Method, system, and computer program product for physician efficiency measurement and patient health risk stratification

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.

What is claimed is: 
     
         1 . A computer system comprising:
 at least one memory with instructions stored thereon; and   at least one processor in communication with the at least one memory, wherein the instructions, when executed by the at least one processor, cause the at least one processor to:
 perform patient analysis using medical claims data to form episodes of care; 
 perform an output process based on the patient analysis, the output process comprising:
 assigning episodes of care to physicians, wherein an episode of care is allowed to be assigned to more than one physician; 
 utilizing a first maximum duration rule to identify episodes of care for first conditions; and 
 utilizing a second maximum duration rule to identify episodes of care for second conditions; 
 
 assign at least one physician to a report group, wherein the at least one physician is assigned to no more than one report group; and 
 identify eligible physicians and episode of care assignments by:
 disqualifying episode of care assignments to physicians not meeting a selected criterion for the report group; 
 determining condition-specific episode of care statistics; 
 determining episode of care statistics across medical conditions; and 
 calculating efficiency scores for physicians based at least in part upon at least one of the condition-specific episode of care statistics or the episode of care statistics calculated across medical conditions. 
 
   
     
     
         2 . The computer system of  claim 1 , wherein the first conditions comprise chronic conditions. 
     
     
         3 . The computer system of  claim 2 , wherein the second conditions comprise acute conditions. 
     
     
         4 . The computer system of  claim 1 , wherein determining the episode of care statistics across medical conditions utilizes direct standardization. 
     
     
         5 . The computer system of  claim 1 , wherein determining the episode of care statistics across medical conditions utilizes indirect standardization. 
     
     
         6 . The computer system of  claim 1 , wherein determining the condition-specific episode of care statistics comprises calculating the condition-specific episode of care statistics for physicians in the report group. 
     
     
         7 . The computer system of  claim 1 , wherein determining the condition-specific episode of care statistics comprises calculating the condition-specific episode of care statistics for peer groups. 
     
     
         8 . The computer system of  claim 1 , wherein the output process further comprises disqualifying partial episodes of care. 
     
     
         9 . At least one non-transitory computer-readable storage medium with instructions stored thereon that, in response to execution by at least one processor, cause the at least one processor to:
 perform patient analysis using medical claims data to form episodes of care;   perform an output process based on the patient analysis, the output process comprising:
 assigning episodes of care to physicians, wherein an episode of care is allowed to be assigned to more than one physician; 
 utilizing a first maximum duration rule to identify episodes of care for first conditions; and 
 utilizing a second maximum duration rule to identify episodes of care for second conditions; 
   assign at least one physician to a report group, wherein the at least one physician is assigned to no more than one report group; and   identify eligible physicians and episode of care assignments by:
 disqualifying episode of care assignments to physicians not meeting a selected criterion for the report group; 
 determining condition-specific episode of care statistics; 
 determining episode of care statistics across medical conditions; and 
 calculating efficiency scores for physicians based at least in part upon at least one of the condition-specific episode of care statistics or the episode of care statistics calculated across medical conditions. 
   
     
     
         10 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein the first conditions comprise chronic conditions. 
     
     
         11 . The at least one non-transitory computer-readable storage medium of  claim 10 , wherein the second conditions comprise acute conditions. 
     
     
         12 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein determining the episode of care statistics across medical conditions utilizes direct standardization. 
     
     
         13 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein determining the episode of care statistics across medical conditions utilizes indirect standardization. 
     
     
         14 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein determining the condition-specific episode of care statistics comprises calculating the condition-specific episode of care statistics for physicians in the report group. 
     
     
         15 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein determining the condition-specific episode of care statistics comprises calculating the condition-specific episode of care statistics for peer groups. 
     
     
         16 . The at least one non-transitory computer-readable storage medium of  claim 9 , wherein the output process further comprises disqualifying partial episodes of care. 
     
     
         17 . A method for determining physician efficiency implemented by a computer system comprising at least one processor in communication with at least one memory, the method comprising:
 performing patient analysis using medical claims data to form episodes of care;   performing an output process based on the patient analysis, the output process comprising:
 assigning episodes of care to physicians, wherein an episode of care is allowed to be assigned to more than one physician; 
 utilizing a first maximum duration rule to identify episodes of care for first conditions; and 
 utilizing a second maximum duration rule to identify episodes of care for second conditions; 
   assigning at least one physician to a report group, wherein the at least one physician is assigned to no more than one report group; and   identifying eligible physicians and episode of care assignments by:
 disqualifying episode of care assignments to physicians not meeting a selected criterion for the report group; 
 determining condition-specific episode of care statistics; 
 determining episode of care statistics across medical conditions; and 
 calculating efficiency scores for physicians based at least in part upon at least one of the condition-specific episode of care statistics or the episode of care statistics calculated across medical conditions. 
   
     
     
         18 . The method of  claim 17 , wherein the first conditions comprise chronic conditions. 
     
     
         19 . The method of  claim 18 , wherein the second conditions comprise acute conditions. 
     
     
         20 . The method of  claim 17 , wherein determining the episode of care statistics across medical conditions utilizes at least one of direct standardization or indirect standardization.