Growth Of Medical Costs Research Articles

Identifying fraud in medical insurance based on blockchain and deep learning

With the rapid growth of medical costs, the control of medical expenses has been becoming an important task of Health Insurance Department. Traditional medical insurance settlement is paid on a per-service basis, which leads to lots of unreasonable expenses. To cope with this problem, the single-disease payment mechanism has been widely used in recent years. However, the single-disease payment also has a risk of fraud. In this work, we propose a framework to identify fraud of medical insurance based on consortium blockchain and deep learning, which can recognize suspicious medical records automatically to ensure valid implementation on single-disease payment and lighten the work of medical insurance auditors. An explainable model BERT-LE is designed to evaluate the reasonability of ICD disease code for Medicare reimbursement by predicting the probability of a disease according to the chief complaint of a patient. We also put forward a storage and management process of medical records based on consortium blockchain to ensure the security, immutability, traceability, and auditability of the data. The experiments on two real datasets from two 3A hospitals demonstrate that the proposed solution can identify fraud effectively and greatly improve the efficiency in medical insurance reviews.

Editors' Note

This issue's symposium on future research directions in forensic economics originated with papers that were presented at the January 4, 2020, National Association of Forensic Economics (NAFE) session “NAFE: An Agenda for Future Research” at the Allied Social Science Associations annual meeting in San Diego, California. The impetus for the session was to honor Jack Ward, the first editor of the Journal of Forensic Economics (JFE) by having him provide insights on what research in forensic economics has contributed to the current knowledge of practitioners, as well as his thoughts on the future directions of forensic economics research. This symposium contains papers on the topic of future research directions in forensic economics that were prepared by the presenters at the San Diego meeting.Jack Ward's paper suggests that there have been advances over the last three decades in forensic economics that include the Markov analyses of worklife expectancy; Expectancy Data's Dollar Value of a Day and Full-time Earnings in the United States that have advanced the projection of replacement household services and lost earnings; research based on Bureau of Labor Statistics Family Expenditure Survey data that has added greater precision to measures of self-consumption of earnings; and papers that have helped clarify differences between measuring probable earnings and earning capacity. Ward's paper concludes with a list of topics for further research in the forensic economics literature that includes more work on the role of race and gender in determining earnings; modeling dynamic changes in industry specific employment and wage growth; and the incorporation of Bayesian methodologies in lost wage projections, including the assignment of meaningful probabilities to outcomes.The paper by Michael Brookshire and Frank Slesnick discusses what their 10 surveys of NAFE members have revealed about important research topics. They argue that their surveys suggest that NAFE members place high importance on research on worklife of the disabled, worklife of the self-employed, personal consumption, and household services. Brookshire and Slesnick also offer, based on their experience as practitioners and researchers, the following agenda: whole-time approach to damages estimation; forensic economics in the classroom; a paper summarizing what is known as a result of the papers published in the JFE state paper series; tailoring, i.e., accounting for qualitative factors and variables omitted from standard economic models; the market for forensic economists; the definition of earning capacity; and what is meant by reasonable economic probability.The paper by Steven Shapiro suggests that despite the large body of published research in forensic economics, there are still controversial topics that are lacking consensus. Shapiro suggests that the controversial areas that should be the focus of research include the choice of interest rates for discounting; interest rates, earnings growth and inflation; interest rates, growth in medical costs and inflation; how many years of earnings history is necessary to project base earnings and earnings history; alternative approaches to hedonic damages; and punitive damages. Shapiro expresses the hope that research on these topics will improve the reliability and validity of the work of forensic economists.

An Agenda for Future Research in Forensic Economics: New Approaches to Viewing Controversial Topics

AbstractDespite a large body of published research in forensic economics, there are still controversial topics that are lacking consensus. This paper presents an agenda for research on controversial topics in the hope that the results of such research will improve the reliability and validity of the work of forensic economists. Specifically, the paper presents suggestions for research on the choice of interest rates for discounting; interest rates, earnings growth and inflation; interest rates, growth in medical costs and inflation; how many years of earnings history is necessary to project base earnings and earnings history; alternative approaches to hedonic damages; and punitive damages.

Impacts of government supervision on hospitalization costs for inpatients with COPD

To address the remaining medical misconducts after the zero-makeup drug policy (ZMDP), e.g., over-examinations, China has given the priority to government supervision on medical institutions. This study evaluated the effect of government supervision on medical costs among inpatients with chronic obstructive pulmonary disease (COPD) in Sichuan province, the first province in China where the medical supervision was conducted.A linear interrupted time series (ITS) model was employed to analyze data about 72,113 inpatients from 32 hospitals. Monthly average medicine costs, diagnostic costs, and medical services costs, nursing costs from January 2015 to June 2018 were analyzed, respectively.The average hospitalization costs fell with a monthly trend of 42.90Yuan before the implementation of supervision (P < .001), and the declining trend remained with the more dramatic rate (−158.70Yuan, P < .001) after the government audit carried out. For western medicine costs, the monthly decreasing trend remained after the implementation of supervision (−66.44Yuan, P < .001); meanwhile, the monthly upward trend was changed into a downtrend trend for traditional Chinese medicine costs (−11.80Yuan, P = .009). Additionally, the increasing monthly trend in average diagnostics costs disappeared after government supervision, and was inversed to an insignificant decreasing trend at the rate of 26.18Yuan per month. Moreover, the previous upward trends were changed into downward trends for both medical service costs and nursing costs (P = .056, −44.71Yuan; P = .007, −11.17Yuan, respectively) after the supervision carried out.Our findings reveal that government supervision in Sichuan province was applicable to curb the growth of medical costs for inpatients with COPD, which may reflect its role in restraining physicians’ compensating behaviors after the ZMDP. The government medical supervision holds promise to dismiss medical misconducts in Sichuan province, the experience of which may offer implications for other regions of China as well as other low- and middle-income countries.

High intensity lifestyle intervention and long-term impact on weight and clinical outcomes.

BackgroundObesity increases the risk for diabetes and cardiovascular events, with a corresponding growth in medical costs. High intensity lifestyle intervention (HILI) is the cornerstone for weight management. We assessed the effectiveness of clinic-based HILI on weight loss and associated clinical outcomes by duration of program participation and comorbid conditions.MethodsThis was a retrospective cohort study of patients who enrolled in HILI weight management programs at Health Management Resources (HMR) clinics located across the U.S. Patients completed health risk assessments (HRA) and were enrolled for up to 24 months at the time of follow-up HRA. HMR programs provide weekly group coaching to achieve reduced calorie intake, increased fruit/vegetable intake, and physical activity ≥2,000 kcal/wk. A Markov model predicted avoidance of diabetes and cardiovascular events and projected cost savings due to weight loss.ResultsOf the 500 patients included in the analysis, 67% were female and mean age was 54.1 years (s.d. 11.6). The baseline weight and BMI were 243.5 lbs (range 144.0–545.0) and 38.8 kg/m2 (range 25.4–85.0), respectively. Overall, patients lost an average of 47.4 lbs (18.9% of initial body weight [IBW]); the amount of weight loss was consistent among those with diabetes/pre-diabetes (50%), high/moderate risk for dyslipidemia (60%), hypertension/pre-hypertension (86%), and severe obesity (37%). The mean IBW lost was 16.4%, 19.3%, 20.7% for ≤6 months (n = 165), 7–12 months (n = 140), 13–24 months (n = 195) of program participation, respectively. The simulation model estimated 22 diabetes and 30 cardiovascular events and $1,992,370 medical costs avoided over 5 years in the 500 patients evaluated.ConclusionPatients in the HMR clinic-based HILI program achieved substantial weight loss regardless of duration of program participation, risk profile and comorbid status. The HMR program could be an effective strategy to prevent costly diabetes and cardiovascular events, particularly in high risk patients.

Evidence for capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, Shanghai: A longitudinal study.

Currently, China has been experiencing rapid growth of medical costs, serious waste of medical resources, increasing disease burden for residents, and a medical insurance fund deficit. Therefore, an urgent problem that needs to be solved is to choose a rational payment for the insurance system. To empirically evaluate the long-term effects of capitation reform in a New Rural Cooperative Medical Scheme in Pudong New Area, we collected and analysed data regarding financing, fund operation, medical service cost, and medical care-seeking behaviour from 2011 to 2015, a duration that includes data before and after reform. The data for financing and behaviours were compared year by year, and the monthly data for inpatient and outpatient costs were evaluated in a retrospective time series study. The capitation reform in Pudong New Area showed strong evidence of the power of medical cost control in the long run, while it was weak in reversing the number of patients flowing into secondary and tertiary hospitals. To make the payment of capitation play a bigger role in cost control in China, a tighter alignment of capitation with the general practitioner system and achieving dual referral is critical for future studies.

Discussions on the " Tripartite-sector reform" , a model empowered by medical insurance: Sanming as a focal

Tripartite-sector reform (a synergistic reform in public health services, medical insurance and medicine production-circulation) in Sanming city was described in the paper which centers on medical insurance. Tapping full potentials of the medical insurance, the city achieved efficient synergy among healthcare, medical insurance and medication systems. This reform has trimmed out inflated drug pricing to some extent for rooms of maneuver of medical service pricing changes, thus curbing excessive growth of medical costs successfully. The authors proposed areas of further improvements including the relationship between achieving such objective as curbing medical expenditure, and advancement of technical/medical service capacity; that between integrative control of medical insurance expenditure and protection of people's health; the equilibrium of interests between medical insurance, healthcare and medication. All these will contribute to the goal of healthy patients flow and a hierarchical medical system. Key words: Sanming; Medical insurance function; Tripartite-sector reform; People's health

Research on 1 282 cases of per-hospitalization high inpatient expenditure: influencing factors

Objective To explore the causes of per-hospitalization high inpatient expenditure of a tertiary hospital in 2015, by analyzing the influencing factors. Methods We retrospectively studied 1 282 inpatient cases who cost more than 100 000 yuan per case at a tertiary hospital in 2015, analyzing statistically major influencing factors of such expenditure in variance analysis and multiple stepwise regression analysis. Results The average days of stay of these cases were 27.6 days, and the average medical cost of those cases was 149 153 yuan per person. Costs for medicines and material made up a large proportion of medical costs, respectively accounting for 33.38% and 31.98% of the total. The days of stay, prognosis of the patient, complications as well as hospital infection, surgeries, gender of the patients constituted major factors on inpatient medical expenditure. Conclusions Reducing the average days of stay, guiding reasonable applications of drugs and medical materials, strengthening management on operations and controlling excessive medical services are effective approaches to reducing excessive growth of medical costs. Key words: High inpatient expenditure cases; In patients; Average medical cost per hospitalization; Influencing factors

Recommendations on hospitals practicing the total prepaid system

The authors,based on understanding the basic concepts of the total prepaid system,recommend the following to minimize unreasonable growth of medical costs and promote healthy development of the hospital,namely enhancing hospital management,standardizing medical practice,and scientifically managing foundation quotas.They also proposed to correctly handle such relationships as that between medical costs and quality of care,and that between partial interests and global interests. Key words: Total prepaid; Hospital; Medical insurance; Relationship

Caring for identified versus statistical lives: An evolutionary view of medical distributive justice

A central medical ethical concern is distributive justice, which may be framed as a problem in valuing identified lives versus statistical lives. Framing the issue in this way is important for two reasons. First, the growth of medical costs has been fueled and will continue to be fueled primarily by the growth of medical technology focused intensively, and often with little benefit for cost, on the care of identified lives. Second, there is some evidence that less expensive primary care, as opposed to high-tech medicine, is positively correlated with improved life expectancy, decreased infant and neonatal mortality, and fewer cases of low birth weight. However, shifting resources from high-tech medicine to primary care will be difficult because people find it psychologically painful to deny care to identified lives. People value identified lives more than statistical lives because we are influenced by certain cognitive preferences inherent to human nature. Natural selection has primed these cognitive preferences. There are no easy solutions to the profound problems facing healthcare systems. However, evolutionary insights can help us understand these problems and could productively inform attempts to promote primary care as opposed to high-tech medicine, thereby improving benefit for cost and enhancing social welfare.

The quality of medical evidence: implications for quality of care.

Prologue: Most of the proposals advanced in the 1980s for rationalizing the use of medical care derived chiefly from an economic model —more consumer cost sharing, the development of alternative health delivery systems, and new financial incentives. One of the working assumptions of the analysts and policymakers who designed these proposals was that the scientific basis of medicine was solid. If purchasers of care could only determine how to make providers more efficient, they reasoned, the growth of medical costs could be moderated. In this paper, David Eddy and John Billings call into question that assumption. They make a case for why it is imperative that the medical profession get on with the job of examining more closely the scientific basis of medical practice. Eddy holds a medical degree from the University of Virginia and a doctor of philosophy degree in applied mathematics from Stanford University. Eddy, who currently directs the Center for Health Policy at Duke University, is the J. Alexander McMahon professor of Health Policy Research and Management. Eddy operates at the intersection of math and medicine, applying probability theory to the uncertainty of approaches to care. Billings holds a law degree from the University of California, Berkeley, and has been actively involved in a variety of health care activities for a decade. Billings, who is currently an independent consultant, wrote this article with Eddy while serving as a visiting professor at Duke. He served as one of the first staff directors of a community-based (Salt Lake City) health care coalition (1979–1980) and was executive director of The John A. Hartford Foundation for four years (1981–1985).