Method, system, and computer program product for physician efficiency measurement and patient health risk stratification utilizing variable windows for episode creation

• US 8,768,726 B1
• Filed: 03/11/2013
• Issued: 07/01/2014
• Est. Priority Date: 03/02/2004
• Status: Expired due to Term

• Current Assignee: Cave Consulting Group LLC
• Original Assignee: Cave Consulting Group LLC
• Inventors: Cave, Douglas G
• Primary Examiner(s): Chng, Joy
• Application Number:
  US13/794,765
• Time in Patent Office: 477 Days
• Field of Search: 705 2- 3
• US Class Current: 705/2
• CPC Class Codes: A61B 2505/05 Surgical care
• CPC Class Codes: G06Q 10/06398 Performance of employee with respect to a job function
• 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: 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 40/63 for local operation
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A method for measuring physician efficiency and patient health risk stratification is disclosed. Episodes of care are formed from medical claims data and an output process is performed. Physicians are assigned to report groups, and eligible physicians and episode assignments are determined. Condition-specific episode statistics and weighted episode statistics are calculated, from which physician efficiency scores are determined.

Claims

1. A method implemented on a computer system of determining physician efficiency, the method comprising:

obtaining medical claims data stored in a non-transitory computer readable medium on the computer system;

performing patient analysis using said obtained medical claims data to form episodes of care utilizing the computer system;

assigning complete (non-partial) episodes of care to physicians utilizing an assignment rule that allows assignment of an episode of care to more than one physician;

assigning at least one physician to a report group based on geographic area designation utilizing the computer system, each physician assigned to no more than one report group;

determining eligible physicians and episode of care assignments utilizing the computer system;

calculating condition-specific episode of care statistics utilizing the computer system;

calculating weighted episode of care statistics across medical conditions utilizing a predefined set of medical conditions for a specific specialty type utilizing the computer system; and

determining efficiency scores for physicians from said calculated condition-specific episode of care statistics and said weighted episode of care statistics calculated across medical conditions utilizing the computer system.

2. The method of claim 1, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 150 unique medical conditions.

3. The method of claim 2, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 100 unique medical conditions.

4. The method of claim 3, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 50 unique medical conditions.

5. The method of claim 4, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 30 unique medical conditions regardless of severity of illness, comorbidities, or presence or absence of a specific surgery or service.

6. The method in claim 1, wherein:

the calculating of weighted episode of care statistics across medical conditions utilizing indirect standardization.

7. The method in claim 1, wherein:

the calculating of weighted episode of care statistics across medical conditions utilizing direct standardization.

8. The method of claim 1, wherein:

the efficiency score consists of a single aggregate score for each eligible physician aggregated from the weighted episode of care statistics calculated across medical conditions for that eligible physician.

9. The method of claim 1 wherein:

the predefined set of medical conditions for a specific specialty type consists of fewer than all of the medical conditions associated with that specialty type.

10. The method of claim 1 wherein:

the predefined set of medical conditions for a specific specialty type consists of a subset of most prevalent medical conditions related to that specialty type.

11. The method of claim 1 wherein:

the predefined set of medical conditions for a specific specialty type consists of a subset of most prevalent medical conditions by severity-of-illness level related to that specialty type.

12. A method implemented on a computer system of determining physician efficiency, the method comprising:

obtaining medical claims data stored in a non-transitory computer readable medium on the computer system;

performing patient analysis using said obtained medical claims data to form episodes of care utilizing the computer system;

assigning complete (non-partial) episodes of care to physicians utilizing an assignment rule that allows assignment of an episode of care to more than one physician;

assigning at least one physician to a report group based on at least one of a set consisting of products and business lines utilizing the computer system, each physician assigned to no more than one report group;

determining eligible physicians and episode of care assignments utilizing the computer system;

calculating condition-specific episode of care statistics utilizing the computer system;

calculating weighted episode of care statistics across medical conditions utilizing a predefined set of medical conditions for a specific specialty type utilizing the computer system; and

determining efficiency scores for physicians from said calculated condition-specific episode of care statistics and said weighted episode of care statistics calculated across medical conditions utilizing the computer system.

13. The method of claim 12, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 150 unique medical conditions.

14. The method of claim 13, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 100 unique medical conditions.

15. The method of claim 14, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 50 unique medical conditions.

16. The method of claim 15, wherein:

the predefined set of medical conditions for a specific specialty type consists of no more than 30 unique medical conditions regardless of severity of illness, comorbidities, or presence or absence of a specific surgery or service.

17. The method in claim 12, wherein:

the calculating of weighted episode of care statistics across medical conditions utilizing indirect standardization.

18. The method in claim 12, wherein:

the calculating of weighted episode of care statistics across medical conditions utilizing direct standardization.

19. The method of claim 12, wherein:

the efficiency score consists of a single aggregate score for each eligible physician aggregated from the weighted episode of care statistics calculated across medical conditions for that eligible physician.