Understanding the Deterrence in Medical Insurance Fund Regulatory Systems for Fraud and Abuse Behaviors by Enrollees in China: An Analysis Based on Deterrence Theory

Abstract Background: To effectively improve the regulatory systems of medical insurance, a deep dive into their impact on enrollees is essential. The challenge lies in comprehensively and quantitatively assessing these effects, amidst a noticeable research gap in evaluating regulatory impacts within the medical insurance domain. This study aimed to develop a conceptual framework based on deterrence theory to assess the effects of medical insurance regulations on deterring medical insurance fraud and abuse (MIFA) among enrollees, focusing on Shanghai as a case study. Methods: This study integrated data for analysis from three distinct sources and used mixed methods. The Database of Medical Insurance Supervision on Enrollees (DMISE), spanning 2017 to 2021, provided a foundational analysis of the system's implementation. We utilized a multistage stratified sampling method to conduct a questionnaire survey to gauge enrollees' perceptions of deterrence, employing the Enrollees' Perceived Deterrence Scale (EPDS), developed for this study. Semi-structured interviews with key informants offered deeper insights into the regulatory systems. Our evaluation was guided by a conceptual framework that identified three key dimensions of deterrence: severity, certainty, and celerity. Results: Our study analyzed 12,898 historical fraud and abuse cases, involving 10,723 enrollees, alongside 965 valid questionnaires. It revealed that the medical insurance regulatory system in Shanghai exerted a high level of deterrence. Enrollees rated the perceived severity of the regulatory system as the highest. Although administrative sanctions were the primary measures, and were effective, there is a need for greater intensity and precision in their application. The certainty of detection was high, at approximately 80–90%. Whilst some covert activities remained difficult to detect, the certainty of enforcement was approximately 99%. Celerity received the lowest scores, indicating delays in both detection and penalty imposition within the regulatory response. Conclusion: The study developed a theoretical analytical framework to assess the effectiveness of deterrence within medical insurance regulatory systems. It identified both the strengths and weaknesses of severity, certainty, and celerity in the current regulatory system, providing valuable insights for enhancing deterrence. These findings offer important guidance for policymakers to strengthen regulatory schemes against MIFA, contributing to the advancement of more effective healthcare policies.