Unsupervised learning for anomaly detection in Australian medical payment data

Fraudulent or wasteful medical insurance claims made by health care providers are costly for insurers. Typically, OECD healthcare organisations lose 3-8% of total expenditure due to fraud. As Australia’s universal public health insurer, Medicare Australia, spends approximately $A 34 billion per annum on the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme, wasted spending of$A1–2.7 billion could be expected.However, fewer than 1% of claims to Medicare Australia are detected as fraudulent, below international benchmarks. Variation is common in medicine, and health conditions, along with their presentation and treatment, are heterogenous by nature. Increasing volumes of data and rapidly changing patterns bring challenges which require novel solutions. Machine learning and data mining are becoming commonplace in this field, but no gold standard is yet available. In this project, requirements are developed for real-world application to compliance analytics at the Australian Government Department of Health and Aged Care (DoH), covering: unsupervised learning; problem generalisation; human interpretability; context discovery; and cost prediction. Three novel methods are presented which rank providers by potentially recoverable costs. These methods used association analysis, topic modelling, and sequential pattern mining to provide interpretable, expert-editable models of typical provider claims. Anomalous providers are identified through comparison to the typical models, using metrics based on costs of excess or upgraded services. Domain knowledge is incorporated in a machine-friendly way in two of the methods through the use of the MBS as an ontology. Validation by subject-matter experts and comparison to existing techniques shows that the methods perform well. The methods are implemented in a software framework which enables rapid prototyping and quality assurance. The code is implemented at the DoH, and further applications as decision-support systems are in progress. The developed requirements will apply to future work in this fiel

The influence of marketing factors and substance characteristics on pharmaceutical sales in a state-controlled prescriptions pharmaceuticals market

The present dissertation investigates the influence of brand as well as substance-related marketing attributes on prescription pharmaceutical sales within a state-controlled market. For this purpose, a systematic literature review was conducted in the first instance, during which knowledge about the most relevant research within this field was gathered. Consequently, over 538 publications were reviewed and indicated as being potentially relevant, leading to an eventual count of 98 core publications. However, most of these studies had been conducted in the mainly unrestricted US market. These findings were then summarised and statistically evaluated. In a second step, based on the literature review, a qualitative study, containing focus and Delphi groups, was then performed. The participants in these studies were involved in pharmaceutical marketing within a state-controlled prescriptions pharmaceuticals market. Consequently, the findings were slightly different to those derived by the systematic literature review. Based on this second step, seven hypotheses were proposed. In the third step, these hypotheses were tested, using collected data and a secondary market dataset provided by a market research institute. A statistical analysis was then performed, applying descriptive as well as multiple regression analytical methods. The evaluation of the results resulted in a conceptual model of physician targeting, leading to several theoretical, methodological and managerial implications

The influence of marketing factors and substance characteristics on pharmaceutical sales in a state-controlled prescriptions pharmaceuticals market

The present dissertation investigates the influence of brand as well as substance-related marketing attributes on prescription pharmaceutical sales within a state-controlled market. For this purpose, a systematic literature review was conducted in the first instance, during which knowledge about the most relevant research within this field was gathered. Consequently, over 538 publications were reviewed and indicated as being potentially relevant, leading to an eventual count of 98 core publications. However, most of these studies had been conducted in the mainly unrestricted US market. These findings were then summarised and statistically evaluated. In a second step, based on the literature review, a qualitative study, containing focus and Delphi groups, was then performed. The participants in these studies were involved in pharmaceutical marketing within a state-controlled prescriptions pharmaceuticals market. Consequently, the findings were slightly different to those derived by the systematic literature review. Based on this second step, seven hypotheses were proposed. In the third step, these hypotheses were tested, using collected data and a secondary market dataset provided by a market research institute. A statistical analysis was then performed, applying descriptive as well as multiple regression analytical methods. The evaluation of the results resulted in a conceptual model of physician targeting, leading to several theoretical, methodological and managerial implications.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Federal Register

Daily publication of the U.S. Office of the Federal Register contains rules and regulations, proposed legislation and rule changes, and other notices, including "Presidential proclamations and Executive Orders, Federal agency documents having general applicability and legal effect, documents required to be published by act of Congress, and other Federal agency documents of public interest" (p. ii). Table of Contents starts on page iii

Federal Register

Daily publication of the U.S. Office of the Federal Register contains rules and regulations, proposed legislation and rule changes, and other notices, including "Presidential proclamations and Executive Orders, Federal agency documents having general applicability and legal effect, documents required to be published by act of Congress, and other Federal agency documents of public interest" (p. ii). Table of Contents starts on page iii

Manager’s and citizen’s perspective of positive and negative risks for small probabilities

So far „risk‟ has been mostly defined as the expected value of a loss, mathematically PL, being P the probability of an adverse event and L the loss incurred as a consequence of the event. The so called risk matrix is based on this definition. Also for favorable events one usually refers to the expected gain PG, being G the gain incurred as a consequence of the positive event. These “measures” are generally violated in practice. The case of insurances (on the side of losses, negative risk) and the case of lotteries (on the side of gains, positive risk) are the most obvious. In these cases a single person is available to pay a higher price than that stated by the mathematical expected value, according to (more or less theoretically justified) measures. The higher the risk, the higher the unfair accepted price. The definition of risk as expected value is justified in a long term “manager‟s” perspective, in which it is conceivable to distribute the effects of an adverse event on a large number of subjects or a large number of recurrences. In other words, this definition is mostly justified on frequentist terms. Moreover, according to this definition, in two extreme situations (high-probability/low-consequence and low-probability/high-consequence), the estimated risk is low. This logic is against the principles of sustainability and continuous improvement, which should impose instead both a continuous search for lower probabilities of adverse events (higher and higher reliability) and a continuous search for lower impact of adverse events (in accordance with the fail-safe principle). In this work a different definition of risk is proposed, which stems from the idea of safeguard: (1Risk)=(1P)(1L). According to this definition, the risk levels can be considered low only when both the probability of the adverse event and the loss are small. Such perspective, in which the calculation of safeguard is privileged to the calculation of risk, would possibly avoid exposing the Society to catastrophic consequences, sometimes due to wrong or oversimplified use of probabilistic models. Therefore, it can be seen as the citizen‟s perspective to the definition of risk

European Distance and E-Learning Network (EDEN). Conference Proceedings

Erasmus+ Programme of the European UnionThe powerful combination of the information age and the consequent disruption caused by these unstable environments provides the impetus to look afresh and identify new models and approaches for education (e.g. OERs, MOOCs, PLEs, Learning Analytics etc.). For learners this has taken a fantastic leap into aggregating, curating and co-curating and co-producing outside the boundaries of formal learning environments – the networked learner is sharing voluntarily and for free, spontaneously with billions of people.Supported by Erasmus+ Programme of the European Unioninfo:eu-repo/semantics/publishedVersio

Diagnostic Fluidity: Working with Uncertainty and Mutability

Diagnostic procedures are emblematic of medical work. Scholars in the field of social studies of medicine identify diverse dimensions of diagnosis that point to controversies, processual qualities and contested evidence. In this anthology, diagnostic fluidity is seen to permeate diagnostic work in a wide range of contexts, from medical interactions in the clinic, domestic settings and other relations of affective work, to organizational structures, and in historical developments. The contributors demonstrate, each in their own way, how different agents ‘do diagnosis’, highlighting the multi-faceted elements of uncertainty and mutability integral to diagnostic work. At the same time, the contributors also show how in ‘doing diagnosis’ enactments of subjectivities, representations of cultural imaginaries, bodily processes, and socio-cultural changes contribute to configuring diagnostic fluidity in significant ways