Is it possible to forecast medical treatment and costs using big data and predictive models? How does a big data approach compare to conventional methods?

The foundation for these questions was the beginning of a 10-year journey, a quest to validate existing methods and determine if a better solution might exist to answer the problem of forecasting medical care for care coordination and claim settle settlements.

How did we get where we are today?

If you were around, flashback to the disability rights movement of the 1980’s, following the passage of the Rehabilitation Act of 1973, when activists lobbied hard for people with disabilities to have access to public transportation and public education. After decades of campaigning, the Americans with Disabilities Act (ADA) was passed in 1990 providing equal treatment and equal access of people with disabilities to employment and public accommodations. Under the ADA, businesses were mandated to provide reasonable accommodations to people with disabilities and full participation, inclusion and integration of people with disabilities. With this the emergence, the field of Life Care Planning evolved, entering the litigation space, to offer valuations of the injury costs to a person’s life and livelihood, in the event of an accident or injury causing disability. The Life Care Planning process was developed by Vocational Rehabilitation experts responsible for working with individuals with disabilities to restore and/ or maximize their functional capacity to perform independently both at home and at work. Life Care Planning methodology has become the standard for forecasting medical treatment over an individual’s lifetime and has been used extensively by both plaintiff and defense sides in litigation and jury trials to valuate medical damages, becoming the accepted standard for valuating medical costs.

Life Care Planners also found an opportunity to provide a solution to the dilemma of forecasting medical exposure for “Medicare Set Aside Arrangements” by streamlining and hybridizing the methodology to forecast care that is Medicare covered, related to an injury in the form of a “mini” Life Care Plan that could be used to satisfy the Centers for Medicare and Medicaid Services (CMS) Medicare Secondary Payer (MSP) requirements involving a Workers Compensation commutation settlement. The concept was quickly adopted by the Workers Compensation industry as the gold standard for meeting the requirement of future obligations to protect Medicare. When the first Workers Compensation Review Contractor (WCRC) was established in 2003 to evaluate Workers Compensation Medicare Set Asides (WCMSA), the “mini” Life Care Plans became the standard accepted methodology by CMS, introduced to them by the MSA industry.

Research and Analysis of the Accuracy/ Validity of Life Care Planning

In 2013 an analysis of 100 Medicare Set Asides (MSAs) was submitted to CMS for review and approval and compared the CMS future care results to actual treatment rendered, two-year post settlement. Upon review of the medical records, it was identified that 94 of the 100 claimants treated less frequently and received less prescription drugs than what was allocated by 30% or more. Of the remaining 6 claims, which closely aligned with the Medicare Set Asides forecasts, the common denominator was they each represented a catastrophic or chronic, progressive condition i.e. spinal cord injury, chronic obstructive pulmonary disease (COPD) due to an exposure and/ or debilitating rheumatoid arthritis.

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