Practitioner fraud and abuse in medical benefit programs: government regulation and professional white-collar crime

Physicians who defraud and abuse medical benefit programs provide a unique group of lawbreakers for scientific study. They could be considered to epitomize white collar criminals given their exceedingly high socioeconomic status and power as a professional group. Using official reports and documents, as well as interviews with enforcement and program personnel at both state and federal levels, this study examines the problem of physician fraud and abuse in Medicare and Medicaid. Major areas relevant to understanding this phenomenon and its control are presented and policy implications of present knowledge in the area are discussed.     

On economic values in policy analysis

Analyses of public policy are rooted in the economic theory of the private sector. How relevant is this approach to the public sector? Specifically, where the organization is generally viewed as a controlled variable it often exhibits the characteristics of an independent variable working to constrain the feasible solution space. An illustration of this phenomenon is discussed, using a state rehabilitation agency as the case in point. Conclusions of an analysis based mainly on maximizing the economic value of return on investment conflicted with the agency professional values of individualized client service. This external/internal value conflict led to the apparent inability of the agency to implement the study conclusions in the near term. The substance of this conflict is seen as the main problem facing many public administrators. Recognition of economic values as but one element of public agency analysis is suggested as an approach superior to sole concentration on maximization of the return on public investment. By taking a broader view, the analyst may be able to encourage more rapid implementation of his recommendations.