Ethically Questionable Practices in Health Care: Explaining Provider Intentions in Puerto Rico

Ethically questionable practices (EQPs) in health care represent a persistent challenge to the sustainability, integrity, and legitimacy of health systems worldwide. While prior research has extensively documented fraudulent behaviors after they occur, considerably less attention has been devoted to the cognitive and organizational mechanisms that shape providers’ intentions before such practices materialize. Addressing this gap, this study proposes and empirically tests an integrative model that combines the Fraud Triangle Theory—pressure, opportunity, and rationalization—with the Theory of Planned Behavior—attitude, subjective norms, and perceived behavioral control—to explain healthcare providers’ intentions to engage in EQPs toward insurers in Puerto Rico. Using a quantitative, cross-sectional design, primary data were collected from health care providers across multiple sectors. The proposed model was analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM). Results indicate that rationalization plays a central mediating role, transforming structural pressures and perceived opportunities into cognitively justifiedintentions. The findings conceptualize EQPs as deliberate cognitive processes and offer implications for ethics-based governance, compliance design, and policy interventions.