Abstract: A method of obtaining a virtual provider cluster is provided. The method includes obtaining a medical effectiveness per member, obtaining a preliminary virtual provider cluster, for each preliminary virtual provider cluster, calculating a MedicalEffectiveness as: MedicalEffectiveness=mean of the MedicalEffectiveness per member for all members associated with the preliminary virtual cluster; for each preliminary virtual provider cluster, calculating a RiskAdjustedCostEfficiency as RiskAdjustedCostEfficiency=sum of all MemberExpectedClaimAmount/sum of all MemberAllowedClaimAmount; and obtaining a virtual provider cluster by updating each preliminary virtual provider cluster with its corresponding MedicalEffectiveness and corresponding RiskAdjustedCostEfficiency.

Abstract: An enhanced risk management method is provided in which a diverse set of inputs, such as demographic variables, risk adjustment factors (RAF) of previous years, and claims of previous years, are used in the training of a prediction model configured to predict both a standard RAF based on the assumption that a healthcare system in question continues its current, possibly suboptimal, operations, and an improved RAF based on an idealized workflow in which all of a member's Hierarchical Condition Category (HCC) codes are captured appropriately at the earliest time possible.