Assessing Hospital Opportunity from Medicare Claims
Value-based-care venture
The question
The company needed to assess hospital opportunity under payment models and use that analysis in commercial planning and prospective-partner conversations.
The work
We modeled approximately seven million Medicare episodes, examined care-pathway economics, and built applications for comparing hospitals and service lines. The work included payment standardization, estimates for partially observed spending, and documented benchmarks. Reporting and presentation tools supported hospital-specific discussions.
The spending model accounted for partially observed Part B claims rather than treating the sample as complete. Peer comparisons and hospital-specific presentation tools connected the episode analysis to prospective-partner discussions.
What the client gained
An analytical application and reusable process for opportunity assessment and commercial planning, with calculations and assumptions available for review.
The application ranked approximately 3,000 hospitals and supported hospital-specific prospect presentations. The ranking helped the commercial team prioritize partner conversations.
Delivery and modeled opportunity
The cloud application ran in the client’s AWS account, with a hospital-specific presentation generator that the commercial team could use without engineering support. The analysis extended across 30-day and 90-day episode windows and included ACO overlap.
For flagship systems, the analysis identified more than $10 million in modeled annual post-acute opportunity. The original targeting analysis included roughly 335 hospitals in the mandatory-program cohort; this describes the cohort used for that analysis, not a current program count.
The methodology combined payment standardization, RVU-based estimates for the 5% Part B sample, peer-cohort benchmarks, and explicit risk assumptions. This made hospital comparisons and the opportunity estimates available for review.
Limits
Opportunity figures are modeled estimates. They depend on sample coverage, peer benchmarks, and care-pathway assumptions, and do not represent realized savings or guaranteed contract results.