Method and system for gainsharing of physician services

• US 20030163352A1
• Filed: 01/17/2003
• Published: 08/28/2003
• Est. Priority Date: 01/17/2002
• Status: Active Grant

• Current Assignee: AMS Applied Medical Software Incorporated
• Original Assignee: AMS Applied Medical Software Incorporated
• Inventors: Surpin, Jo, Kalison, Michael
• Granted Patent: US 7,546,245 B2
• Time in Patent Office: Days
• 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 30/0211 Determining the effectiveness of discounts or incentives
• CPC Class Codes: G06Q 30/0283 Price estimation or determination
• CPC Class Codes: G06Q 40/00 Finance; Insurance; Tax strategies; Processing of corporate or income taxes
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 70/20 relating to practices or guidelines

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 for gainsharing of physician services between a plurality of physicians comprising the steps of:

establishing a best practice norm for a plurality of classified diagnosis related groups from base patient data;

determining an incentive constraint of an amount of a payment made to said physicians which is available for gainsharing;

determining an incentive pool from payments made to said physicians in advance associated with said plurality of classified diagnosis related groups up to said incentive constraint; and

determining distribution of said incentive pool by comparing current physician performance associated with one of said classified diagnosis related groups to the established best practice norm for said one of said classified diagnosis related groups.

2. The method of claim 1 wherein said payments made to physicians in advance is determined from part B costs of a uniform bill and said incentive pool is determined from a ratio of payments to a hospital determined from part A to said payments made to physicians determined from part B costs.

3. The method of claim 1 wherein said base patient data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said inpatient data comprises inpatient claim information and hospital cost data.

4. The method of claim 3 wherein said inpatient claim information is determined from a uniform bill (UB).

5. The method of claim 3 wherein said step of establishing a best practice norm comprises the steps of:

a. determining a costed patient record by combining said inpatient claim information and said hospital cost data of a patient;

b. assigning one of said classified diagnosis related groups to said costed patient record;

c. assigning a responsible physician to said costed patient record;

d. repeating steps a-c for each patient claim of said base patient data for determining an expected cost statistic for each said classified diagnosis related group to form said best practice norm.

6. The method of claim 5 wherein said step of determining an expected cost statistic comprises the steps of:

computing a normative expected cost statistic;

determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

determining a subset of physicians in said ordered list as physicians meeting a threshold of physician claims; and

recomputing said normative expected cost statistic using said subset of physicians in said ordered list and said difference of actual patient cost from said expected cost statistic.

7. The method of claim 6 wherein the threshold of physician claims is 25% of a total number of inpatient claims.

8. The method of claim 6 further comprising the step of:

excluding said responsible physicians from said ordered list if each of said responsible physicians has a number of cases for said classified diagnosis group which is less than a threshold of a number of physician cases.

9. The method of claim 8 wherein the threshold of a number of physician cases is less than three cases.

10. The method of claim 6 wherein before said recomputing step, further comprising the step of:

determining if a number of said responsible physicians for said classified diagnosis related groups is greater than a threshold of a number of physicians meeting a selection criteria, and

if said determined number of responsible physicians is greater than said threshold of a number of physicians meeting a selection criteria then performing said recomputing step, or

if said determined number of responsible physicians is not greater than said threshold of a number of physicians meeting a selection criteria;

indicating that said recomputed expected cost statistic is not said best practice norm.

11. The method of claim 10 wherein before said recomputing step, further comprising the step of:

determining a minimum number of claims for each classified diagnosis related group, and

if a determined number of claims for said classified diagnosis related group is greater than said minimum number of claims then performing said recomputing step or if a determined number of claims for said classified diagnosis related group is less than said minimum number of claims;

indicating that said recomputed expected cost statistic is not said best practice norm.

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

adjusting said classified diagnosis related groups for severity of illness.

13. The method of claim 1 wherein said classified diagnosis related groups are determined as an All Patient Refined Diagnosis Related Group.

14. The method of claim 1 wherein said step of determining said incentive pool further comprises the steps of:

determining a weight or percentage of a type of healthcare provider for said classified diagnosis related group, said type of healthcare provider comprising a responsible physician, consultant physician and hospital based physician;

determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims; and

applying said percentage of responsible physician claims to said incentive pool for determining a responsible physician incentive pool.

15. The method of claim 14 wherein said step of determining a weight or percentage of a type of healthcare provider type comprises the steps of:

e. inputting data of inpatient claims for a plurality of patients,

f. classifying said inpatient claim into one of said diagnosis related groups,

g. inputting physician billing data associated with said classified inpatient claim,

h. linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim,

i. assigning said merged data to one of said healthcare provider types, and

j. repeating steps e-i for each inpatient claim.

16. The method of claim 15 wherein said step of assigning said merged data to said healthcare provider type comprises the steps of:

assigning a classification of hospital based physicians selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue;

physicians who use ionizing radiation, radioactive substances or magnetic resonance in the diagnosis and treatment of disease; and

physicians who perform scientific studies on blood, body fluids, tissue and microscopic organisms for the purpose of diagnosis of illness and disease;

assigning a classification of said responsible physician on surgical claims selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue that are not identified as an anesthesiologist, said physicians having highest charges and said physicians having the highest charges and having a highest number of CPT codes;

assigning a classification of a responsible physician on medical claims based on a limitation selected from the group having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

assigning a classification of a consulting physician who provides expertise in one or more specialties to the responsible physician when such expertise is outside the responsible physician'"'"'s area of expertise and not already identified as a hospital based physician.

17. The method of claim 15 wherein said step of assigning said merged data to said healthcare provider type comprises the steps of:

assigning hospital based physicians based on a limitation selected from the group consisting of;

all physicians having a surgical CPT code 10000-69999 that are associated with a surgical procedure;

all physicians from the Radiology department with a CPT code between 70000 and 79999 or between 93000 and 93550;

all physicians having a CPT code between 80000 and 89999; and

all other physician line items that have a same physician ID identified as a hospital based physician;

assigning said responsible physician on surgical claims based on a limitation selected from the group consisting of;

having a physician with a surgical CPT code (10000-69999) that is not identified as an anesthesiologist;

having an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

said physician having highest charges;

an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

as said physicians having the highest charges and having a highest number of CPT codes;

assigning a responsible physician on medical claims based on a limitation selected from the group consisting of;

having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

assigning a consulting physician based on a limitation selected from the group of all physicians having a CPT code between 99251 and 99274 and not already identified as a hospital based physician and after the responsible physicians and hospital based physicians have been assigned remaining physician line items.

18. The method of claim 14 wherein said step of determining said incentive pool further comprises the steps of:

allocating said responsible physician incentive pool between a medical incentive pool and a surgical inventive pool based on a ratio of a total medical payments received for medical claims from said classified diagnosis related groups and a total of surgical payments received for surgical claims for said classified diagnosis related groups.

19. The method of claim 18 wherein said step of determining said incentive pool further comprises the steps of:

allocating said medical incentive pool between a medical improvement pool and a medical performance pool; and

allocating said surgical incentive pool between a surgical improvement pool and a surgical performance pool.

20. The method of claim 19 before said step of allocating said responsible physician incentive pool further comprising the steps of:

subtracting a loss of income pool from said responsible physician incentive pool to form an adjusted responsible physician incentive pool;

allocating said adjusted responsible physician incentive pool between said surgical incentive pool and said medical performance pool; and

determining said medical improvement pool as said loss of income pool.

21. The method of claim 20 wherein said step of determining said incentive pool further comprises the steps of:

determining a maximum medical performance incentive per case for each classified diagnosis related group;

determining a maximum medical improvement incentive per case for each classified diagnosis related group;

determining a maximum surgical performance incentive per case for each classified diagnosis related group; and

determining a maximum surgical improvement incentive per case for each classified diagnosis related group.

22. The method of claim 21 wherein said physician performance is determined from current patient data comprising current inpatient claim information and current hospital cost data.

23. The method of claim 22 wherein said step of determining distribution further comprises the steps of:

determining a current costed patient record from said current patient data;

assigning one of said classified diagnosis related groups to said current costed patient record;

assigning a responsible physician to said current costed patient record; and

categorizing said responsible physician into a medical responsible physician or a surgical responsible physician based on said current costed patient record.

24. The method of claim 23 wherein a performance ratio is established for said compared current physician performance for one of said classified diagnosis related groups to the established best practice norm for said one of said classified diagnosis related groups and wherein said step of determining said incentive pool further comprises the steps of:

applying said performance ratio to said maximum medical performance incentive per case to determine a medical performance incentive; and

applying said performance ratio to said maximum surgical performance incentive per case to determine a surgical performance incentive.

25. The method of claim 24 wherein said medical performance incentive and said surgical performance incentive is determined by:

26. The method of claim 25 wherein said percentile cost is a 90^th percentile cost.

27. The method of claim 21 wherein a ratio of improvement in operational performance is established and wherein said step of determining said incentive pool further comprises the steps of:

applying said ratio of improvement in operational performance to said maximum medical improvement incentive per case to determine a medical improvement incentive; and

applying said ratio of improvement in operational performance to said maximum surgical improvement incentive per case to determine a medical improvement incentive.

28. The method of claim 27 wherein said medical improvement incentive and said surgical improvement incentive is determined by:

29. The method of claim 27 further comprising the step of:

determining a total of said medical performance incentive, a total of said medical improvement incentive, a total of said surgical performance incentive and a total of said surgical improvement incentive.

30. The method of claim 29 further comprising the step of:

generating a report of said total medical performance incentive and said total medical improvement incentive for each said responsible physician.

31. The method of claim 29 further comprising the step of:

generating a report of said total surgical performance incentive and said total surgical improvement incentive for each said responsible physician.

92. The system of claim 2 wherein said step of establishing a best practice norm comprises:

means for determining a costed patient record by combining said inpatient claim information and said hospital cost data of a patient;

means for assigning one of said classified diagnosis related groups to said costed patient record;

means for assigning a responsible physician to said costed patient record;

means for repeating for each patient claim of said base patient data for determining an expected cost statistic for each said classified diagnosis related group to form said best practice norm.

93. The system of claim 92 wherein said means for determining an expected cost statistic comprises:

means for computing a normative expected cost statistic;

means for determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

means for ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

means for determining a subset of physicians in said ordered list as physicians meeting a threshold of physician claims; and

means for recomputing said normative expected cost statistic using said subset of physicians in said ordered list and said difference of actual patient cost from said expected cost statistic.

94. The system of claim 93 wherein the threshold of physician claims is 25% of a total number of inpatient claims.

95. The system of claim 93 further comprising:

means for excluding said responsible physicians from said ordered list if each of said responsible physicians has a number of cases for said classified diagnosis group which is less than a threshold of a number of physician cases.

96. The system of claim 95 wherein the threshold of a number of physician cases is less than three cases.

97. The system of claim 93 further comprising:

means for determining if a number of said responsible physicians for said classified diagnosis related groups is greater than a threshold of a number of physicians meeting a selection criteria, and

if said determined number of responsible physicians is greater than said threshold of a number of physicians meeting a selection criteria then performing said recomputing step, or

if said determined number of responsible physicians is not greater than said threshold of a number of physicians meeting a selection criteria;

means for indicating that said recomputed expected cost statistic is not said best practice norm.

98. The system of claim 97 further comprising:

means for determining a minimum number of claims for each classified diagnosis related group, and

if a determined number of claims for said classified diagnosis related group is greater than said minimum number of claims then performing said recomputing step or if a determined number of claims for said classified diagnosis related group is less than said minimum number of claims;

means for indicating that said recomputed expected cost statistic is not said best practice norm.

32. A system for gainsharing of physician services between a plurality of physicians comprising:

means for establishing a best practice norm for a plurality of classified diagnosis related groups from base patient data;

means for determining an incentive constraint of an amount of a payment made to said physicians which is available for gainsharing;

means for determining an incentive pool from payments made to said physicians in advance for said plurality of classified diagnosis related groups up to said incentive constraint; and

means for determining distribution of said incentive pool by comparing current physician performance for one of said classified diagnosis related groups to the established best practice norm for said one of said classified diagnosis related groups.

33. The system of claim 32 wherein said payments made to physicians in advance is determined from part B costs of a uniform bill and said incentive pool is determined from a ratio of payments to a hospital determined from part A to said payments made to physicians determined from part B costs.

34. The system of claim 32 wherein said base patient data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said inpatient data comprises inpatient claim information and hospital cost data.

35. The system of claim 34 wherein said inpatient claim information is determined for a uniform bill (UB).

36. The system of claim 34 wherein said means for establishing a best practice norm comprises:

means for determining a costed patient record by combining said inpatient claim information and said hospital cost data of a patient;

means for assigning one of said classified diagnosis related groups to said costed patient record;

means for assigning a responsible physician to said costed patient record;

means for repeating for each patient claim of said base patient data for determining an expected cost statistic for each said classified diagnosis related group to form said best practice norm.

37. The system of claim 36 wherein said means for determining an expected cost statistic comprises:

means for computing a normative expected cost statistic;

means for determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

means for ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

means for determining a subset of physicians in said ordered list as physicians meeting a threshold of physician claims; and

means for recomputing said normative expected cost statistic using said subset of physicians in said ordered list and said difference of actual patient cost from said expected cost statistic.

38. The system of claim 37 wherein the threshold of physician claims is 25% of a total number of inpatient claims.

39. The system of claim 38 further comprising means for excluding said responsible physicians from said ordered list if said responsible physician has a number of cases for said classified diagnosis group which is less than a threshold of a number of physician cases.

40. The system of claim 39 wherein the threshold of a number of physician cases is less than three cases.

41. The system of claim 40 further comprising:

means for determining if a number of said responsible physicians for said classified diagnosis related groups is greater than a threshold of a number of physicians meeting a selection criteria, and

if said determined number of responsible physicians is greater than said threshold of a number of physicians meeting a selection criteria then performing said means for recomputing, or

if said determined number of responsible physicians is not greater than said threshold of a number of physicians meeting a selection criteria;

means for indicating that said recomputed expected cost statistic is not said best practice norm.

42. The system of claim 40 further comprising:

means for determining a minimum number of claims for each classified diagnosis related group, and

if a determined number of claims for said classified diagnosis related group is greater than said minimum number of claims then performing said means for recomputing or if a determined number of claims for said classified diagnosis related group is less than said minimum number of claims;

means for indicating that said recomputed expected cost statistic is not said best practice norm.

43. The system of claim 32 further comprising:

means for adjusting said classified diagnosis related groups for severity of illness.

44. The system of claim 32 further comprising means for storing said established best practice norm.

45. The system of claim 44 wherein said means for storing said established best practice norm is a database.

46. The system of claim 32 wherein said classified diagnosis related groups are determined as an All Patient Refined Diagnosis Related Group.

47. The system of claim 32 wherein said means for determining said incentive pool further comprises:

means for determining a weight or percentage of a type of healthcare provider for said classified diagnosis related group, said type of healthcare provider comprising a responsible physician, consultant physician and hospital based physician;

means for determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims; and

means for applying said percentage of responsible physician claims to said incentive pool for determining a responsible physician incentive pool.

48. The system of claim 47 further comprising means for storing said weight or percentage of said type of healthcare provider.

49. The system of claim 48 wherein said means for storing said weight or percentage of said type of healthcare provider is a database.

50. The system of claim 47 wherein said means for determining a weight or percentage of a type of healthcare provider type comprises:

means for inputting data of inpatient claims for a plurality of patients,

means for classifying said inpatient claim into one of said diagnosis related groups,

means for inputting physician billing data associated with said classified inpatient claim,

means for linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim, and

means for assigning said merged data to one of said healthcare provider types.

51. The system of claim 50 wherein said means for assigning said merged data to said healthcare provider type comprises:

means for assigning a classification of hospital based physicians selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue;

physicians who use ionizing radiation, radioactive substances or magnetic resonance in the diagnosis and treatment of disease; and

physicians who perform scientific studies on blood, body fluids, tissue and microscopic organisms for the purpose of diagnosis of illness and disease;

means for assigning a classification of said responsible physician on surgical claims selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue that are not identified as an anesthesiologist, said physicians having highest charges and said physicians having the highest charges and having a highest number of CPT codes;

means for assigning a classification of a responsible physician on medical claims based on a limitation selected from the group having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

means for assigning a classification of a consulting physician who provides expertise in one or more specialties to the responsible physician when such expertise is outside the responsible physician'"'"'s area of expertise and not already identified as a hospital based physician.

52. The system of claim 50 wherein said means for assigning said merged data to said healthcare provider type comprises:

means for assigning hospital based physicians based on a limitation selected from the group consisting of all physicians having a surgical CPT code between 10000 and 69999 that are associated with a surgical procedure;

all physicians from the Radiology department with a CPT code between 70000 and 79999 or between 93000 and 93550;

all physicians having a CPT code between 80000 and 89999; and

all other physician line items that have a same physician ID identified as a hospital base physician;

means for assigning said responsible physician on surgical claims based on a limitation selected from the group consisting of;

having a physician with a surgical CPT code (10000-69999) that is not identified as an anesthesiologist;

having an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist and said physician having highest charges;

an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

as said physicians having the highest charges and having a highest number of CPT codes;

means for assigning a responsible physician on medical claims based on a limitation selected from the group consisting of;

having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

means for assigning a consulting physician based on a limitation selected from the group consisting of all physicians having a CPT code between 99251 and 99274 and not already identified as a hospital based physician and after the responsible physicians and hospital based physicians have been assigned remaining physician line items.

53. The system of claim 47 wherein said means for determining said incentive pool further comprises:

means for allocating said responsible physician incentive pool between a medical incentive pool and a surgical inventive pool based on a ratio of a total medical payments received for medical claims from said classified diagnosis related groups and a total of surgical payments received for surgical claims for said classified diagnosis related groups.

54. The system of claim 53 wherein said means for determining said incentive pool further comprises:

means for allocating said medical incentive pool between a medical improvement pool and a medical performance pool; and

means for allocating said surgical incentive pool between a surgical improvement pool and a surgical performance pool.

55. The system of claim 54 further comprising:

means for subtracting a loss of income pool from said responsible physician incentive pool to form an adjusted responsible physician incentive pool;

means for allocating said adjusted responsible physician incentive pool between said surgical incentive pool and said medical performance pool; and

means for determining said medical improvement pool as said loss of income pool.

56. The system of claim 55 wherein said means for determining said incentive pool further comprises:

means for determining a maximum medical performance incentive per case for each classified diagnosis related group;

means for determining a maximum medical improvement incentive per case for each classified diagnosis related group;

means for determining a maximum surgical performance incentive per case for each classified diagnosis related group; and

means for determining a maximum surgical improvement incentive per case for each classified diagnosis related group.

57. The system of claim 56 further comprising:

means for storing said determined maximum medical performance incentive per case for each classified diagnosis related group, determined maximum medical improvement incentive per case for each classified diagnosis related group, determined maximum surgical performance incentive per case for each classified diagnosis related group, and determined maximum surgical improvement incentive per case for each classified diagnosis related group.

58. The system of claim 57 wherein said means for storing said determined maximum medical performance incentive per case for each classified diagnosis related group, determined maximum medical improvement incentive per case for each classified diagnosis related group, determined maximum surgical performance incentive per case for each classified diagnosis related group, and determined maximum surgical improvement incentive per case for each classified diagnosis related group comprises one or more databases.

59. The system of claim 56 wherein said physician performance is determined from current patient data comprising current inpatient claim information and current hospital cost data.

60. The system of claim 59 wherein said means for determining distribution further comprises:

means for determining a current costed patient record from said current patient data;

means for assigning one of said classified diagnosis related groups to said current costed patient record;

means for assigning a responsible physician to said current costed patient record; and

means for categorizing said responsible physician into a medical responsible physician or a surgical responsible physician based on said current costed patient record.

61. The system of claim 59 further comprising:

means for establishing performance ratio for said compared current physician performance for one of said classified diagnosis related groups to the established best practice norm for said one of said classified diagnosis related groups and wherein said means for determining said incentive pool further comprises;

means for applying said performance ratio to said maximum medical performance incentive per case to determine a medical performance incentive; and

means for applying said performance ratio to said maximum surgical performance incentive per case to determine a surgical performance incentive.

62. The system of claim 61 wherein said medical performance incentive and said surgical performance incentive is determined by:

63. The system of claim 62 wherein said percentile cost is a 90^th percentile cost.

64. The system of claim 60 further comprising means for establishing a ratio of improvement in operational performance and wherein said means for determining said incentive pool further comprises:

means for applying said ratio of improvement in operational performance to said maximum medical improvement incentive per case to determine a medical improvement incentive; and

means for applying said ratio of improvement in operational performance to said maximum surgical improvement incentive per case to determine a medical improvement incentive.

65. The system of claim 64 wherein said medical improvement incentive and said surgical improvement incentive is determined by:

66. The system of claim 65 further comprising:

means for determining a total of said medical performance incentive, a total of said medical improvement incentive, a total of said surgical performance incentive and a total of said surgical improvement incentive.

67. The system of claim 65 further comprising means for generating a report of said total medical performance incentive and said total medical improvement incentive for each said responsible physician.

68. The system of claim 67 further comprising means for generating a report of said total surgical performance incentive and said total surgical improvement incentive for each said responsible physician.

69. A method for evaluating physician economic performance comprising the steps of:

establishing a best practice norm for a plurality of classified diagnosis related groups from base patient data; and

determining said physician economic performance by comparing current physician performance associated with one of said classified diagnosis related groups to the established best practice norm for one of said classified diagnosis related groups.

70. The method of claim 69 wherein said current physician performance is determined from part B costs of a uniform bill.

71. The method of claim 69 wherein said base patient data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said inpatient data comprises inpatient claim information and hospital cost data.

72. The method of claim 71 wherein said inpatient claim information is determined for a uniform bill (UB).

73. The method of claim 71 wherein said step of establishing a best practice norm comprises the steps of:

a. determining a costed patient record by combining said inpatient claim information and said hospital cost data of a patient;

b. assigning one of said classified diagnosis related groups to said costed patient record;

c. assigning a responsible physician to said costed patient record;

d. repeating steps a-c for each patient claim of said base patient data for determining an expected cost statistic for each said classified diagnosis related group to form said best practice norm.

74. The method of claim 73 wherein said step of determining an expected cost statistic comprises the steps of:

computing a normative expected cost statistic;

determining for each of said responsible physicians a difference of actual patient cost from said normative expected cost statistic;

ordering a list of all said responsible physicians in ascending order based on said differences of actual patient cost from said normative expected cost statistic;

determining a subset of physicians in said ordered list as physicians meeting a threshold of physician claims; and

recomputing said normative expected cost statistic using said subset of physicians in said ordered list and said difference of actual patient cost from said expected cost statistic.

75. The method of claim 74 wherein the threshold of physician claims is 25% of a total number of inpatient claims.

76. The method of claim 74 further comprising the step of:

excluding said responsible physicians from said ordered list if each of said responsible physicians has a number of cases for said classified diagnosis group which is less than a threshold of a number of physician cases.

77. The method of claim 76 wherein the threshold of a number of physician cases is less than three cases.

78. The method of claim 74 wherein before said recomputing step, further comprising the step of:

determining if a number of said responsible physicians for said classified diagnosis related groups is greater than a threshold of a number of physicians meeting a selection criteria, and

if said determined number of responsible physicians is greater than said threshold of a number of physicians meeting a selection criteria then performing said recomputing step, or

if said determined number of responsible physicians is not greater than said threshold of a number of physicians meeting a selection criteria;

indicating that said recomputed expected cost statistic is not said best practice norm.

79. The method of claim 78 wherein before said recomputing step, further comprising the step of:

determining a minimum number of claims for each classified diagnosis related group, and

if a determined number of claims for said classified diagnosis related group is greater than said minimum number of claims then performing said recomputing step or if a determined number of claims for said classified diagnosis related group is less than said minimum number of claims;

indicating that said recomputed expected cost statistic is not said best practice norm.

80. The method of claim 69 further comprising the step of:

adjusting said classified diagnosis related groups for severity of illness.

81. The method of claim 69 wherein said classified diagnosis related groups are determined as an All Patient Refined Diagnosis Related Group.

82. The method of claim 69 further comprising:

determining a weight or percentage of a type of healthcare provider for said classified diagnosis related group, said type of healthcare provider comprising a responsible physician, consultant physician and hospital based physician; and

determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims.

83. The method of claim 79 wherein said step of determining a weight or percentage of a type of healthcare provider type comprises the steps of:

k. inputting data of inpatient claims for a plurality of patients,

l. classifying said inpatient claim into one of said diagnosis related groups,

m. inputting physician billing data associated with said classified inpatient claim,

n. linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim,

o. assigning said merged data to one of said healthcare provider types, and

p. repeating steps k-o for each inpatient claim.

84. The method of claim 83 wherein said step of assigning said merged data to said healthcare provider type comprises the steps of:

assigning a classification of hospital based physicians selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue;

physicians who use ionizing radiation, radioactive substances or magnetic resonance in the diagnosis and treatment of disease; and

physicians who perform scientific studies on blood, body fluids, tissue and microscopic organisms for the purpose of diagnosis of illness and disease;

assigning a classification of said responsible physician on surgical claims selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue that are not identified as an anesthesiologist, said physicians having highest charges and said physicians having the highest charges and having a highest number of CPT codes;

assigning a classification of a responsible physician on medical claims based on a limitation selected from the group having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

assigning a classification of a consulting physician who provides expertise in one or more specialties to the responsible physician when such expertise is outside the responsible physician'"'"'s area of expertise and not already identified as a hospital based physician.

85. The method of claim 83 wherein said step of assigning said merged data to said healthcare provider type comprises the steps of:

assigning hospital based physicians based on a limitation selected from the group consisting of;

all physicians having a surgical CPT code 10000-69999 that are associated with a surgical procedure;

all physicians from the Radiology department with a CPT code between 70000 and 79999 or between 93000 and 93550;

all physicians having a CPT code between 80000 and 89999; and

all other physician line items that have a same physician ID identified as a hospital based physician;

assigning said responsible physician on surgical claims based on a limitation selected from the group consisting of;

having a physician with a surgical CPT code (10000-69999) that is not identified as an anesthesiologist;

having an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

said physician having highest charges;

an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

as said physicians having the highest charges and having a highest number of CPT codes;

assigning a responsible physician on medical claims based on a limitation selected from the group consisting of;

having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

assigning a consulting physician based on a limitation selected from the group of all physicians having a CPT code between 99251 and 99274 and not already identified as a hospital based physician and after the responsible physicians and hospital based physicians have been assigned remaining physician line items.

86. The method of claim 69 wherein said step of determining said physician economic performance further comprises the steps of:

determining a current costed patient record from said current patient data;

assigning one of said classified diagnosis related groups to said current costed patient record;

assigning said healthcare provider type to said current costed patient record;

categorizing said healthcare provider type into a medical responsible physician or a surgical responsible physician based on said current costed patient record; and

determining said physician economic performance for each said healthcare provider type.

87. The method of claim 69 further comprising generating a report of said established physician economic performance.

88. A system for evaluating physician economic performance comprising:

means for establishing a best practice norm for a plurality of classified diagnosis related groups from base patient data; and

means for determining said physician economic performance by comparing current physician performance associated with one of said classified diagnosis related groups to the established best practice norm for one of said classified diagnosis related groups.

89. The system of claim 88 wherein said base patient data comprises inpatient data of a plurality of patients for one or more hospitals in a base time frame, said inpatient data comprises inpatient claim information and hospital cost data.

90. The system of claim 89 wherein said inpatient claim information is determined for a uniform bill (UB).

91. The system of claim 88 wherein said current physician performance is determined from part B costs of a uniform bill.

99. The system of claim 88 further comprising:

means for adjusting said classified diagnosis related groups for severity of illness.

100. The system of claim 88 wherein said classified diagnosis related groups are determined as an All Patient Refined Diagnosis Related Group.

101. The system of claim 88 further comprising:

means for determining a weight or percentage of a type of healthcare provider for said classified diagnosis related group, said type of healthcare provider comprising a responsible physician, consultant physician and hospital based physician; and

means for determining a percentage of a sum of claims associated with said responsible physician by said classified diagnosis related group to a total percentage of physician claims of said responsible physician, said consultant physician and said hospital based physician to determine a percentage of responsible physician claims.

102. The system of claim 101 wherein said means for determining a weight or percentage of a type of healthcare provider type comprises:

means for inputting data of inpatient claims for a plurality of patients,

means for classifying said inpatient claim into one of said diagnosis related groups,

means for inputting physician billing data associated with said classified inpatient claim,

means for linking said classified inpatient claim to said physician billing data to form merged data of said physician billing data and said classified inpatient claim,

means for assigning said merged data to one of said healthcare provider types.

103. The system of claim 101 wherein said means for assigning said merged data to said healthcare provider type comprises:

means for assigning a classification of hospital based physicians selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue;

physicians who use ionizing radiation, radioactive substances or magnetic resonance in the diagnosis and treatment of disease; and

physicians who perform scientific studies on blood, body fluids, tissue and microscopic organisms for the purpose of diagnosis of illness and disease;

means for assigning a classification of said responsible physician on surgical claims selected from the group consisting of physicians who perform a surgical procedure, comprising operative manual methods, incision(s) of the body, internal manipulation and/or removal of a diseased organ or tissue that are not identified as an anesthesiologist, said physicians having highest charges and said physicians having the highest charges and having a highest number of CPT codes;

means for assigning a classification of a responsible physician on medical claims based on a limitation selected from the group having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

means for assigning a classification of a consulting physician who provides expertise in one or more specialties to the responsible physician when such expertise is outside the responsible physician'"'"'s area of expertise and not already identified as a hospital based physician.

104. The system of claim 101 wherein said means for assigning said merged data to said healthcare provider type comprises:

means for assigning hospital based physicians based on a limitation selected from the group consisting of;

all physicians having a surgical CPT code 10000-69999 that are associated with a surgical procedure;

all physicians from the Radiology department with a CPT code between 70000 and 79999 or between 93000 and 93550;

all physicians having a CPT code between 80000 and 89999; and

all other physician line items that have a same physician ID identified as a hospital based physician;

means for assigning said responsible physician on surgical claims based on a limitation selected from the group consisting of;

having a physician with a surgical CPT code (10000-69999) that is not identified as an anesthesiologist;

having an inpatient admission with a surgical CPT code (10000-69999) that has not been already identified as an anesthesiologist; and

as said physicians having the highest charges and having a highest number of CPT codes;

means for assigning a responsible physician on medical claims based on a limitation selected from the group consisting of;

having a physician not identified as a hospital based physician or consulting physician and a physician having a highest number of CPT codes; and

means for assigning a consulting physician based on a limitation selected from the group of all physicians having a CPT code between 99251 and 99274 and not already identified as a hospital based physician and after the responsible physicians and hospital based physicians have been assigned remaining physician line items.

105. The system of claim 101 wherein said means for determining said physician economic performance further comprises:

means for determining a current costed patient record from said current patient data;

means for assigning one of said classified diagnosis related groups to said current costed patient record;

means for assigning said healthcare provider type to said current costed patient record;

means for categorizing said healthcare provider type into a medical responsible physician or a surgical responsible physician based on said current costed patient record; and

means for determining said physician economic performance for each said healthcare provider type.

106. The system of claim 105 further comprising generating a report of said established physician economic performance.