System and method for modeling of healthcare utilization
AssigneeIngenix, Inc.
InventorsBadri N. Prasad, Louise H. Anderson, Felix Friedman, Gerald L. Lutgen
Life of this patent
Estimating the term…
Abstract
A system and method for modeling healthcare utilization based on usage data from physician claims, hospital claims, and pharmacy claims. The method includes extracting from a claims file the portion of the data from a base period that is relevant to modeling healthcare utilization in a target period by computing a utilization score based on the usage data. The models may be used concurrently by calibrating them with the base period equal to the target period and they may be also be used prospectively by calibrating the models with the target period representing a future time period.
Claims28
A method in a computer system for predicting a level of consumption of healthcare resources by modeling utilization of healthcare resources in a target period, the method comprising:
- a computer system performing the following:
- compiling a plurality of provider claims for each of a plurality of members of a health plan, wherein the provider claims for the plurality of members occur within a base period and include a plurality of health conditions or diseases;
- storing a plurality of disease categories representing a plurality of health conditions or diseases;
- storing category weight data, wherein the category weight data comprises a weight value associated with each stored disease category, wherein each weight value associated with a stored disease category represents an average incremental cost for a plan member associated with the presence of the associated stored disease category during the base period;
- for each of the plurality of health plan members, identifying each stored disease category present in the plurality of provider claims for the member;
- calculating a burden of illness score for each member, wherein the burden of illness score is a number calculated by summing the stored weight values associated with each disease category identified in the member's provider claims;
- storing at least one explanatory variable, wherein the explanatory variable is derived from demographic data or prior healthcare utilization data associated with the member;
- computing a utilization score for each health plan member as a function of the burden of illness score and the at least one explanatory variable, wherein the utilization score is computed by assigning a weight factor to the burden of illness score and to the explanatory variable and summing (a) the product of the burden of illness score and its assigned weight factor and (b) the product of the explanatory variable and its assigned weight factor;
- and
- using the utilization score to predict healthcare resource consumption in the target period by at least one plan member.
A method in a computer system for determining consumption of healthcare resources by a plurality of plan members in a healthcare plan during a base time period, comprising:
- a computer system performing the following
- compiling pharmacy claims for each of a plurality members of a health plan, wherein the pharmacy claims for the plurality of members include a plurality of drug categories;
- storing a plurality of drug categories;
- storing category weight data, wherein the category weight data comprises a weight value associated with each stored drug category, wherein each weight value associated with a stored drug category represents an average incremental cost for a plan member associated with the presence of the associated stored drug category during the base period;
- for each of the plurality of health plan members, identifying each stored drug category present in the plurality of pharmacy claims for the member;
- calculating a burden of illness score for each member, wherein the burden of illness score is a number calculated by summing the stored weight values associated with each drug category identified in the member's pharmacy claims;
- storing at least one explanatory variable, wherein the explanatory variable is derived from demographic data or prior healthcare utilization data associated with the member;
- computing a utilization score for each health plan member as a function of the burden of illness score and the at least one explanatory variable, wherein the utilization score is computed by assigning a weight factor to the burden of illness score and to the explanatory variable and summing (a) the product of the burden of illness score and its assigned weight factor and (b) the product of the explanatory variable and its assigned weight factor;
- and
- using the utilization score to predict healthcare resource consumption by at least one plan member.
Dependencies are inferred from the claim text.