The Canadian Institute for Health Information (CIHI) reports than Canada spends $253.5 billion annually on health, and growing at above 4% per year. This is, by far, the largest cash dispensing industry in Canada, dwarfing defense spending (22 Billion).
This post is about exogenous [outside the system] financial threats posed by predators.
Frankly, no one knows what the financial slippage is from fraud and other external crime attacks. For the most part, estimates are based in perception (attitudinal surveys) and anecdote. Having said this, it doesn’t take much of an Internet search to determine European countries and the United States are concerned about transnational organized crime and other types of gang attacks to their health care systems.
In Canada the private sector experiences staged accident injury claims. During my time as a property and casualty insurance fraud investigator, and from comments by government health employees, a belief prevails that privacy legislation prohibits sharing personal information horizontally across insurers for investigative purposes.
The Ontario Freedom of Information and Protection of Privacy Act (FIPPA) doesn’t prohibit inter-agency sharing of personal health information for investigation. What it does is provide for how this information is to be shared.
Part III of FIPPA identifies the conditions for disclosing personal information. Section 42 (1) states “An institution shall not disclose personal information in its custody or under its control, with exceptions including under s.42. These exceptions include allowing institutions disclosure personal information to a law enforcement agency in Canada, if: (i) the disclosure is to aid in an investigation undertaken by the institution or the agency with a view to a law enforcement proceeding, or (ii) there is a reasonable basis to believe that an offence may have been committed and the disclosure is to enable the institution or the agency to determine whether to conduct such an investigation
Most insurers already disclose personal identifiers and other information to a police service when they have a reasonable basis that an offence has been committed, and they want it pursued criminally. The problem with this linear approach; organized crime and gangs may be simultaneously attacking multiple insurers (public and private) in multiple police jurisdictions.
One way to mitigate this problem may be for insurers to rally behind a singular law enforcement service with a strategic and tactical health crimes analysis capacity. The police have jurisdiction to conduct intelligence probes and to conduct targeted enforcement against organized crime and gang related activity.
A precedent for an integrated health agency/police cooperation approach may have already been established in Ontario. During the Harris administration, the Ministry of Health and Long-Term Care disbanded its investigations unit and contracted with the Ontario Provincial Police for their Anti-Rackets Branch to conduct investigations forwarded directly by this Ministry.
Could private sector insurers co-contract with the Ontario Provincial Police Anti-Rackets to provide Ontario health care insurers with a strategic and tactical crimes analytical service? When recognizing an organized crime/gang pattern, an “Anti-Rackets tactical intelligence task force would be able to contact insurers for additional information if germane to their investigation. An alternative for strategic intelligence might be Criminal Intelligence Services Ontario for strategic analysis.
The only question perhaps remaining is whether government and private insurers have the appetite and resolve to get after transnational organized crime and localized gang activity gaming the health insurance industry.