On Designing of a Low Leakage Patient-Centric Provider Network

TL;DR

This paper presents a data-driven approach to identify patient-driven provider communities and analyze leakage patterns to reduce out-of-network healthcare costs, especially for diabetic patients in ACO settings.

Contribution

It introduces a novel method combining community detection and import-export analysis to understand and minimize healthcare service leakage.

Findings

Identified six major provider communities with diverse profiles.

Most communities show high within-community utilization and spending.

Leakage persists despite high within-community engagement, indicating room for further reduction.

Abstract

When a patient in a provider network seeks services outside of their community, the community experiences a leakage. Leakage is undesirable as it typically leads to higher out-of-network cost for patient and increases barrier for care coordination, which is particularly problematic for Accountable Care Organization (ACO) as the in-network providers are financially responsible for patient quality and outcome. We aim to design a data-driven method to identify naturally occurring provider networks driven by diabetic patient choices, and understand the relationship among provider composition, patient composition, and service leakage pattern. We construct a healthcare provider network based on patients' historical medical insurance claims. A community detection algorithm is used to identify naturally occurring communities of collaborating providers. Finally, import-export analysis is conducted to benchmark their leakage pattern and identify further leakage reduction opportunity. The design yields six major provider communities with diverse profiles. Some communities are geographically concentrated, while others tend to draw patients with certain diabetic co-morbidities. Providers from the same healthcare institution are likely to be assigned to the same community. While most communities have high within-community utilization and spending, at 85% and 86% respectively, leakage still persists. Hence, we utilize a metric from import-export analysis to detect leakage, gaining insight on how to minimizing leakage. In conclusion, we identify patient-driven provider organization by surfacing providers who share a large number of patients. By analyzing the import-export behavior of each identified community using a novel approach and profiling community patient and provider composition we understand the key features of having a balanced number of PCP and specialists and provider heterogeneity.