Tech for the health sector
BLOCKCHAIN: WAY TO LIMIT MEDICAL AID ABUSE
Funds lose R22 billion to R28 billion a year.
The Government Employees Medical Scheme (Gems), the second biggest scheme in the country, identified KwaZulu-Natal as the most problematic when it came to fraudulent claims. In one example, Gems uncovered irregular claims of R93 million by a service provider who had 36 practices registered under its name.
They are not alone.
Medical aid claims attributed to fraud, waste and abuse cost the sector between R22 billion and R28 billion a year.
These numbers were revealed at the inaugural Fraud, Waste and Abuse Summit, organised by industry regulator the Council for Medical Schemes (CMS) earlier this year. They accounted for an average of around 25% of the total healthcare claims paid by the industry in 2017.
Discovery Health, the largest open medical aid scheme in the country, says in 2018, its efforts to curb fraud, waste and abuse resulted in it recovering R555 million and it estimates an annual “halo effect” brings this number up to R1 billion.
Medical expert Dr Ntuthuko Bhengu says technological solutions, like blockchain, have the potential to drastically curb fraud and wasteful expenditure.
Data management
Blockchain is a type of distributed ledger technology used to record and store transaction records. It is a shared and fixed record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger.
Given that blockchain is a decentralised system where transactions are recorded and shared among all network participants, by using it, the CMS, for instance, would have access to the immutable audit trail of all interactions between medical schemes, their members and practitioners. This would make it easier for it to detect patterns of fraud.
Blockchain is not bitcoin
“The biggest challenge is to make the case that blockchain is not bitcoin,” Bhengu said.
He gave a presentation at the Gems Symposium in Durban earlier this month on the advantages of incorporating blockchain in the way the healthcare sector stores patient information, saying it would remove the inefficiency and fragmentation in how the sector currently operates.
“The problem with healthcare, both locally and globally, is that there is too much of silos and, if you think about it, this is one industry that needs to see patient data shared to the extent that any practitioner that sees the data should know what the previous one actually found, examined and prescribed,” said Bhengu.
“One of the things blockchain will do, and is doing in other jurisdictions, is to make sure that when the patient moves along the healthcare chain, they take their data with them because it introduces the holy grail of interoperability,” said Bhengu.
This means a patient’s record can be seen by any practitioner at any time – provided the patient has given permission.
Not a panacea
If blockchain presents so many solutions, why is the healthcare sector not embracing it?
Well, for starters, Bhengu notes, the technology is not fully mature and cannot be immediately adopted.
Secondly, he said there is a reluctance to fund the uptake – particularly by those in the venture capital industry who see healthcare as complex.