Provider Altruism and Medical Fraud: Evidence from an Audit Study of Malaria Treatment
中文摘要
我们提供了欺诈性诊断误报导致不必要医疗支出的证据，并表明这种行为与提供者的利润动机强烈相关，且与其较弱的亲社会偏好密切相关。我们使用隐匿身份的标准化患者（SP），令其以真实就诊者的身份，向肯尼亚的私人提供者呈现完全相同的急性疟疾症状，从而在疾病状态经外部核实的受控条件下观察诊断和治疗决策。由于这些标准化患者已被确认为疟疾阴性，因此按设定，任何报告的阳性诊断均为假阳性。提供者在81%的标准化患者就诊中安排了疟疾检测。在实施疟疾检测的条件下，提供者在30%的就诊中报告了假阳性结果，大大超过了诊断准确性研究中针对相同疟疾检测所报告的约3%–5%的假阳性率。尽管提供者对适当的诊断规程几乎完全了解，这种情况依然发生。我们将这一行为与通过一项具有真实收益的改良独裁者博弈所测得的提供者偏好联系起来。安排检测与偏好不相关；但在安排疟疾检测的条件下，与更具利他性的提供者相比，利润动机最强的前25%提供者报告假阳性的比例高出16个百分点，销售抗疟药物的比例高出20个百分点。误报行为还伴随着对患者选择性隐瞒诊断证据。
Abstract
We provide evidence of fraudulent diagnostic misreporting leading to spending on unnecessary medical care and show that it is strongly associated with provider profit motivation and weak prosocial preferences. Using incognito standardized patients (SP) presenting identical acute malaria symptoms as real walk-in clients to private providers in Kenya, we observe diagnostic and treatment decisions under controlled conditions with externally verified disease status. Because the SPs were confirmed to be malaria-negative, any reported positive diagnosis is a false positive by construction. Providers ordered malaria tests in 81% of the SP encounters. Conditional on administering a malaria test, providers report false positive results in 30% of encounters, substantially exceeding the approximately 3-5% false positive rates reported for the same malaria tests in diagnostic accuracy studies. This occurs despite near-perfect knowledge of appropriate diagnostic protocols. We link this behavior to provider preferences measured using a real-stakes, modified dictator game. While ordering a test is uncorrelated with preferences, the top 25% most profit-motivated providers report 16 percentage point (pp) more false positives and sell 20 pp more antimalarial drugs than more altruistic providers, conditional on ordering a malaria test. Misreporting is accompanied by selective concealment of diagnostic evidence from patients.