Method and apparatus for objectively monitoring and assessing the performance of health-care providers based on the severity of sickness episodes treated by the providers

• US 5,845,254 A
• Filed: 06/04/1996
• Issued: 12/01/1998
• Est. Priority Date: 06/07/1995
• Status: Expired due to Term

• Current Assignee: CIGNA Health Corporation (CIGNA Corporation)
• Original Assignee: CIGNA Health Corporation (CIGNA Corporation)
• Inventors: Tarrant, Jeffrey, Volpe, Michael, Lockwood, Edward J.
• Primary Examiner(s): MacDonald, Allen R.
• Assistant Examiner(s): Rhodes, Jason W.
• Application Number:
  US08/658,991
• Time in Patent Office: 910 Days
• Field of Search: 705/2, 705/3, 705/4
• US Class Current: 705/2
• 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 30/06 Buying, selling or leasing transactions
• CPC Class Codes: G06Q 40/08 Insurance
• 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

A method and apparatus for objectively monitoring the performance of a group of health-care providers. In-patient payment claim records representative of in-patient health-care services performed for patients by health-care providers within the group of health-care providers and out-patient payment claim records representative of out-patient health-care services performed for patients by health-care providers within group of health-care providers are stored in databases. A plurality of sickness episode data records are built from the in-patient payment claim records and the out-patient payment claim records, and an objective severity adjustment analysis is performed on the sickness episode data records to form a plurality of severity-adjusted sickness episode data records. A cost-efficiency performance level is determined for each individual health-care provider within the group of health-care providers from the plurality of severity-adjusted sickness episode data records, and a qualitative performance level is determined for the group of health-care providers as a whole.

Claims

1. An apparatus for objectively monitoring the performance of a group of health-care providers, comprising:

(A) a database storage means for storing in-patient payment claim records representative of in-patient health-care services performed for patients by health-care providers within said group of health-care providers and out-patient payment claim records representative of out-patient health-care services performed for said patients by health-care providers within said group of health-care providers;

(B) episode building means, coupled to said database storage means, for building a plurality of sickness episode data records from said in-patient payment claim records and said out-patient payment claim records;

(C) severity adjustment means, coupled to said episode building means, for performing an objective severity adjustment analysis on said plurality of sickness episode data records to form a plurality of severity-adjusted sickness episode data records; and

(D) a computer workstation, coupled to said database storage means, said computer workstation including;

(i) cost-efficiency performance assessment means, responsive to said plurality of severity adjusted sickness episode data records, for objectively determining a cost-efficiency performance level for each individual health-care provider within said group of health-care providers;

(ii) qualitative-performance assessment means, responsive to said in-patient payment claim records and said out-patient payment claim records, for objectively measuring a qualitative performance level of said group of health-care providers as a whole; and

(iii) budget monitoring means for determining a total illness cost value representing costs incurred by said group of health-care providers as a whole for treating a selected condition and comparing said total illness cost value to a predetermined budgeted illness cost value associated with said selected condition.

2. The apparatus of claim 1, wherein each of said in-patient payment claim records and each of said out-patient payment claim records includes a provider identification code field, a patient identification code field, a service provided code field and a date of service field, said apparatus further comprising:

(E) individual payment claim record auditing means, coupled to said computer workstation, for analyzing said in-patient payment claim records and said out-patient payment claim records on a record-by-record basis and identifying predetermined sentinel events from said in-patient and said out-patient payment claim records.

3. The apparatus of claim 2, wherein said predetermined sentinel events represent unapproved medical services performed by health-care providers within said group of health-care providers.

4. The apparatus of claim 1, wherein said cost-efficiency performance assessment means determines a cost-efficiency performance level associated with treating said selected condition for each individual health-care provider within said group of health-care providers when said budget monitoring means determines that said total illness cost value for treating said selected condition exceeds said predetermined budgeted illness cost value.

5. The apparatus of claim 4, wherein said episode building means builds said plurality of sickness episode data records by combining information from said in-patient and out-patient payment claim records, each sickness episode data record within said plurality of sickness episode data records corresponding to an individual sickness episode for which health-care services were performed for one of said patients by at least one health-care provider from said group of health-care providers.

6. The apparatus of claim 5, wherein said severity assessment means performs objective severity assessments on a group of sickness episode data records and assigns, in response to said objective severity assessments, an episode severity score to each sickness episode data record within said group of sickness episode data records.

7. The apparatus of claim 6, wherein said cost-efficiency performance assessment means is coupled to means for objectively determining case load complexity levels for health-care providers within said group of health-care providers from said episode severity scores, and said cost-efficiency performance levels are determined in accordance with said case load complexity levels.

8. The apparatus of claim 7, wherein each of said case load complexity levels is representative of patients that received a common procedure from one of said health-care providers within said group of health-care providers.

9. The apparatus of claim 5, wherein said individual sickness episode corresponds to a time period that begins when a patient begins to feel sick and ends when said patient is no longer sick.

10. The apparatus of claim 9, wherein said time period begins before any health-care services were performed for said patient by any health-care provider.

11. A computer-implemented method for objectively monitoring the performance of a group of health-care providers, comprising the steps of:

(A) storing in a database storage means in-patient payment claim records representative of in-patient health-care services performed for patients by health-care providers within said group of health-care providers and out-patient payment claim records representative of out-patient health-care services performed for said patients by health-care providers within said group of health-care providers;

(B) building a plurality of sickness episode data records from said in-patient payment claim records and said out-patient payment claim records;

(C) performing an objective severity adjustment analysis on said plurality of sickness episode data records to form a plurality of severity-adjusted sickness episode data records;

(D) objectively determining a cost-efficiency performance level for each individual health-care provider within said group of health-care providers from said plurality of severity-adjusted sickness episode data records;

(E) objectively measuring a qualitative performance level of said group of health-care providers as a whole; and

(F) determining a total illness cost value representing costs incurred by said group of health-care providers as a whole for treating a selected condition and comparing said total illness cost value to a predetermined budgeted illness cost value associated with said selected condition.

12. The method of claim 11, wherein each of said in-patient payment claim records and each of said out-patient payment claim records includes a provider identification code field, a patient identification code field, a service provided code field and a date of service field, said method further comprising the step of:

(G) analyzing said in-patient payment claim records and said out-patient payment claim records on a record-by-record basis and identifying predetermined sentinel events from said in-patient and said out-patient payment claim records.

13. The method of claim 12, wherein said predetermined sentinel events represent unapproved medical services performed by health-care providers within said group of health-care providers.

14. The method of claim 11, wherein a cost-efficiency performance level associated with treating said selected condition for each individual health-care provider within said group of health-care providers is determined in step (D) when said total illness cost value for treating said selected condition exceeds said predetermined budgeted illness cost value.

15. The method of claim 14, wherein said plurality of sickness episode data records are built in step (B) by combining information from said in-patient and out-patient payment claim records, each sickness episode data record within said plurality of sickness episode data records corresponding to an individual sickness episode for which health-care services were performed for one of said patients by at least one health-care provider from said group of health-care providers.

16. The method of claim 15, wherein step (C) comprises the step of performing objective severity assessments on a group of sickness episode data records and assigning, in response to said objective severity assessments, an episode severity score to each sickness episode data record within said group of sickness episode data records.

17. The method of claim 16, further comprising the step of objectively determining case load complexity levels for health-care providers within said group of health-care providers from said episode severity scores, wherein said cost-efficiency performance levels are determined in step (D) in accordance with said case load complexity levels.

18. The method of claim 17, wherein each of said case load complexity levels is representative of patients that received a common procedure from one of said health-care providers within said group of health-care providers.

19. The method of claim 15, wherein said individual sickness episode corresponds to a time period that begins when a patient begins to feel sick and ends when said patient is no longer sick.

20. The method of claim 19, wherein said time period begins before any health-care services were performed for said patient by any health-care provider from said group of health-care providers.

21. An apparatus for objectively monitoring the performance of a group of health-care providers, comprising:

(A) a database storage means for storing in-patient payment claim records representative of in-patient health-care services performed for patients by health-care providers within said group of health-care providers and out-patient payment claim records representative of out-patient health-care services performed for said patients by health-care providers within said group of health-care providers;

(B) episode building means, coupled to said database storage means, for building a plurality of sickness episode data records from said in-patient payment claim records and said out-patient payment claim records;

(C) severity adjustment means, coupled to said episode building means, for performing an objective severity adjustment analysis on said plurality of sickness episode data records to form a plurality of severity-adjusted sickness episode data records; and

(D) a computer workstation, coupled to said database storage means, said computer workstation including;

(i) cost-efficiency performance assessment means, responsive to said plurality of severity adjusted sickness episode data records, for objectively determining a cost-efficiency performance level for each individual health-care provider within said group of health-care providers;

(ii) qualitative-performance assessment means, responsive to said in-patient payment claim records and said out-patient payment claim records, for objectively measuring a qualitative performance level of said group of health-care providers as a whole based on preventive-care services associated with a selected condition; and

(iii) budget monitoring means for determining a total illness cost value representing costs incurred by said group of health-care providers as a whole for treating a selected condition and comparing said total illness cost value to a predetermined budgeted illness cost value associated with a selected condition.

22. The apparatus of claim 21, wherein said qualitative-performance assessment means determines a qualitative-performance level associated with treating said selected condition for said group of health-care providers as a whole when said budget monitoring means determines that said total illness cost value for treating said selected condition exceeds said predetermined budgeted illness cost value.

23. The apparatus of claim 22, wherein said selected condition corresponds to breast cancer and said qualitative-performance level corresponds to a percentage of women treated by said group of health-care providers receiving mammograms.

24. The apparatus of claim 22, wherein said selected condition corresponds to diabetes and said qualitative-performance level corresponds to a percentage of diabetes patients treated by said group of health-care providers receiving eye examinations.

25. A computer-implemented method for objectively monitoring the performance of a group of health-care providers, comprising the steps of:

(A) storing in a database storage means in-patient payment claim records representative of in-patient health-care services performed for patients by health-care providers within said group of health-care providers and out-patient payment claim records representative of out-patient health-care services performed for said patients by health-care providers within said group of health-care providers;

(B) building a plurality of sickness episode data records from said in-patient payment claim records and said out-patient payment claim records;

(C) performing an objective severity adjustment analysis on said plurality of sickness episode data records to form a plurality of severity-adjusted sickness episode data records;

(D) objectively determining a cost-efficiency performance level for each individual health-care provider within said group of health-care providers from said plurality of severity-adjusted sickness episode data records;

(E) objectively measuring a qualitative performance level of said group of health-care providers as a whole based on preventive-care services associated with a selected condition; and

(F) determining a total illness cost value representing costs incurred by said group of health-care providers as a whole for treating a selected condition and comparing said total illness cost value to a predetermined budgeted illness cost value associated with said selected condition.

26. The method of claim 25, wherein a qualitative-performance level associated with treating said selected condition for said group of health-care providers as a whole is determined in step (E) when said total illness cost value for treating said selected condition exceeds said predetermined budgeted illness cost value.

27. The method of claim 26, wherein said selected condition corresponds to breast cancer and said qualitative-performance level corresponds to a percentage of women treated by said group of health-care providers receiving mammograms.

28. The method of claim 27, wherein said selected condition corresponds to diabetes and said qualitative-performance level corresponds to a percentage of diabetes patients treated by said group of health-care providers receiving eye examinations.