age, gender, and specialization), coders' characteristics (age, gender, education level, number of training, and length of service), and patients' characteristics (age, birth weight, length of stay, the discharge status, and the severity of patient's illness). We use logistic regression to investigate the determinants of moral hazard.

Results

We found that the incidences of possible unnecessary admissions, up-coding, and readmissions were 17.8%, 11.9%, and 2.8%, respectively. Senior physicians, medical specialists, coders with shorter lengths of service, and patients with longer lengths of stay had a significant relationship with the incidence of moral hazard.

Conclusion

Unnecessary admission is the most common form of a provider's moral hazard. The characteristics of physicians and coders significantly contribute to the incidence of moral hazard. Hospitals should implement reward and punishment systems for doctors and coders in order to control moral hazards among the providers.

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China

Objective

The huge loss of health insurance funds has been a topic of concern around the world. This study aims to explore the network of moral hazard activities and the attribution mechanisms that lead to the loss of medical insurance funds.

Methods

Data were derived from 314 typical cases of medical insurance moral hazards reported on Chinese government official websites. Social network analysis (SNA) was utilized to visualize the network structure of the moral hazard activities, and crisp-set qualitative comparative analysis (cs/QCA) was conducted to identify conditional configurations leading to funding loss in cases.

Results

In the moral hazard activity network of medical insurance funds, more than 50% of immoral behaviors mainly occur in medical service institutions. Designated private hospitals (degree centrality = 33, closeness centrality = 0.851) and primary medical institutions (degree centrality = 30, closeness centrality = 0.857) are the main offenders that lead to the core problem of medical insurance fraud (degree centrality = 50, eigenvector centrality = 1). Designated public hospitals (degree centrality = 27, closeness centrality = 0.865) are main contributor to another important problem that illegal medical charges (degree centrality = 26, closeness centrality = 0.593). Non-medical insurance items swap medical insurance items (degree centrality = 28), forged medical records (degree centrality = 25), false hospitalization (degree centrality = 24), and overtreatment (degree centrality = 23) are important immoral nodes. According to the results of cs/QCA, low-economic pressure, low informatization, insufficient policy intervention, and organization such as public medical institutions, were the high-risk conditional configuration of opportunism; and high-economic pressure, insufficient policy intervention, and organizations, such as public medical institutions and high violation rates, were the high-risk conditional configuration of risky adventurism (solution coverage = 31.03%, solution consistency = 90%).

Conclusion

There are various types of moral hazard activities in medical insurance, which constitute a complex network of behaviors. Most moral hazard activities happen in medical institutions. Opportunism lack of regulatory technology and risky adventurism with economic pressure are two types causing high loss of funds, and the cases of high loss mainly occur before the government implemented intervention. The government should strengthen the regulatory intervention and improve the level of informatization for monitoring the moral hazard of medical insurance funds, especially in areas with low economic development and high incident rates, and focus on monitoring the behaviors of major medical services providers.

Why Not Blow the Whistle on Health Care Insurance Fraud? Evidence from Jiangsu Province, China

Purpose

To identify the factors that influence whistleblowing behavior as it relates to health care insurance fraud in Jiangsu Province, China.

Methods

To construct a factor model and formulate research hypotheses using the Motivation–Opportunity–Ability framework. We designed a questionnaire containing 24 items and distributed it on-site to 2081 respondents in Jiangsu Province, China. Afterward, we applied structural equation modeling to validate the research hypotheses.

Results

Policy awareness negatively contributes to whistleblowing behavior, risk perception does not reduce the incentive to blow the whistle, and an inability to recognize fraud is another critical barrier to converting whistleblowing intentions into behavior.

Conclusion

Practices that are likely to promote citizen whistleblowing on insurance fraud may focus on the constraints identified by the comprehensive Motivation–Opportunity–Ability framework.

The Shared Experience of Insured and Uninsured Patients: A Comparative Study

Background

Despite efforts to ensure equitable quality of care for all patients, a significant gap persists between the quality of care experienced by insured and uninsured patients in Saudi Arabia. This study aims to identify and compare the differences between insured and uninsured patients in terms of their experience of quality of care in a tertiary hospital.

Methods

A descriptive cross-sectional study was utilized. Insured and uninsured individuals who had undergone identical medical procedures in early 2021 were identified from a public 500-bed tertiary hospital. About 350 patients participated in this study by completing an online, self-administered questionnaire, adopted by Abuosi and others in 2016, assessing six dimensions of quality of care.

Results

Significant differences were reported between the quality of care experienced by insured and uninsured subjects (M = 3.37, SD = 0.525, and M = 3.06, SD = 0.452, respectively, p=0.001). While insured group reported high quality of care, followed by fairness of care (r = 0.744 and r = 0.675, p ≤ 0.001, n = 175), uninsured subjects experienced less fairness with low quality of care.

Conclusions

The insured individuals were found to be more attentive to the quality of care offered by the hospital than their counterparts. Efforts to close the gap in quality of care should include monitoring healthcare outcomes, adopting transparency standards, and facilitating procedures to minimize barriers among patients.

Building learning organizational culture during COVID-19 outbreak: a national study

Background

Hospitals and healthcare institutions should be observant of the ever-changing environment and be adaptive to learning practices. By adopting the steps and other components of organizational learning, healthcare institutions can convert themselves into learning organizations and ultimately strengthen the overall healthcare system of the country. The present study aimed to examine the influence of several organizational learning dimensions on organization culture in healthcare settings during the COVID-19 outbreak.

Methods

During COVID-19 crisis in 2020, an online cross-sectional study was performed. Data were collected via official emails sent to 1500 healthcare professionals working in front line at four sets of hospitals in Saudi Arabia. Basic descriptive analysis was constructed to identify the variation between the four healthcare organizations. A multiple regression was employed to explore how hospitals can adopt learning process during pandemics, incorporating several Dimensions of Learning Organizations Questionnaire (DLOQ) developed by Marsick and Watkins (2003) and Leufvén and others (2015).

Results

Organizational learning including system connections (M = 3.745), embedded systems (M = 3.732), and team work and collaborations (M = 3.724) tended to have major significant relationships with building effective learning organization culture. Staff empowerment, dialogues and inquiry, internal learning culture, and continuous learning had the lowest effect on building health organization culture (M = 3.680, M = 3.3.679, M = 3.673, M = 3.663, respectively). A multiple linear regression was run to predict learning organization based on the several variables. These variables statistically significantly predicted learning organization, F (6, 1124) = 168.730, p < .0005, R² = 0.471, (p < .05).

Discussion

The findings concluded that although intrinsic factors like staff empowerment, dialogues and inquiry, and internal learning culture, revealed central roles, still the most crucial factors toward the development of learning organization culture were extrinsic ones including connections, embed system and collaborations.

Conclusions

Until knowledge-sharing is embedded in health organizational systems; organizations may not maintain a high level of learning during crisis.

Identifying Healthcare Professional Roles in Developing Palliative Care: A Mixed Method

Background: Creating a holistic approach in healthcare services is the ultimate aim for the integrated healthcare system. Theoretically, healthcare policy makers constantly expected optimal operations within the hospitals through capitalizing the maximum potential of healthcare expertise, professionals, practitioners, and supporting staff. The objective of this study is to explore the role of healthcare individuals to sustain effective palliative care programs in a safe environment with high-quality of care.

Methods: This study employed a mixed method (qualitative and quantitative) to accomplish the set objective. For this purpose, a balanced sampling technique was adopted and 28 healthcare professionals were selected in two stages (last week of January and the 1st week of February, 2020). These respondents were playing significant role in palliative care policy making process. In the first stage, respondents were classified into three parallel groups to document the major factors affecting palliative care reforms. To minimize the chance of individual biases, each group was supervised by an independent healthcare professional who was not involved in the study. Then, in the second stage, respondents were divided into two clusters for further abstraction of themes to analysis the data. In this phase, each group was comprised on 14 individuals. Data were transcribed, coded, and analyzed (subjectively and objectively) by using NVivo 12 to extract the final themes. These themes were described and analyzed quantitatively for further catchphrases abstraction to identify significant components.

Findings: The initial results incorporated 36 key factors in building effective and sustained palliative healthcare centers. The domains were feasible and practical as they homogeneously patterned within cultural change. These were quality of care, effective management, institute of medicine criteria, and health governance. The Spearman correlation matrix showed significant relationships between the four critical components (P < 0.01 and P < 0.05).

Conclusions: This study explored and identified the significant factors that healthcare professional might consider to make their role more productive and effective in palliative care centers. The key findings also indicated the need of comprehensive periodic assessment especially from the perspective of managerial implications and quality of care.