Book Review

Prescription for Profit: How Doctors Defraud Medicaid

N Engl J Med 1993; 329:892September 16, 1993

Article

Prescription for Profit: How Doctors Defraud Medicaid
By Paul Jesilow, Henry N. Pontell, and Gilbert Geis. 247 pp. Berkeley, Calif., University of California Press, 1993. $25. ISBN: 0-520-07614-1

Medicaid fraud is one of the more sordid moral lapses to which physicians have succumbed. Its detection, prosecution, and prevention are in the interests of both the public and the profession. Yet its magnitude, economic impact, and genesis are not as precisely known as they should be. This book attempts to redress that deficiency -- with mixed success.

The authors focus on three sources of information in two states (New York and California): interviews with enforcement agents, excerpts from their investigative files, and interviews with physicians punished for misconduct and physicians never punished.

The composite picture that emerges is one of a series of sleazy practices such as padding bills, charging for tests and services that were unnecessary or were never performed, illicitly prescribing controlled substances, and charging Medicaid for “therapeutic time” while having sexual intercourse with patients. The cases presented are characterized as “the tip of the conning tower of a very large and very elusive submarine.”

Medicaid fraud exhibits many of the features of white-collar crime. It is investigated with kid gloves and is less intensively searched out or prosecuted than more ordinary crimes. It is more frequently punished by community service, cash restitution, or fines than by imprisonment, except in the most egregious cases. Demographically, foreign graduates and psychiatrists are disproportionately represented. Women are proportionately represented. Convicted and punished physicians see themselves as victims of the system, their own lapses of memory or attention, bookkeeping or paperwork errors, or excessive beneficence toward patients. Rarely do they see themselves as committing crimes or even doing harm. Nonoffenders -- the “control group” -- are close to offenders in their negative attitudes toward Medicaid payments and paperwork.

The authors end with a chapter of speculation in which they distribute blame for the problem widely: on Medicaid legislation, for its failure to provide stricter surveillance and for its fee-for-service reimbursement system; on the courts and prosecutors, for an indulgent attitude toward physician offenders; on the profession, for failure to police itself; and on medical schools, for the values they inculcate that supposedly set the stage for fraudulent behavior.

This book serves well to jar the reader into better awareness of a serious and neglected aberration of professional morality. Few conscientious physicians will read it without feeling that the profession has been diminished by its complacency. Patients will be justifiably angry and anxious about their next medical encounter. Policy makers will vow to “do something about it.”

The book fails, however, to provide the firm, factual foundation that an effective policy of detection and prevention would require. Its genre is more that of investigative reporting than scholarship. The anecdotes are graphic and dramatic, but there is a tendency to superciliousness as well. At times, the anecdotes about the psychiatrists' sexual exploits with patients verge on the voyeuristic.

The methodologic shortcomings are considerable. Samples are small (42 of 125 identified offenders) and limited to two states. The control group consisted of 32 physicians (16 percent of those invited), one third of whom were interviewed by telephone. The final chapter consists of speculation about the psychosocial dynamics of the offenders, with a dearth of supporting data.

This book has all the polemic value of an attention getter. It forces all of us to take notice of a species of serious professional misbehavior that is known too vaguely and treated too complacently. But, for solutions and the kind of solid data on which to base any radical systemic reform, we shall have to look elsewhere.

Edmund D. Pellegrino, M.D.
Georgetown University, Washington, DC 20057

Citing Articles (1)

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1. 1

   Robert M. Goldwyn. (2004) The Politicization of the Physician. Plastic and Reconstructive Surgery106-110
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