TURKEY: Healthcare Fraud Costs Millions

The Turkish state has reimbursed YTL 18 bn to cover health expenditures in 2007, a figure that has seen a 17-fold increase over seven years. Most of this amount was spent for medicine.

Official statistics disclosed by the state indicate that corruption and rules infractions in Turkey's health sector have reached terrifying heights.

A recent month-long inspection conducted by the Social Security Institution (SGK) has revealed that YTL 16 mln of YTL 39 mln, a sum monthly paid to private health institutions, is not spent for the reported purposes. According to the inspection results, the SGK has paid tenfold of what would normally suffice for the birth bills sent to it. While it should have paid a YTL 252 000 total for the reported caesarian births, the institution paid YTL 2.52 mln instead -- meaning that YTL 2.27 mln was not spent as reported. In one case uncovered by the SGK, the institution covered the expenses of a woman "who gave birth 10 times last year," each time via induced labor. Scores of similar, tragicomic corruption cases were discovered in the SGK inquiry.

According to the SGK's findings, YTL 955 000 of the YTL 1.82 mln in payments for injections was paid out in return for fake bills. Also, the SGK paid YTL 437 000 for the opening of clogged cardiac arteries, whereas the actual sum that needed payment was only a third of this, YTL 119 000.

The corruption in the health sector is spreading despite police prevention measures. Despite counter-corruption operations conducted almost daily, authorities have so far failed in preventing the vast majority of cases of abuse of the healthcare system. They have been foiled by a twisted chain of fake reports, fake retirement claims and fake health reports coupled with corrupt doctors, chemists, drug companies and, most importantly, the mala fide patients, who are the central pieces of the tale. As has been seen in one of the most recent exposed corruption cases, where the SGK paid an unnecessary YTL 100 000 for prostheses that were never used, doctors draw up fake health reports and make deals with contact persons from drug companies, even sometimes using even dead people's names to bill the SGK. A fraudulent chemist completes the vicious cycle, thereby imposing a heavy cost on the institution for the unreal disabilities of real people.

The astronomical upsurge in recent years in health expenditures covered by the state demonstrates the magnitude of the corruption in the system. While health expenditures covered by the state in 2000 totaled YTL 1.06 bn, that figure has ballooned to YTL 18 bn as of 2007. Experts say a major factor in this nearly 20-fold rise is increasing corruption.

Another factor augmenting medical bills is that doctors employed in private hospitals demand unnecessary magnetic resonance imagine (MRI) tests to diagnose even minor ailments, such as backaches. The 2007 SGK records reveal this: While state hospitals demanded MRIs for only 0.6 percent of their patients, private hospitals had 1.9 percent of their patients undergo MR imaging. Similarly, private hospitals and medical centers demanded a far higher number of computerized tomography (CT) angiographies from their patients. On the other hand, even though state hospitals and the private sector employ the same number of obstetricians, the number of in vitro fertilization (IVF) operations conducted in private hospitals is eight times higher.

Provincial health directors conduct onsite inspections

The health sector's corruption is the most pressing issue on the SGK's own agenda as well. Provincial health directors conduct onsite inspections to avert systems abuses as much as possible. For instance, teams founded and led by provincial health directors in 16 cities conduct on site inspections every fortnight. SGK President Fatih Acar gives examples of the forms of corruption unearthed: "While an average person can undergo an angiography only once a day, some appear on the bills to have undergone three or even four angiographies in one day. Then they bill the institution. The number of similar cases is quite high, and we fear that it will grow in the coming years."

Acar cautioned hospitals, drug stores and drug companies against participating in such corruption, warning that the SGK was determined to end the abuse. "We are really determined this time. We have made great leaps forward in the health sector, but we will not allow any abuse or corruption. We will show zero-tolerance to those companies that have committed an infraction of rules and become involved in corruption. We will impose a number of sanctions, including the cancelation of their contracts with the SGK," he emphasized.

Labor Minister Faruk Çelik demands that the SGK use the Medula system bill tracking more effectively and actively to detect all abnormalities. Online bill tracking can facilitate efforts to uncover abnormalities such as the abovementioned reports of a woman giving birth 10 times in a year, or a heart patient having four angiographies in a day.

While the state drives a tough bargain with drug stores for the implementation of the Drug Purchase Protocol, the current scene in drug corruption is unsatisfactory. A police department report says drugs obtained through drug smuggling and theft are repackaged in fake boxes and are put on the market.

"The promotions given to drug sales representatives as well as the overly lenient sanctions involved encourage corruption and infractions of the rules," the report stresses, adding that many in the most impoverished parts of eastern and southeastern Anatolia rent out their health cards, turning the corruption into a profitable business. The chemists or doctors with rented health cards write fake prescriptions using the cards. If it is a doctor preparing the fake prescription -- given that the health card has to end up in a drug store -- the chemist adds medications to the prescription and as a result, 16 percent of the YTL 9 bn paid by the SGK to drug companies is illegally used by them to cover their promotional expenses. According to the police report, drug companies pay an average of YTL 10 000 for promotional expenses per doctor.

The report also points out that the number of private medical centers has rapidly increased in recent years as the prospect of making "extra money" lures them into the sector. Their number was 600 before July 2007, and it has risen to over 800 in six months, which made the Health Ministry suspicious and take immediate action. The ministry has made it very difficult for three-four doctors to get together and open a medical center. They now have to have a separate building like hospitals.

With health cards gone, number of prescriptions skyrockets

The Turkish Pharmacist Employers' Union (TEİS) President Nurten Saydan emphasizes that the abrogation of health cards has triggered an incredible upsurge in the number of prescriptions. Noting that any citizen registered with the SGK can take the prescribed medications of more than one person only by providing his ID number because of the system the SGK has switched to before the building of a sound infrastructure, she said: "It will not be possible to use the smart health card for another while. Therefore, it is a must to return to the previous system of hardcopy health cards."

Most private hospitals and medical centers complain about the SGK, thinking that the declaration of fake bills to the SGK by a certain number of corrupt people is casting a shadow over the entire sector. Representatives of the sector demand that the SGK cancel its contracts with all the hospitals and medical centers that are discovered to have committed any of the crimes in question. "They don't even send a legal admonition to those hospitals and medical centers that send fake bills," a representative from the sector complained.

Ahmet Karataş, chairman of the Association of All Health Institutions (TÜMSAD), also emphasized: "Every time we go to the SGK, bureaucrats complain of corruption and the infraction of rules. But they don't do anything about it. Even though what the state must normally do under these circumstances is to annul their contracts, they don't even warn those hospitals and medical centers."

Asserting that the number of inspections conducted by the ministry is insufficient, he noted that the most frequent form of corruption involved medical analyses and various tests that do not require a patient to be present in the lab. "They send a flu patient to all the clinics. And most of the time, they prepare the patient's forms and prescriptions and forward them to the accounting department of the hospital even before the doctors at the clinics in question examine the patient," he said.

Source: Today's Zaman