Big Data Tackles Cost Shifting in Healthcare Insurance Payments

Chongqing - The National Intelligent Healthcare Security Contest 2024 finals recently concluded at Mingyue Lake, Chongqing's Liangjiang New Area. The contest used real data and modern technologies like big data and AI to tackle challenges in China's healthcare insurance operations.

Geng Tao, deputy director of the Administrative Enforcement Division at the Shanghai Municipal Healthcare Security Administration, explained that his team leverages big data to tackle regulatory issues in China's healthcare payment system, which is mainly used for inpatient reimbursements and has limited trials for outpatient services.

These regulatory issues involve improper cost shifting, where medical institutions transfer patient hospitalization expenses to outpatient payments. This allows institutions to pass costs that should be covered by healthcare insurance onto patients, increasing the institutions' revenue.

Geng raised an example that when a patient is hospitalized, the healthcare fund reimburses the hospital a fixed amount of 10,000 yuan (USD 1,404.9) for the patient’s hospital expenses.

However, the hospital may shift some of these costs, such as 2,000 yuan, to outpatient expenses, which the patient must pay out of pocket. As a result, the patient only receives 8,000 yuan for hospital services, while the hospital still claims the full 10,000 yuan reimbursement from the healthcare fund.

Geng noted that investigating cost-shifting practices involves multiple parties, including hospitals and supervisory agencies, making the investigation process costly.

Geng suggested using clinical pathways to standardize procedures from diagnosis to rehabilitation to reduce investigation costs and improve regulatory effectiveness. By leveraging big data technology, medical record data can be integrated, creating data pathways that include patients' diagnosis results and specific medical examination details, such as blood tests.

He explained that by comparing a patient's medical records with each step in the clinical pathways, anomalies like cost shifting can be quickly detected, enabling timely monitoring and alerts.

At the opening ceremony, Yu Mingfeng, a member of the Leading Party Group of the Chongqing Big Data Application and Development Administration, announced that more than 839 TB of real and anonymized data, totaling over 1.1 billion records, would be made available to participants. This data includes personal, corporate, natural resources, spatial geography, healthcare business, and medical imaging information.

Xu Qian, head of the medical team at Neusoft Corporation, accepted Bridging News' interview at Mingyue Lake in Chongqing Liangjiang New Area on October 1. (Photo/Huxin Luo)

Deng Li, director general and secretary of the Leading Party Group of Chongqing Municipal Healthcare Security Administration, emphasized the importance of using real and anonymized data to evaluate the practical applicability of the participating teams' cases. He stated that leveraging Chongqing's extensive real data will aid in assessing the feasibility of proposed solutions and support their implementation.

According to Yan Qinghui, a member of the Leading Party Group and deputy director general of the National Healthcare Security Administration, this contest is China’s first national-level digital event jointly organized by central and local governments following the release of the Plan for the Overall Layout of Building a Digital China.