Uncovering healthcare cons

April 09, 2015

Reducing healthcare fraud is one long-term goal of a new research initiative by Australia’s Capital Markets Cooperative Research Centre (CMCRC).

Supported by new funding available from 1 July 2014, the program will operate three streams to explore and compare huge datasets available in the healthcare sector. The goal is to make improvements to the detection and management of fraud, consumer choice and data management.

The CMCRC is adapting one of its existing analytical solutions, I+Plus, to analyse and cross-reference the many disparate sources of information available in healthcare. It’s hoped this tool could prove useful for healthcare providers to compare their performance with competitors by using industry benchmarks once they are developed.

The CMCRC hopes to have the first results of its new research initiative into healthcare by the end of this year, said Chief Operating and Commercial Officer, David Jonas.

Jonas, who is also CEO of the organisation’s health insurance spin-off company, CMC Insurance Solutions, said the new research program is a natural extension of the group’s work into health insurance.

“It’s broadened out in the past two years to the whole of health,” he explained.

Although it’s a foray out of capital markets for the CRC, success in identifying fraud in the health insurance market, along with a raft of other achievements, led the centre to investigate the detection of similar inefficiencies in the provision of health in general.

The CMCRC will receive $32 million in funding through round 16 of the Australian Government’s CRC Program. About 40% of that will be going into the new health market quality program.

Industry partners already signed up by the CRC include 29 private health insurers, the National Health Performance Authority, NSW Health, and the Victorian Government’s WorkSafe and TAC (Transport Accident Commission) compensation schemes.

“We don’t yet have a public health insurer as an industry partner, but we are gradually engaging with Medicare and the Department of Veterans’ Affairs,” Jonas said.

The new program’s first initiatives will identify the metrics required for assessing market integrity and efficiency. The research will then look at what data needs to be gathered to generate those metrics and how such benchmarks can be used to find solutions.

The centre is already engaging in a range of small start-up projects with all of its industry partners. Jonas pointed out that one of the main difficulties with the healthcare industry is the fragmentation of data, with diagnosis and treatment records for patients being distributed across multiple healthcare providers and funders.

But if healthcare is looked at as a market, rather than a system, it could be easier to identify inefficiencies and then achieve efficiencies.

“Part of our program is to assure market quality in healthcare for providers and users,” Jonas said.

Penny Pryor


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