Research On The Effectiveness Of Public Whistle-blowing On Social Medical Insurance Fraud From A Collaborative Governance Perspective

Building up the security of the medicare fund and cracking down on social medical insurance fraud is an inevitable requirement to safeguard the vital interests of all participants,as well as a tough battle to deeply clean up the operating environment of the medicare system.In recent years,relying on the administrative enforcement raids led by the National Healthcare Security Administration,China’s social medical insurance anti-fraud work has achieved milestones,but ultimately unable to fundamentally tackle the persistent problem of fraudulent practices,a variety of illegal phenomena are still repeatedly prohibited.The Government alone cannot solve the problem of the widespread and high incidence of social medical insurance fraud.It is necessary to introduce public participation in regulation and to pool efforts to efficiently promote social medical insurance anti-fraud work.As a result,since 2018 national and local whistle-blowing reward policies have been introduced one after another,providing an incentive platform for the public to actively report fraudulent insurance practices and serving as a practical model for anti-fraud collaborative governance.However,from the data publicly available nationwide and from field research in the sample areas,the effectiveness of whistle-blowing is not very satisfactory,caught in a dilemma of high intention but low actual whistle-blowing behavior among the public.Based on this,this paper aims at identify the factors that influence the public’s whistle-blowing behavior and explore ways to improve the effectiveness of whistle-blowing,so as to promote the value of whistle-blowing reward policies.This paper proceeds in two stages:In the first stage,we designed questionnaires and interview outlines based on relevant literature,selected the pilot cities of Jiangsu Province for medical insurance fund supervision,Huai’an(north),Taizhou(middle),and Wuxi(south)as the sample areas,with on-site research conducted in the sample areas several times in 2021,2022 and 2023 to collect information on social medical insurance fraud and public whistle-blowing.In the second stage,the research hypothesis on the factors influencing whistleblowing behavior was formulated using the motivation-opportunity-competence model,and a 27-item questionnaire was designed.A survey containing 2,250 questionnaires was distributed to the public at Healthcare Security Administration in the sample area,of which 2,081 valid questionnaires were returned and then a structural equation modelling was used to test the research hypotheses empirically.The results found that the sample areas were caught in a dilemma of low cases brought by the public,few funds recovered,and a discrepancy between the public’s intention and whistle-blowing behavior.This paper argues that the paradox of "high intention and weak behavior" in public whistle-blowing is the key to the effectiveness in whistle-blowing social medical insurance fraud,where the public’s awareness of the policy is enhanced by the promotion of the whistle-blowing incentive policy,but the behavior is discouraged.Risk perception does not reduce the public’s incentive to blow the whistle on fraudulent insurance practices,the lack of fraud recognition abilities to detect cases of fraud in a timely manner is another important factor that prevents actual whistle-blowing behavior from occurring.Based on this,promoting the positive transformation of the intention into behavior is fundamental to improving the effectiveness of public whistle-blowing,and specific measures can focus on the constraints identified in the Motivation-Opportunity-Ability model:First,creating an atmosphere of collaborative governance in which the pubic is actively engaged in blowing the whistle,increasing the transparency of information and strengthening the culture of whistleblowing;Second,optimizing the whistle-blowing reward policy,loosening the award conditions and raising the standard level as well;Third,improving the infrastructure of whistle-blowing channels and receiving agencies,providing dedicated staff and reinforcing communication;Fourth,intensifying anti-fraud education,improving the content and enriching the forms of education.