Method and system for evaluating a physician's economic performance and gainsharing of physician services

• US 20060149596A1
• Filed: 11/18/2005
• Published: 07/06/2006
• Est. Priority Date: 01/17/2002
• Status: Active Grant

• Current Assignee: AMS Applied Medical Software Incorporated
• Original Assignee: AMS Applied Medical Software Incorporated
• Inventors: Surpin, Jo, Kalison, Michael
• Granted Patent: US 7,640,173 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06F 9/44 Arrangements for executing specific programs
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

The invention relates to a method and system of physician economic performance evaluation in which the relative medical difficulty associated with patients admitted by a particular physician is determined and, given that measurement, judgments made concerning the relative amount of inpatient resources that the physician required. Also, one application of the present invention relates to a method for gainsharing of physician services using a surplus allocation methodology for rewarding physicians in relation to their performance. An incentive pool is determined from previous patient claims and payments made to physicians in advance, such as in a base year. Best practice norms are established for a plurality of classified diagnosis groups. In one embodiment of the present invention, the classified diagnosis related groups are adjusted for severity of illness to compensate for actual clinical challenges faced by individual physicians. The best practice norms can be used in the surplus allocation method for determining physician performance. The incentive is established proportional to the relationship between a physician'"'"'s individual performance and the best practice norm.

Claims

1. A method of evaluating physician'"'"'s economic performance comprising the steps of:

determining a standard cost value from data of an all patient refined diagnosis related group; and

determining a physician'"'"'s economic performance by comparing current physician'"'"'s economic performance associated with one of the all patient refined diagnosis related group to the standard cost value.

2. The method of claim 1 wherein said data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said data comprises inpatient claim information and hospital cost data.

3. The method of claim 2 wherein said inpatient claim information is determined from a uniform bill (UB) or hospital claim.

4. The method of claim 2 wherein said step of determining a standard cost value comprises the steps of:

a) determining a costed patient record by combining said inpatient claim information normalized for cost differences across hospitals and said hospital cost data of a patient;

b) assigning one of said classified all patient refined diagnosis related groups to said costed patient record;

c) assigning a responsible physician to said costed patient record;

d) repeating step a) through step c) for each patient claim of said base patient data for determining an expected cost statistic for each said classified all patient refined diagnosis related group to form said standard cost value.

5. The method of claim 4 further comprising the step of editing said hospital cost data to exclude outlier hospital cost data.

6. The method of claim 4 wherein in step b) if one of said classified all patient refined diagnosis related groups to said costed patient record cannot be assigned, further comprising the step of removing said inpatient claim from said costed patient record.

7. The method of claim 4 wherein in step c), if a responsible physician cannot be assigned, further comprising the step of:

removing said inpatient claim from said patient costed record.

8. The method of claim 4 wherein said step of determining an expected cost statistic comprises the steps of:

excluding from said each patient claim any outlier costs;

computing a normative expected cost statistic;

determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

excluding any of said responsible physicians having a number of cases within said all patient refined diagnosis related group lower than a predetermined threshold of number of physicians cases;

ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

determining a subset of physicians in said ordered list as physicians meeting a standard cost value; and

if said subset of physicians meeting said standard cost value is greater than a threshold of number of physicians meeting said standard cost value, recomputing said normative expected cost statistic using said subset of physicians in said ordered list meeting said selection standard cost value within each all patient refined diagnostic related group and recomputing said standard cost value with the recomputed normative cost statistic and said difference of actual patient cost from said expected cost statistic.

9. The method of claim 8 further comprising the step of:

storing said standard cost value.

10. The method of claim 9 wherein before said recomputing step, further comprising the step of:

determining a minimum number of claims for each classified all patient refined diagnosis related group, and

if a determined number of claims for said classified all patient refined diagnosis related group is greater than said minimum number of claims then performing said recomputing step or if a determined number of claims for said classified all patient refined diagnosis related group is less than said minimum number of claims then indicating that said recomputed expected cost statistic is not said standard cost value.

11. The method of claim 10 wherein said step of determining said incentive pool further comprises the steps of:

e) inputting data of inpatient claims for a plurality of patients,

f) classifying said inpatient claim into one of said all patient refined diagnosis related groups,

g) inputting physician billing data associated with said classified inpatient claim,

h) linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim,

i) assigning said merged data to one of said physician provider types comprising a responsible physician, consultant physician and hospital based physician, and

j) repeating step e) through step i) for each inpatient claim.

12. The method of claim 11, further comprising the steps of:

determining hospital to physician cost ratios for each said all patient refined diagnosis related groups from either parametric hospital to physician cost ratios or hospital to physician cost ratios computed from ratios of said physician billing data and said inpatient claims.

13. The method of claim 12 further comprising:

storing physician cost ratios for each said all patient refined diagnosis related groups.

14. The method of claim 13 further comprising:

generating a report of said physician cost ratios for each said all patient refined diagnosis related groups.

15. The method of claim 1 wherein said step of determining said incentive pool further comprises the steps of:

determining a percentage of a type of physician provider for said classified all patient refined diagnosis related group, said type of physician provider comprising a responsible physician, consultant physician and hospital based physician;

determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims; and

applying said percentage of responsible physician claims to said incentive pool for determining a responsible physician incentive pool.

17. A method for gainsharing of physician services between a plurality of physicians comprising the steps of:

establishing a best practice norm for a plurality of classified all patient refined related diagnosis groups from base patient data;

determining an incentive constraint of an amount of a payment made to said physicians which is available for gainsharing;

determining an incentive pool from payments made to said physicians in advance associated with said plurality of classified all patient refined diagnosis related groups up to said incentive constraint;

computing a maximum physician incentive;

determining distribution of said incentive pool by comparing current physician performance associated with each of said classified all patient refined diagnosis related groups to the established best practice norm for said one of said classified all patient refined diagnosis related groups and to said maximum physician incentive.

18. The method of claim 17 wherein said payments made to physicians in advance is determined from part B costs of a uniform bill and said incentive pool is determined from a ratio of payments to a hospital determined from part A to said payments made to physicians determined from part B costs or a percentage of payments to a hospital.

19. The method of claim 18 wherein said base patient data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said inpatient data comprises inpatient claim information and hospital cost data.

20. The method of claim 19 wherein said inpatient claim information is determined from a uniform bill (UB) or hospital claim.

21. The method of claim 19 wherein said step of establishing a best practice norm comprises the steps of:

a) determining a costed patient record by combining said inpatient claim information normalized for cost differences across hospitals and said hospital cost data of a patient;

b) assigning one of said classified all patient refined diagnosis related groups to said costed patient record;

c) assigning a responsible physician to said costed patient record;

d) repeating step a) through step c) for each patient claim of said base patient data for determining an expected cost statistic for each said classified all patient refined diagnosis related group to form said best practice norm.

22. The method of claim 21 further comprising the step of editing said hospital cost data to exclude outlier hospital cost data.

23. The method of claim 21 wherein in step b) if one of said classified all patient refined diagnosis related groups to said costed patient record cannot be assigned, further comprising the step of removing said inpatient claim from said costed patient record.

24. The method of claim 21 wherein in step c), if a responsible physician cannot be assigned, further comprising the step of:

removing said inpatient claim from said patient costed record.

25. The method of claim 21 wherein said step of determining an expected cost statistic comprises the steps of:

excluding from said each patient claim any outlier costs;

computing a normative expected cost statistic;

determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

excluding any of said responsible physicians having a number of cases within said all patient refined diagnosis related group lower than a predetermined threshold of number of physicians cases;

ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

determining a subset of physicians in said ordered list as physicians meeting a selection criteria best practice norm; and

if said subset of physicians meeting a selection criteria best practice norm is greater than a threshold of number of physicians meeting said best practice norm, recomputing said normative expected cost statistic using said subset of physicians in said ordered list meeting said selection criteria best practice norm within each all patient refined diagnostic related group and recomputing said best practice norm with the recomputed normative cost statistic and said difference of actual patient cost from said expected cost statistic.

26. The method of claim 17 further comprising the step of:

storing said best practice norm.

27. The method of claim 26 wherein before said recomputing step, further comprising the step of:

determining a minimum number of claims for each classified all patient refined diagnosis related group, and if a determined number of claims for said classified all patient refined diagnosis related group is greater than said minimum number of claims then performing said recomputing step or if a determined number of claims for said classified all patient refined diagnosis related group is less than said minimum number of claims then indicating that said recomputed expected cost statistic is not said best practice norm.

28. The method of claim 27 wherein said step of determining said incentive pool further comprises the steps of:

e) inputting data of inpatient claims for a plurality of patients,

f) classifying said inpatient claim into one of said all patient refined diagnosis related groups,

g) inputting physician billing data associated with said classified inpatient claim,

h) linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim,

i) assigning said merged data to one of said physician provider types comprising a responsible physician, consultant physician and hospital based physician, and

j) repeating step e) through step i) for each inpatient claim.

29. The method of claim 28, further comprising the steps of:

determining hospital to physician cost ratios for each said all patient refined diagnosis related groups from either parametric ratios or hospital to physician cost ratios computed from ratios of said physician billing data and said inpatient claims.

30. The method of claim 28 further comprising:

storing physician cost ratios for each said all patient refined diagnosis related groups.

31. The method of claim 30 further comprising:

generating a report of said physician cost ratios for each said all patient refined diagnosis related groups.

32. The method of claim 17 wherein said step of determining said incentive pool further comprises the steps of:

determining a percentage of a type of physician provider for said classified all patient refined diagnosis related group, said type of physician provider comprising a responsible physician, consultant physician and hospital based physician;

determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims; and

applying said percentage of responsible physician claims to said incentive pool for determining a responsible physician incentive pool.

33. The method of claim 32 wherein said step of determining said incentive pool further comprises the steps of:

allocating said responsible physician incentive pool between a medical incentive pool and a surgical inventive pool based on a ratio of a total medical payments received for medical claims from said classified all patient refined diagnosis related groups and a total of surgical payments received for surgical claims for said classified all patient refined diagnosis related groups.

34. The method of claim 33 wherein said step of determining said incentive pool further comprises the steps of:

allocating said medical incentive pool between a medical improvement pool and a medical performance pool; and

allocating said surgical incentive pool between a surgical improvement pool and a surgical performance pool.

35. The method of claim 34 before said step of allocating said responsible physician incentive pool further comprising the steps of:

subtracting a loss of income pool from said responsible physician incentive pool to form an adjusted responsible physician incentive pool;

allocating said adjusted responsible physician incentive pool between said surgical incentive pool and said medical performance pool; and

determining said medical improvement pool as said loss of income pool.

36. The method of claim 35 wherein said step of determining said incentive pool further comprises the steps of:

determining a maximum medical performance incentive per case for each classified all patient refined diagnosis related group; and

determining a maximum medical improvement incentive per case for each classified all patient refined diagnosis related group.

37. The method of claim 36 wherein said step of determining said incentive pool further comprises the steps of:

determining a maximum surgical performance incentive per case for each classified diagnosis related group; and

determining a maximum surgical improvement incentive per case for each classified diagnosis related group.

38. The method of claim 37 wherein said step of determining distribution further comprises the steps of:

determining a current costed patient record from said current patient data physician cost ratios for each said all patient refined diagnosis related groups;

assigning one of said classified all patient refined diagnosis related groups to said current costed patient record;

assigning a responsible physician to said current costed patient record;

removing any said claims not having assigned a responsible physician; and

categorizing said responsible physician into a medical responsible physician or a surgical responsible physician based on said current costed patient record.

39. The method of claim 38 wherein a performance ratio is established for said compared current physician performance for one of said classified all patient refined diagnosis related groups to the established best practice norm for said one of said classified all patient refined diagnosis related groups and a physician can receive a performance incentive if the performed ratio of the physician is greater than a threshold wherein said step of determining said incentive pool further comprises the steps of:

calculating said performance incentive using data of the maximum medical performance incentive per case or data of the maximum surgical performance incentive per case and the performance ratio.

40. The method of claim 39 wherein said performance incentive is reduced by a predetermined amount for claims at or below said best practice norm.

41. The method of claim 40 wherein a surgical improvement incentive is determined as a difference between a base year case mix adjusted incentive and a current year case mix adjusted incentive times the number of claims in the current year.

42. The method of claim 41 wherein said case mix adjusted incentive is determined using a set of all patient refined diagnosis related group weights.

43. The method of claim 42 wherein a medical improvement incentive is determined as a difference between a base year case mix adjusted incentive and a current year case mix adjusted LOS times the loss of income per diem times the number of claims in the current year.

44. The method of claim 43 wherein said case mix adjusted incentive is determined using a set of all patient refined diagnosis related group weights.

45. The method of claim 44 further comprising the step of:

determining a total of said medical performance incentive, a total of said medical improvement incentive, a total of said surgical performance incentive and a total of said surgical improvement incentive.

46. The method of claim 45 further comprising the step of:

generating a report of said total medical performance incentive and said total medical improvement incentive for each said responsible physician.

47. The method of claim 45 further comprising the step of:

generating a report of said total surgical performance incentive and said total surgical improvement incentive for each said responsible physician.

48. The method of claim 17 further comprising the step of:

storing data collected for said established best practice norm.

49. The method of claim 17 further comprising the step of:

generating a report for visually displaying said data collected from said established best practice norm.

50. The method of claim 29 wherein said parametric ratios are determined as a first ratio of a percentage of savings for determining an amount of said incentive goal available for physician gainsharing and a second ratio of a percentage of savings for determining payments to participating third-party payors.