SYSTEM AND METHOD FOR CARE PATH PERFORMANCE ANALYSIS AND OPTIMAL PROVIDER NETWORK FORMATION

• Main Authors: MENON, Prakash, DESIKAN, Prasanna, FAKHRAI-RAD, Hossein, ZARKOOB, Hadi
• Format: Patent
• Language: English
• Published: 27.05.2021
• Subjects: CALCULATING; COMPUTING; COUNTING; DATA PROCESSING SYSTEMS OR METHODS, SPECIALLY ADAPTED FORADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORYOR FORECASTING PURPOSES; HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATIONTECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING ORPROCESSING OF MEDICAL OR HEALTHCARE DATA; INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTEDFOR SPECIFIC APPLICATION FIELDS; PHYSICS; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE,COMMERCIAL, FINANCIAL, MANAGERIAL, SUPERVISORY OR FORECASTINGPURPOSES, NOT OTHERWISE PROVIDED FOR

A method of obtaining a virtual provider cluster is provided. The method includes obtaining a medical effectiveness per member, obtaining a preliminary virtual provider cluster, for each preliminary virtual provider cluster, calculating a MedicalEffectiveness as: MedicalEffectiveness=mean of the MedicalEffectiveness per member for all members associated with the preliminary virtual cluster; for each preliminary virtual provider cluster, calculating a RiskAdjustedCostEfficiency as RiskAdjustedCostEfficiency=sum of all MemberExpectedClaimAmount/sum of all MemberAllowedClaimAmount; and obtaining a virtual provider cluster by updating each preliminary virtual provider cluster with its corresponding MedicalEffectiveness and corresponding RiskAdjustedCostEfficiency.