Tag Archives: health care

The Hidden System of Legal Kickbacks Shaping the U.S. Prescription Drug Market

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In the United States, as in most other countries, it is illegal for pharmaceutical companies to bribe doctors or hospitals to prescribe their products. Those who get caught engaging in this sort of corruption can suffer severe penalties. For example, in 2020, the pharmaceutical giant Novartis agreed to pay the U.S. government almost $700 million to settle a case involving allegations that the company had violated the federal Anti-Kickback statute by offering “cash payments, recreational outings, lavish meals, and expensive alcohol” to doctors to induce them to prescribe Novartis drugs. Yet when pharmaceutical companies offer financial inducements worth billions of dollars to Pharmacy Benefit Managers (PBMs)—not the meager thousands spent on doctors—to promote use of their drugs, the conduct is entirely legal.

What, you may ask, are PBMs? Good question. Most laypeople outside the health care field are unfamiliar with PBMs, and may not even know they exist. But PBM’s play a crucial, if underappreciated and extremely complex role in determining prescription drug prices and insurance coverage decisions. Simplifying somewhat, PBMs’ primary function is to manage insurance companies’ prescription drug plans, a role that includes, among other things, negotiating with drug companies to determine which drugs insurance will cover, and which will be favored. Given that just three PBMs control over 80% of the prescription drug market, PBMs can have an enormous effect on pharmaceutical sales, as drugs that lack insurance coverage are significantly less attractive to consumers than those with coverage. Additionally, PBMs also reimburse pharmacies on behalf of insurance providers for the costs of filling beneficiaries’ prescriptions.

In short, PBMs, which stand in between many of the transactions in the pharmaceutical supply chain, play a major role determining the prices paid by insurers, pharmacies, and patients for prescription drugs. And although kickbacks to doctors, hospitals, insurance companies, and other actors in the system are strictly prohibited, drug companies can and do take advantage PBMs’ complex payment structures to discreetly offer financial inducements in order to gain PBMs’ favor during insurance coverage determinations. There are two main ways in which this de facto bribery occurs: Continue reading →

Curbing Corruption in India’s Healthcare System

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The Indian healthcare system is rife with corruption, and much of this corruption arises from the way that healthcare is regulated (or not). Because healthcare in India is inexpensive, at least by Western standards, private health insurance is relatively rare, and a sizeable majority of total health expenditures are made out-of-pocket. With little regulation, and without much meaningful price negotiation by either the government or private insurance companies, India’s healthcare system has become a vast “network of unregulated private sector hospitals.” This lack of regulation, coupled with intense competition, encourages doctors (who are often under substantial financial pressure) “to enter a happy axis of corruption where they routinely prescribe expensive investigations and perform operations which a patient might not need” in order to increase their profit margins. Doctors have also been known to take bribes from other healthcare entities in return for patient referrals, or to accept kickbacks from pharmaceutical companies disguised as “professional fees” in order to outcompete other private hospitals. As a recent WHO-Eurohealth publication concluded, health sector corruption in India includes not only “collusion, bribes and kickbacks in procurement which may result in overpayment for goods and contracted services” and doctors’ willingness to accept “payments in exchange for special privileges or treatment,” but also “distort[ions in] medical professionals’ prescribing practices.” 

Prime Minister Narendra Modi’s government has sought to address some of these concerns through a healthcare initiative known as PMJAY. The main objective of this program is to increase access to healthcare for the poorest 50% of the population—approximately 700 million people—who are given biometric government “smart cards” to purchase eligible inpatient healthcare services at both private and public hospitals. But while PMJAY is principally designed as a system for subsidizing healthcare for low-income people, it also serves as an anticorruption tool by bringing under government oversight millions of previously unregulated out-of-pocket healthcare transactions, requiring enrolled physicians to acquire digital pre-authorization before administering nonemergency services to PMJAY beneficiaries, and giving the government more power to negotiate with private hospitals participating in the program over healthcare rates. PMJAY’s computerized billing platform also serves a surprising secondary role as an AI-powered “comprehensive fraud analytics solution” for millions of transactions that were previously beyond the government’s reach. The program has already detected over 18,000 fraudulent insurance transactions, leading to penalties against hundreds of healthcare entities so far. The government has even made a list of “corrupt” hospitals available on the PMJAY website. Given PMJAY’s early successes, the government should expand the program. Not only would this increase healthcare access in general—a worthy aim in its own right—but it would further reduce corruption in the healthcare system. This is more easily said than done, however, in light of several practical obstacles to further expansions.

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The “Big Government Causes Corruption” Zombie Shambles On

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I don’t make a practice of responding to opinion columns in mainstream newspapers, especially when they’re not specifically or primarily about corruption. But the opening of Bret Stephens’ piece in yesterday’s New York Times caught my eye, mainly because the column used corruption in the Greek health care system as the “hook” for an argument that President Biden’s ambitious plans for an expanded social safety net will lead to American decline. Here’s how Stephens opens his column:

Years ago, Alexis Tsipras, the party leader of Greece’s Coalition of the Radical Left, surprised me with a question. “Here in the United States,” the soon-to-be prime minister asked me over breakfast in New York, “why do you not have this phenomenon of passing money under the table?”

The subject was health care. Greece has a public health care system that, in theory, guarantees its citizens access to necessary medical care.

Practice, however, is another matter. Patients in Greek public hospitals, Tsipras explained, would first have to slip a doctor “an envelope with a certain amount of money” before they could expect to get treatment. The government, he added, underpaid its doctors and then looked the other way as they topped up their income with bribes.

Take a close look at any country or locality in which the government offers allegedly free or highly subsidized goods and you’ll usually discover that there’s a catch.

What is the point of opening with this anecdote (other than not-so-subtly alerting the reader that the author is the sort of important person who has chit-chats with world leaders)? The implication, so far as I can tell, seems to be that countries that provide free or heavily subsidized social welfare benefits tend to be more corrupt.

There is, however, an important problem with this argument: It’s not true.

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New Podcast, Featuring Taryn Vian

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A new episode of KickBack: The Global Anticorruption Podcast is now available. This episode is particularly timely, as it features an interview with Taryn Vian, a professor at the University of San Francisco whose research focuses on the links between corruption and public health. Unsurprisingly, much of our discussion revolves around the current coronavirus pandemic, and how to address and manage the corruption challenges associated with the current health emergency. But our broad-ranging conversation also covers the corruption-health connection in more normal times (including issues like informal payments to doctors and embezzlement or misappropriation of medical supplies), as well as lessons learned from corruption in previous public health emergencies, such as the Ebola outbreak in West Africa in 2013-2016.

You can find this episode here. You can also find both this episode and an archive of prior episodes at the following locations:

KickBack is a collaborative effort between GAB and the ICRN. If you like it, please subscribe/follow, and tell all your friends! And if you have suggestions for voices you’d like to hear on the podcast, just send me a message and let me know.

Some Recent Commentaries on Corruption and the Coronavirus Pandemic

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As I noted last week, although this blog is going to keep on going during the COVID-19 crisis (though perhaps with somewhat reduced output), it’s a bit challenging to proceed with blogging about one problem (corruption) when another problem (the COVID-19 pandemic) is so much at the forefront of everybody’s mind. And in that last post, I noted that although there’s a well-known connection between corruption and public health generally, “so far corruption doesn’t seem to be a major issue in the COVID-19 situation.”

I think perhaps I spoke too soon. We’re already starting to see a number of interesting and useful commentaries on the connections between corruption/anticorruption and the COVID-19 pandemic (several of which readers helpfully noted in comments on last week’s post). I do think we should always try to be a bit cautious about straining to find links between whatever it is we work on and the most salient problem of the day. (I can’t help but remember that in the aftermath of the 9/11 attacks, people suddenly discovered that whatever problem they’d been working on for the past decade was inextricably linked to the threat of global terrorism.) But in this case I’m persuaded that the links are particularly plausible and important that this is something that deserves further study.

At some point, I may post some original content on this topic to GAB, but for now let me just provide links to some of the interesting early commentaries on the possible connections between corruption and the COVID-19 pandemic:

  • Natalie Rhodes, who works with the Transparency International Health Initiative, has an essay–subsequently expanded into a longer feature on Transparency International’s website–discusses some of the corruption risks during the response to an epidemic, including shortage-induced bribery risks, diversion of emergency response resources, and kickbacks in the procurement process.
  • Jodi Vittori, a fellow at the Carnegie Endowment, has a piece entitled “Corruption Vulnerabilities in the U.S. Response to Coronavirus,” which similarly emphasizes corruption risks in medical supply chains, and the greater difficulty in securing transparency and accountability during times of crisis. She lays out a series of measures that, she argues, must be integrated into all COVID-19 response legislation, and also suggests some things that ordinary citizens can do.
  • Another Carnegie Endowment fellow, Abigail Bellows, has a piece called “Coronavirus Meets Corruption: Recommendations for U.S. Leadership,” which emphasizes that the combination of systemic corruption and the COVID-19 crisis could prove especially devastating in the developing world, and suggests that the U.S. government could help ameliorate this situation by targeting more of its foreign aid at strengthening fiscal management systems, and by enacting a number of currently-pending bills that, while not specifically related to corruption in the health sector, would provide greater U.S. support to the fight against kleptocracy abroad.
  • In one of the earliest blog commentaries suggesting a corruption-coronavirus link, Gretta Fenner and Monica Guy of the Basel Institute on Governance wrote a post for the FCPA blog in late January that suggested the original coronavirus outbreak in China may have been linked to the illegal wildlife trade, and that the illegal wildlife trade is made possible by corruption–a string of connections that leads them to ask, in the title of their post, “Did corruption cause the deadly coronavirus outbreak?”

I’m sure that in the days and weeks ahead, more commentaries will appear that explore both the ways that corruption may have contributed to, or exacerbated the impact of, the coronavirus pandemic, and the corruption risks associated with the policy responses to this crisis. I probably won’t be able to keep up with all of them, but I’ll do my best to feature them on the blog when I can, and if readers are aware of other useful commentaries, please send me the information through this blog’s contact page.

Thanks everyone, and stay safe.

“Petty” Corruption Isn’t Petty

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Grand corruption attracts plenty of attention—from activists, the mainstream media, and other commentators (including on this blog)—and for good reason. While the media may simply be riveted by the decadent lifestyles of corrupt actors, the anticorruption community has increasingly recognized the devastating impact that kleptocrats and their cronies can have. No doubt, this attention to grand corruption is welcome and recent successes in fighting it are laudable. At the same time, though, this increased focus on grand corruption carries with it the risk of making smaller, more everyday forms of corruption—sometimes called “petty” corruption—seem less consequential.

Yet so-called “petty” corruption remains widespread, and its aggregate impact should not be underestimated. By way of example, consider the most recent results from the Transparency International (TI) Global Corruption Barometer (GCB) survey of citizens in Latin America and the Caribbean, which found that one-third of people who used a public service paid a bribe in order to do so. In other words, for these 90 million people, their ability to access a government service to which they were entitled was conditioned upon an extralegal payment—and that’s just accounting for this one region.

Even as the anticorruption community rightly focuses attention on combatting grand corruption, we can’t forget the real havoc wreaked by smaller-scale corruption. So-called “petty” corruption is not a petty concern. Rather, it’s a serious, pervasive problem that deserves just as much sustained attention as does politicians buying collector cars and oceanfront properties with assets from their secret offshore bank accounts. At the risk of repeating familiar points, it’s worth reviewing the ways in which small-scale corruption has, cumulatively, a range of incredibly destructive effects:

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Is It a Crime To Promise To Support a Legislator Who Votes the Way You Want?

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Last March, while President Trump and House Speaker Paul Ryan were trying—ultimately unsuccessfully—to muster enough votes for the first version of their proposed Obamacare replacement, the American Health Care Act (AHCA), the Koch brothers’ political organizations announced that they would set up a fund to provide substantial campaign support to all Republicans who voted against the AHCA (which the Koch brothers opposed on the grounds that it didn’t go far enough in repealing the health insurance expansions brought about by the Obamacare). Stripped to its essence, the Koch brothers said to Republican House Representatives: “If you vote the way we want on this bill, we’ll donate (more) money to your campaigns; if you don’t, we won’t.”

Was that offer a violation of the federal anti-bribery statute? In a provocative essay, Louisiana State University Law Professor Ken Levy says yes, it was. Professor Levy reasons as follows: The anti-bribery statute, codified at 18 USC § 201(b), prohibits any person from “giv[ing], offer[ing] or promis[ing] anything of value to any public official … with intent to influence any official act.” The Koch brothers certainly “offered” or “promised” campaign donations, and campaign donations indubitably count as a “thing of value.” Moreover, the Koch brothers made this promise in order to influence a vote in the legislature, clearly an official act. Moreover, as Professor Levy points out, although many people seem to think that the Supreme Court has ruled that providing campaign donations in exchange for votes is constitutionally protected, in fact the Court has held the opposite: promising campaign donations in exchange for an “official act” does qualify as an unlawful bribe, so long as there’s a quid pro quo; in the absence of a quid pro quo, Congress’s power to regulate campaign donations or expenditures is more limited. Thus, all the elements of a §201(b) violation are present, and at least in principle, the Koch brothers could be prosecuted, convicted, and sentenced to a prison term of up to 15 years and/or a fine of up to three times the value of the thing of value offered (which this case could run into the tens of millions of dollars).

Professor Levy’s legal analysis seems, at least on a first reading, to be correct. At the same time, I find it unthinkable that any federal prosecutor—not just Jeff Sessions, but even someone like Preet Bharara—would bring criminal charges in this case, or that any judge would allow a conviction to stand. Professor Levy’s provocative essay has forced me to think a bit harder about why that is. The fact that I can’t imagine a federal bribery case could or should be brought against the Koch brothers for their announced campaign support plan, despite the fact that the conduct seems clearly to violate the letter of the law, suggests that something has gone seriously awry with how U.S. law, and U.S. political culture, think about the relationship between campaign donations, political speech, and criminal bribery. Continue reading →

Corruption in Health Aid: Escaping the Scandal Cycle

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William Savedoff, Amanda Glassman and Janeen Madan of the Center for Global Development, a Washington-based development policy think tank, originally wrote this post for CGD.  It is reprinted here with permission.

Health aid pays for life-saving medicines, products, and services in the poorest countries in the world. Funding for such uses needs to be smooth and uninterrupted. But when fraud is detected, funds are subject to sudden stops and starts—the result of a sequence of events set off by the scandal cycle in health aid depicted below. We examine this idea and offer ways to escape the cycle in a new CGD policy paper we summarize here.

The Scandal Cycle

 

To understand the scandal cycle, we looked at four cases of fraud and response involving the World Bank in India, USAID in Afghanistan, the Global Fund in Mali, Djibouti and Mauritania, and European donors in Zambia. While corruption is discovered in different ways, scandals tend to erupt when the press publicizes it or a funder reacts strongly. Once allegations are in the public eye, funders typically react by suspending aid. Then, they work with recipients to create action plans for improving financial management systems, and eventually resume funding.

This scandal cycle is, unfortunately, all too common. In May, the Global Fund published an investigation that tracked down $3.8 million in fraudulent expenditures at Nigeria’s Department of Health Planning, Research & Statistics. The Fund’s executive director issued a statement reaffirming the Fund’s “zero tolerance of corruption” policy, underscoring that the Fund had frozen disbursements to several Nigerian agencies, and calling for reforms to government control measures.

As with the cases we analyzed in our paper, the focus on fraud often comes at the expense of considering the scale of corruption and the impact of disruption on health programs. While $3.8 million is no small number, it represents less than one percent of the $889 million in grants to Nigeria that the Global Fund audited in a companion report on the Wamboo.org project. Furthermore, the impact of international support on improving health has been rather large; the Global Fund’s own statement indicates that international support has helped Nigeria reduce deaths from malaria by 62 percent since 2000.

Halting disbursements to health programs can have serious consequences for service delivery, health outcomes, and institutional development. In light of the scale of fraud and the potential health impact, is suspending aid an effective response? And without information on health impact, how would we know?

We argue that funders may be able to escape the scandal cycle—and reduce such disruptions—by paying greater attention to information on program achievements. Currently, funders pay a lot of attention to procedural issues. For example, a 2013 report from the Special Inspector General for Afghanistan Reconstruction (SIGAR) documented weak accounting systems at the Afghan Ministry of Health. Even though the report had no direct evidence of fraud and the health program was successfully delivering services, SIGAR recommended USAID suspend the program.

By contrast, the World Bank’s 2008 Detailed Implementation Review of the Indian health sector not only included evidence of procedural failures, such as bid rigging, but also documented results failures, like continuing high malaria rates and inoperative hospitals. If the World Bank and India had reported these results failures earlier, the cases where corruption was big enough to affect programs would have come to light much sooner.

We think results on service delivery, population health, and institutional development are the key piece of information that could change the dynamics of the scandal cycle. This kind of information can help funders communicate more effectively about why they are deciding to suspend or continue aid, set appropriate standards for when aid should be halted, and establish new funding mechanisms that make it more difficult to divert funds.

We recommend the following three steps to improve funder response:

  1. Communicate using results. When a scandal erupts, communicating the funder’s actions to control or prevent corruption to stakeholders, the media, and the broader public is important. But emphasizing whether health aid programs are achieving intended results is also an essential component of the communications strategy. If a program is achieving results, stakeholders and constituents would better understand a funder’s decision not to suspend aid when a scandal erupts (while investigating abuse and working with the recipient to address the problem).
  2. Differentiate responses by results. In addition to responding to corruption allegations (which typically come from whistleblowers), tracking program results could help funders detect corruption. If a program is falling short of achieving results, corruption might be a contributing factor and an investigation could help determine whether and how much. Moreover, results data would allow funders to determine whether corruption is—or is not—hampering program implementation, and to recalibrate anti-corruption controls accordingly.
  3. Disburse in proportion to results. Where feasible, paying for results in health could help ensure that funds are only paid out when results are achieved. This approach makes it harder to divert funds because payments only occur after the program’s impact is measured. In programs that pay for results, dishonest people can only skim off funds if they have been very efficient at generating impact. In practice, they are likely to simply set their sights elsewhere.

The Scandal Cycle

The Global Fund’s recent statement recognizes the importance of communicating the results of its health grants to Nigeria, but it doesn’t address whether it is helpful to suspend aid over a relatively small amount of fraud or lack of supporting documentation. Our paper encourages funders to incorporate information about program results into their risk management strategies so they can communicate better, detect corruption sooner, and make more considered choices about creating or responding to scandals.

Continue reading →

Guest Post: Connecting Health and the Fight Against Corruption

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Taryn Vian, Associate Professor of Global Health at the Boston University School of Public Health, contributes the following guest post:

The recent endorsement of the Sustainable Development Goals (SDGs) has prompted greater discussion and debate about the most important aspects of, and the most effective means for achieving, sustainable development. Most of the discussion of corruption in the context of the SDGs has focused on SDG 16 (“Promote just, peaceful, and inclusive societies”), which specifically includes anticorruption and related objectives among its targets (and which has prompted some debate on this blog – see here, here, here, and here.) But the fight against corruption is also closely linked to the achievement of another one of the SDGs: SDG 3 (“Ensure healthy lives and promote well-being for all at all ages”).

On its face, SDG 3 is about health, not corruption. But the fight against corruption is in fact closely connected to SDG 3, and health professionals need to open their eyes to this connection. Corruption worsens health outcomes in many ways: siphoning off resources that are supposed to be devoted to health care (for example, through embezzlement and absenteeism), increasing the cost and decreasing the availability of medicines and medical equipment (or enabling the spread of fake medicines), creating barriers to use of health services (particularly by poor and uneducated people who are especially vulnerable to bribery) and reducing the overall availability and quality of health services. Thus the fight for increased health ought to be—perhaps must be—seen as inextricably connected to the fight against corruption.

Though measuring the impact of corruption on health is challenging, at this point we have a sufficiently large (and growing) body of evidence that corruption threatens health. Consider the following: Continue reading →

At Last, A Good News Corruption Story

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It seems that not a day goes by without some gloomy story about corruption appearing in the popular media or online. “Corruption on the rise in Africa poll as governments seen failing to stop it” says a new TI study.  “In Mexico, 200 million acts of corruption a year” the Mexican Competitiveness Institute reports.  Monday’s Washington Post editorial proclaims that “Mali’s corruption hindered its efforts to fight terror,” and the subtitle of a best-selling book warns that it is not only Malians who are at risk but that corruption “Threatens Global Security as Well.”

With all this bad news it was a surprise to discover a recent good news story about corruption.  The news is doubly surprising as it comes out of three unexpected places: Ghana Kenya, and Uganda.  Even better, rather than broad generalizations drawn from a handful of selected anecdotes, the good news in Professors Rebecca Dizon-Ross, Pascaline Dupas, and Jonathan Robinson’s July 2015 “Governance and the Effectiveness of Public Health Subsidies” paper rests on a careful, clever empirical study that employs rigorous scientific methods.  The only bad news about the paper is that it is on a remote internet site beyond the ken of most web browsers.  For readers whose browsers don’t travel to the National Bureau of Economic Research’s web site, a potted summary follows. Continue reading →