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.

Abstract: A computer-implemented technique, including database processing, is used to identify at risk congestive heart failure patients where information about patients exists in a claims database. The technique includes processing the patient information in the claims database to find and extract claims information for a group of congestive heart failure patients. Next, using the extracted information, a set of events, relevant to congestive heart failure, is defined. Next, the extracted information and set of events are processed to create event level information which is organized with respect to events rather than claims. A time window is defined to provide a timeframe from which to judge whether events should be considered in subsequent processing; and, a set of variables is defined as being potential predictors of adverse health outcomes. Subsequently, the event level information, using the time window and the set of variables, is processed to generate an analysis file.