Methods for generating healthcare provider quality and cost rating data

• US 8,069,080 B2
• Filed: 11/14/2007
• Issued: 11/29/2011
• Est. Priority Date: 11/14/2007
• Status: Active Grant

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Ingenix Incorporated (UnitedHealth Group Incorporated)
• Inventors: Rastogi, Amita
• Primary Examiner(s): DIXON, THOMAS A
• Application Number:
  US11/939,900
• Publication Number:
  US 20090125348A1
• Time in Patent Office: 1,476 Days
• Field of Search: 705/10
• US Class Current: 705/10
• CPC Class Codes: G06Q 30/018 Certifying business or products
• CPC Class Codes: G06Q 30/0202 Market predictions or forecasting for commercial activities
• CPC Class Codes: G06Q 30/0203 Market surveys; Market polls
• CPC Class Codes: G06Q 30/0282 Rating or review of business operators or products
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A method for generating healthcare provider quality rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, assessing the claim records in each claim group using guidelines for the particular disease or condition, and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines, and generating normalized provider quality rating data. A method for generating healthcare provider cost rating data includes grouping claim records into one or more claim groups, assigning each claim group to a responsible provider, calculating the total cost of each claim group, aggregating the total cost for each claim group, and comparing the total aggregate cost of each claim group assigned to each provider to an expected cost value.

Claims

1. A computer-implemented method for generating healthcare provider quality rating data, comprising:

providing data storage for storing medical claim data;

providing at least one computer processor programmed for

receiving a plurality of claim records representing services provided by a plurality of healthcare providers to one or more patients;

grouping the claim records into at least one claim group, each claim group including claim records representing care provided by one or more providers to a patient;

assigning each claim group to a responsible provider;

assessing the claim records in each claim group using expected treatment guidelines for the particular disease or condition associated with the claim group and generating a compliance score for the claim group, wherein the compliance score indicates the extent to which the claim records in the claim group match the guidelines;

aggregating the compliance score for each claim group assigned to each provider to generate a raw aggregate compliance score for each provider;

normalizing the provider'"'"'s raw aggregate compliance score to a defined scale to generate a normalized aggregate compliance score for each provider; and

generating provider quality rating data for each provider using the normalized aggregate compliance score.

2. The method of claim 1, wherein the claim groups are groups of facility claims, pharmacy claims, laboratory claims, and physician claims.

3. The method of claim 1, wherein the claim groups are groups of facility claims representing inpatient care provided by a hospital to a patient.

4. The method of claim 1, wherein the guidelines are evidence based medicine guidelines.

5. The method of claim 1, wherein the aggregate raw compliance score, the normalized aggregate compliance score, and the provider quality rating data are calculated separately for each condition or disease treated by each provider.

6. The method of claim 1, wherein the aggregate raw compliance score, the normalized aggregate compliance score, and the provider quality rating data are calculated to include all conditions and diseases treated by each provider.

7. The method of claim 1, wherein the defined scale used to generate the normalized aggregate compliance score is a scale of 0 to 100.

8. The method of claim 1, wherein the raw aggregate compliance score is normalized using average aggregate compliance values for a defined provider specialty and geographical region in which the provider is located.

9. The method of claim 1, wherein the provider quality rating data comprises one or more performance categories that identify each provider'"'"'s quality of treatment in comparison to an average value.

10. The method of claim 1, wherein the provider quality rating data comprises one or more performance categories that indicate each provider'"'"'s quality of treatment in comparison to others of the plurality of providers.

11. The method of claim 1, wherein the provider quality rating data comprises one or more stars or other graphic symbols that identify each provider'"'"'s quality of treatment in comparison to an average value.

12. The method of claim 1, wherein the raw aggregate compliance score for each provider is a weighted sum of the aggregate compliance score of all claim groups assigned to the provider and at least one additional utilization measure attributable to the provider.

13. The method of claim 12, wherein the raw aggregate compliance score is a weighted sum of the aggregate compliance score of all claim groups assigned to the provider and a plurality of utilization measures, the plurality of utilization measures comprising a number of inpatient days per year, a number of emergency room visits per year, and a number of outlier procedures per year.

14. The method of claim 12, wherein the raw aggregate compliance score is a weighted sum of the aggregate compliance score of all claim groups assigned to the provider and a plurality of utilization measures, the plurality of utilization measures comprising a death rate value, a complication rate value, a length of stay value, and a number of avoidable days per year.

15. The method of claim 1, further comprising generating provider volume data.

16. A computer-implemented method for generating healthcare provider quality rating data, comprising:

providing a data storage for storing medical claim data;

providing at least one computer processor programmed for

receiving a plurality of claim records representing services provided by a plurality of healthcare providers to one or more patients;

grouping the claim records into at least one episode of care, wherein each episode of care comprises claim records that relate to treatment of a patient by a provider for a particular disease or condition;

assigning each episode of care to a responsible provider;

assessing the claim records in each episode of care using expected treatment guidelines for the particular disease or condition associated with the episode of care and generating a compliance score for the episode of care, wherein the compliance score indicates the extent to which the claim records in the episode of care match the guidelines;

aggregating the compliance score for each episode of care assigned to each provider to generate a raw aggregate compliance score for each provider;

normalizing the provider'"'"'s raw aggregate compliance score to a defined scale to generate a normalized aggregate compliance score for each provider; and

generating provider quality rating data for each provider using the normalized aggregate compliance score.

17. A computer-implemented method for generating healthcare provider cost rating data, comprising:

providing a data storage for storing medical claim data;

providing at least one computer processor programmed for

receiving a plurality of claim records representing services provided by a plurality of healthcare providers to one or more patients;

grouping the claim records into at least one claim group, each claim group including claim records representing care provided by one or more providers to a patient;

assigning each claim group to a responsible provider;

calculating the total cost of each claim group, wherein the total cost of a claim group is the sum of the costs associated with each claim record in the claim group;

aggregating the total cost for each claim group to obtain a raw aggregate cost score for each provider;

comparing the total aggregate cost of each claim group of care assigned to each provider to an expected cost value;

normalizing the provider'"'"'s raw aggregate cost score to a defined scale to generate a normalized aggregate cost score for the provider; and

generating provider cost rating data using the normalized aggregate cost score.

18. The method of claim 17, wherein the claim groups are groups of facility claims, pharmacy claims, laboratory claims, and physician claims.

19. The method of claim 17, wherein the claim groups are groups of facility claims representing inpatient care provided by a hospital to a patient.

20. The method of claim 17, wherein the expected cost value for a claim group is an average risk-adjusted cost value calculated from historical cost data.

21. The method of claim 17, wherein the aggregate raw cost score, the normalized aggregate cost score, and the provider cost rating data are calculated separately for each condition or disease treated by the provider.

22. The method of claim 17, wherein the aggregate raw cost score, the normalized aggregate cost score, and the provider cost rating data are calculated to include all conditions and diseases treated by the provider.

23. The method of claim 17, wherein the provider cost rating data comprises one or more performance categories that indicate the provider'"'"'s cost of treatment in comparison to an average value.

24. The method of claim 17, further comprising generating provider volume data.

25. A computer-implemented method for generating healthcare provider cost rating data, comprising:

providing a data storage for storing medical claim data;

providing at least one computer processor programmed for

receiving a plurality of claim records representing services provided by a plurality of healthcare providers to one or more patients;

grouping the claim records into at least one episode of care, wherein each episode of care comprises claim records that relate to treatment of a patient by a provider for a particular disease or condition;

assigning each episode of care to a responsible provider;

calculating the total cost of each episode of care, wherein the total cost of an episode of care is the sum of the costs associated with each claim record in the episode of care;

aggregating the total cost for each episode of care to obtain a raw aggregate cost score for each provider;

comparing the total aggregate cost of each episode of care assigned to each provider to an expected cost value;

normalizing the provider'"'"'s raw aggregate cost score to a defined scale to generate a normalized aggregate cost score for the provider; and

generating provider cost rating data using the normalized aggregate cost score.