Method and computer program product for measuring and utilizing efficiency of medical resource and services providers

• US 20070143135A1
• Filed: 12/16/2005
• Published: 06/21/2007
• Est. Priority Date: 12/16/2005
• Status: Active Grant

• Current Assignee: Coventry Health Care of Missouri, Inc. (CVS Health Corporation)
• Original Assignee: Coventry Health Care of Missouri, Inc. (CVS Health Corporation)
• Inventors: Kitching, Gary, Power, Robert, Lindquist, Tammie, Cooper, Susan, Paskach, Richard, Heim, Chad
• Granted Patent: US 7,831,443 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 70/40 relating to drugs, e.g. their side effects or intended usage

Abstract

A method and computer program product is provided that, in various embodiments, may provide a measure of efficiency of resources used in medical treatment plan options. A normalized Relative Resource Value (RRV) may be obtained that measures the level of resources required to satisfy a “normal” case for a particular aspect of medical care. Applying this value against actual costs allows ranking and/or comparison of health care providers relative to one another on the basis of the price or resources applied or utilized. Moreover, applying the RRV against the quality of outcome allows comparison and ranking of providers on overall value. The invention may be applied to the components of medical care comprising, inter alia, acute inpatient, non-acute inpatient, outpatient, professional office-based care including scheduled outpatient, and pharmacy/prescriptions. The normalized RRV obtained under various embodiments of the invention may measure resource use for medical treatment plan options/resources independent of price. The RRV may be relative across, as well as within, each of the components of medical care. Thus, provider profiling generally as well as profiling across treatment plan options based on efficiency generally is within the scope of various embodiments of the invention. Moreover, providers may be compared based on efficiency for specific conditions, as well as across conditions, across treatment plan options and across components of care using various embodiments of the invention.

Claims

1. A method for measuring and utilizing efficiency of resources utilized by health care providers in the care of medical conditions, comprising:

compiling a patient database comprising data from more than one component of care, wherein the component of care data further comprises data from at least one provider;

providing at least one component of care analysis module;

selecting at least one component of care to analyze;

extracting data corresponding to the at least one selected component of care from the patient database;

providing the extracted data to the appropriate component of care analysis module;

identifying and treating outliers from the data;

generating a modular Relative Resource Value (RRV) using the appropriate component of care analysis module;

adjusting the modular RRV to allow inter-modular and intra-modular comparison by provider;

allowing compensation for preventive care and chronic care medical resources;

performing inter-modular and/or intra-modular comparison of the adjusted modular RRV by provider; and

ranking providers within at least one component of care and/or across all components of care based on the adjusted RRV.

2. The method of claim 1, wherein the more than one component of care further comprises:

acute inpatient;

non-acute inpatient;

hospital outpatient;

professional and scheduled outpatient; and

pharmacy.

3. The method of claim 1, wherein the at least one component of care analysis module further comprises:

acute inpatient analysis module;

non-acute inpatient analysis module;

hospital outpatient analysis module;

professional and scheduled outpatient analysis module; and

pharmacy analysis module.

4. The method of claim 3, wherein the acute inpatient analysis module further comprises:

extracting acute inpatient data from the patent database;

summing the extracted data to admission level;

extracting DRG weights from the patient database;

merging DRG weights with extracted inpatient data;

identifying outliers, minimum volume data points and ungroupable DRG'"'"'s;

creating a conversion factor using non-outlier and ungroupable data;

creating the RRV for outliers, non-outliers, minimum volume data points and ungroupable DRGs; and

adjusting the modular RRV by allocating the modular RRV to the encounter level.

5. The method of claim 3, wherein the non-acute inpatient analysis module further comprises:

extracting non-acute inpatient data from the patent database;

grouping extracted data into two admission groupings comprising hospital based and skilled nursing;

summing extracted grouped data to admission level;

calculating a billed per data rate per admission identify outliers and create categories of identified outliers according to presence or absence of length of stay;

identify non-outlier data and create categories of non-outlier data according to presence or absence of length of stay;

creating median billed per day by admission grouping for outliers categorized as having length of stay;

creating median billed per day by admission grouping for outliers categorized as having no length of stay;

creating the modular RRV for each category of data;

adjusting the modular RRV by allocating the modular RRV to the encounter level.

6. The method of claim 3, wherein the hospital outpatient analysis module further comprises:

extracting hospital outpatient data from the patient database;

excluding scheduled outpatient data from the patient database;

creating unit limits on the extracted data;

performing unit edit checks on the extracted data;

summing the data to encounter line level;

merging APC and RBRVS weights;

creating total weight per line and billed amount per line;

creating APC and RBRVS conversion factors;

creating median billed per unit per procedure code for non-weighted procedures;

identifying total weight errors based on line level conversion factor;

performing unit edit and restating unit field;

creating RRV for APC line;

creating RRV for RBRVS line; and

creating RRV for non-weighted procedures.

7. The method of claim 3, wherein the professional and scheduled outpatient analysis module further comprises:

extracting professional data from the patient database;

applying RBRVS weight adjustment factor to the extracted professional data;

extracting scheduled outpatient data from the patient database;

identifying RBRVS procedure codes that break out technical component weight;

identifying technical component procedure codes in extracted scheduled outpatient data;

combining extracted scheduled outpatient and professional data and sum the combined data to encounter line level;

identifying anesthesia encounter lines;

merging on RBRVS weights by procedure code and modifier;

creating total weight per line and billed amount per total weight creating RBRVS conversion factor and median billed per unit for non-weighted procedure codes;

editing and restating unit fields where appropriate;

creating RRV for RBRVS line; and

creating RRV for non-weighted procedures, including anesthesia.

8. The method of claim 3, wherein the pharmacy analysis module further comprises:

extracting pharmacy data from the patient database;

summing the extracted data to claim number level;

creating a billed per day metric;

performing day edits based on claim level billed per day; and

creating a claim level RRV.

9. The method of claim 2, further comprising:

providing at least one treatment plan option for patient treatment;

using the adjusted RRV to measure resource use for treatment plan options; and

comparing efficiency of provider resource use for the treatment plan options.

10. The method of claim 2, further comprising:

providing at least one treatment plan; and

measuring the resource use required for the treatment plan using the adjusted RRV.

11. The method of claim 2, further comprising using the RRV as an operational metric statistic for a health care provider.

12. The method of claim 2, further comprising

providing a health care provider network, comprising more than one health care provider;

and

using the RRV to assist in improving the efficiency and quality of the medical care delivered by health care provider network.

13. The method of claim 2, further comprising using the RRV to assist in improving the efficiency and quality of health care delivery.

14. The method of claim 13, further comprising using the RRV to assist in the identification of misuse of health care resources.

15. The method of claim 2, further comprising:

providing a plurality of treatment plans, each treatment plan comprising at least one treatment option for at least one medical condition, the treatment plans being provided by a plurality of health care providers; and

using the RRV to measure relative price for treatment plans across at least one medical condition and at least one provider.

16. The method of claim 2, further comprising using the RRV to evaluate the efficiency of collaborative treatment of patients by more than one provider.

17. The method of claim 2, further comprising using the RRV to evaluate and improve the efficient use of pharmaceutical resources.

18. The method of claim 2, further comprising:

providing at least one new treatment plan, comprising at least one treatment option; and

using the RRV to determine the relative efficiency of the at least one new treatment plan.

19. The method of claim 3, further comprising using a programmed digital computer for:

compiling a patient database comprising data from more than one component of care, wherein the component of care data further comprises data from at least one provider;

providing at least one component of care analysis module;

selecting at least one component of care to analyze;

extracting data corresponding to the at least one selected component of care from the patient database;

providing the extracted data to the appropriate component of care analysis module;

identifying and treating outliers from the data;

generating a modular Relative Resource Value (RRV) using the appropriate component of care analysis module;

adjusting the modular RRV to allow inter-modular and intra-modular comparison by provider;

allowing compensation for preventive care and chronic care medical resources;

performing inter-modular and/or intra-modular comparison of the adjusted modular RRV by provider; and

ranking providers within at least one component of care and/or across all components of care based on the adjusted RRV.

20. The method of claim 3, further comprising using a computer program product for:

compiling a patient database comprising data from more than one component of care, wherein the component of care data further comprises data from at least one provider;

providing at least one component of care analysis module;

selecting at least one component of care to analyze;

extracting data corresponding to the at least one selected component of care from the patient database;

providing the extracted data to the appropriate component of care analysis module;

identifying and treating outliers from the data;

generating a modular Relative Resource Value (RRV) using the appropriate component of care analysis module;

adjusting the modular RRV to allow inter-modular and intra-modular comparison by provider;

allowing compensation for preventive care and chronic care medical resources;

performing inter-modular and/or intra-modular comparison of the adjusted modular RRV by provider; and

ranking providers within at least one component of care and/or across all components of care based on the adjusted RRV.

21. A computer program product for measuring and utilizing efficiency of medical care resources, comprising:

computer code for compiling a patient database comprising data from more than one component of care, wherein the component of care data further comprises data from at least one provider;

computer code for providing at least one component of care analysis module;

computer code for selecting at least one component of care to analyze;

computer code for extracting data corresponding to the at least one selected component of care from the patient database;

computer code for providing the extracted data to the appropriate component of care analysis module;

computer code for identifying and treating outliers from the data;

computer code for generating a modular Relative Resource Value (RRV) using the appropriate component of care analysis module;

computer code for adjusting the modular RRV to allow inter-modular and intra-modular comparison by provider;

computer code for allowing compensation for preventive care and chronic care medical resources;

computer code for performing inter-modular and/or intra-modular comparison of the adjusted modular RRV by provider; and

computer code for ranking providers within at least one component of care and/or across all components of care based on the adjusted RRV.

22. A computer program product for measuring and utilizing efficiency of medical care resources, comprising:

computer code for the group consisting of;

using the adjusted RRV to measure resource use for at least one treatment plan;

using the adjusted RRV to compare efficiency of provider resource use for the treatment plan options;

using the adjusted RRV to monitor operational efficiency for a health care provider;

using the adjusted RRV to assist in improving the efficiency and quality of the medical care delivered by a health care provider network;

using the adjusted RRV to assist in the identification of misuse or health care resources;

using the adjusted RRV to measure relative price for at least one treatment plan covering at least one medical condition and at least one provider; and

using the adjusted RRV to evaluate and improve the efficient use of pharmaceutical resources.