Title: An exploration and case study of population classification for managed healthcare within a state-based modelling framework

Authors: Douglas N. Fuller, William T. Scherer, Thomas A. Pomroy

Addresses: Priority Perspective, Inc.,404 Meridian Avenue, Suite B, Louisville, KY 40207, USA. Department of Systems and Information Engineering, University of Virginia, Thornton Hall SE, Charlottesville, VA 22904, USA. Department of Systems and Information Engineering, University of Virginia, Thornton Hall SE, Charlottesville, VA 22904, USA

Abstract: The healthcare industry currently accounts for more than 12% of the US Gross Domestic Product (GDP). The industry is struggling with a shift from the ||fee for service|| compensation model prevalent during the 20th Century to a delivery model based on some form of ||managed care||. Efforts at implementing capitation rate contracts with physicians have been significantly hampered by the inability to accurately forecast and adjust for risk differences among various practice populations. We approach the problem within the framework of state-based modelling to develop state definitions that represent homogeneous sub-populations. We use the state definitions to develop a First Order Markov Model for healthcare expense prediction and compare performance to the current state of the art expense prediction models on actual data from a family practice in Calgary.

Keywords: Markov chains; state-based modelling; capitation rates; managed healthcare; expense prediction.

DOI: 10.1504/IJHTM.2003.003332

International Journal of Healthcare Technology and Management, 2003 Vol.5 No.1/2, pp.123 - 140

Published online: 27 Aug 2003 *

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