Healthcare Claims-Per-Healthy-Day Navigation Engine for Provider Ranking
Solution Overview
Problem
Existing healthcare systems lack a quantitative measure to evaluate healthcare outcomes in terms of dollars and cents, making it difficult to rank healthcare providers and items based on their efficiency and calculate returns on investment.
Innovation Solution
A navigation engine that quantifies healthcare outcomes in terms of risk-adjusted claims per healthy day, combining cost and quality into a single dollar and cent value, using a hierarchical data representation and machine learning to analyze medical and pharmacy claims.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If healthcare outcomes are measured in qualitative terms (compliance with checklists, patient satisfaction scores), then measurement simplicity is maintained, but the ability to rank providers and calculate ROI is lost
Solution Approach 1:
The patent transforms healthcare outcome measurement from qualitative parameters (compliance yes/no, satisfaction scores) to a quantitative parameter (claims per healthy day ratio expressed in dollars and cents). This parameter change enables precise ranking and ROI calculation while maintaining system feasibility through the use of existing claims data infrastructure.
2Loss of information
If healthcare outcomes are quantified in dollars and cents using claims per healthy day, then provider ranking and ROI calculation become possible, but data processing complexity increases
Solution Approach 1:
The patent introduces an intermediary computational framework that processes complex claims data through a structured methodology: determining healthy days using clinical criteria, calculating claims per healthy day ratios, and adjusting for risk factors. This intermediary process transforms raw complex data into standardized quantitative outcomes that enable provider ranking and ROI analysis.
3Ease of operation
If traditional qualitative measurement methods are used, then data collection simplicity is maintained, but the ability to make informed cost-effective decisions is reduced
Solution Approach 1:
The patent creates a universal measurement framework (claims per healthy day) that serves multiple functions simultaneously: it quantifies provider performance, enables ROI calculation, supports informed decision-making, and utilizes existing claims data infrastructure. This multi-functional approach maintains operational simplicity while dramatically improving information quality for decision-making.
Data Source
AI summary
A navigation engine for medical and/or pharmacy claims (in combination with employer human resource records or on a stand-alone basis) that quantifies healthcare outcomes and ranks healthcare providers and other healthcare items by root diagnosis based on their overall average claims per healthy day (i.e., clinical efficiency). Claims per healthy day is the adjusted claims cost per day to keep a patient healthy (or in the case of an employer, keep an employee at work), so the lower, the better. The navigation engine uses drop-down menus and/or similar techniques that require the user to select a root diagnosis on which to search, as well as other variables (e.g., provider category, geographic proximity, in-network versus in or out of network, etc.), turning an open-ended question, e.g., “Which doctor should I go to for back pain?” to a closed-ended one “Which surgeons in my network within 25 miles have the best outcomes for back surgery?”