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

• US 7,640,173 B2
• Filed: 11/18/2005
• Issued: 12/29/2009
• Est. Priority Date: 01/17/2002
• Status: Active Grant

• Current Assignee: AMS Applied Medical Software Incorporated
• Original Assignee: Applied Medical Software, Inc.
• Inventors: Surpin, Jo, Kalison, Michael
• Primary Examiner(s): Gilligan; C. Luke
• Assistant Examiner(s): Nguyen; Tran
• Application Number:
  US11/283,309
• Publication Number:
  US 20060149596A1
• Time in Patent Office: 1,502 Days
• Field of Search: 705/2
• 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 capable of providing gainsharing of physician services for a plurality of physicians comprising the steps of:

(a) identifying a population comprising a plurality of patients;

(b) for each patient, receiving by a computer one or more inpatient admission charges for medical services rendered to the respective patient;

(c) for each inpatient admission charge, adjusting by a computer the inpatient admission charge by a severity of illness experienced by the respective patient during provision of the medical services;

(d) defining a plurality of All Patient Refined Diagnostic Related Groups, wherein each All Patient Refined Diagnostic Related Group is statistically homogenous group of similar medical charges;

(e) for each inpatient admission charge;

(i) categorizing by a computer the inpatient admission charge into the All Patient Refined Diagnostic Related Groups based on the inpatient admission charge'"'"'s designated medical diagnosis;

(ii) identifying the physician responsible therefor;

(f) for each All Patient Refined Diagnostic Related Group;

(i) defining a numeric threshold;

(ii) filtering by a computer from the All Patient Refined Diagnostic Related Group all inpatient admission charges not below the numeric threshold;

(iii) using the billed amounts of the filtered inpatient admission charges below the threshold to determine a best practice norm;

(g) identifying a plurality of physicians participating in the gainsharing program;

(h) for each physician;

(i) assign one or more inpatient admission charges for which the physician is the responsible physician;

(ii) grouping the physician'"'"'s one or more inpatient admission charges by the respective All Patient Refined Diagnostic Related Group;

(iii) analyzing by a computer the physician'"'"'s inpatient admission charges in each All Patient Refined Diagnostic Related Group to determine a current performance profile for each respective All Patient Refined Diagnostic Related Group;

(iv) comparing by a computer each current performance profile with the best practice norm in the appropriate All Patient Refined Diagnostic Related Group to determine the physician'"'"'s performance;

(v) determining by a computer the physician'"'"'s gainsharing amount based on the physician'"'"'s performance, wherein the physician'"'"'s gainsharing amount is capped by a maximum amount;

(i) repeating the method for a future period.

2. The method of claim 1, 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 physician billing data and said inpatient admission charges.

3. The method of claim 2 further comprising:

storing said physician cost ratios for each said All Patient Refined Diagnosis Related Groups.

4. The method of claim 3 further comprising:

generating a report of said physician cost ratios for each said All Patient Refined Diagnosis Related Groups.

5. The method of claim 2 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.

6. The method of claim 1 wherein said inpatient admission charges comprises current inpatient claim information and current hospital cost data.

7. The method of claim 6 wherein said inpatient admission charges is determined from a uniform bill (UB) or hospital claim.

8. The method of claim 1 further comprising the step of:

storing data collected for said determined best practice norm.

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

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

10. The method of claim 1 further comprising the step of editing said filtered inpatient admission charges to exclude outlier hospital cost data.