Milliman Episode Grouper with Risk Adjustment
Milliman ERA turns claims and enrollment data into actionable insights for episodes of care. Health plans, accountable care organizations (ACOs), and other risk-bearing organizations can compare provider performance, understand cost variation, and make more informed network and value-based payment decisions.
Milliman Episode Grouper with Risk Adjustment
Provider comparisons lack context
Health plans and risk-bearing organizations need a consistent way to compare provider costs, efficiency, and care patterns. Many groupers—software tools that categorize patients into specific groups—use definitions that lack clinical meaning, offer limited transparency, or apply insufficient risk adjustment. Without credible performance benchmarking, teams struggle to identify meaningful variation and translate claims data into better network and payment decisions.
Compare providers on a sound basis
Milliman ERA constructs clinically relevant episodes of care from claims and enrollment data using transparent rules. The episode grouper attributes each episode to a provider, applies risk adjustment to the episode and specific line of business, and determines a provider efficiency score based on performance relative to expectations. Results are compared against regional or national episode benchmarks, giving organizations a defensible basis for provider evaluation, network decisions, and value-based payment design.
The four episode types included in Milliman ERA
Milliman ERA contains four distinct episode types: chronic condition, acute condition, procedural, and oncology episodes.
- Chronic condition episodes capture the ongoing management of long-term illnesses over a defined period.
- Acute condition episodes focus on the treatment of short-term medical events.
- Procedural episodes group all clinically related services surrounding a specific procedure.
- Oncology episodes provide a comprehensive view of active treatment cancer care, including the treatment, supportive services, and complications associated with a patient's oncology journey.
Organizations can assess individual episode types to support targeted analyses or combine episodes across types to create a holistic, risk-adjusted framework for measuring and managing healthcare performance across a variety of clinical areas.
Benefits
Evaluate provider performance
Optimize provider performance by leveraging episode insights for specialists within the network.
Support care and network strategy
Rely on performance benchmarking with credible external comparisons across regions and specialties.
Advance value-based payment models
Use episode-level insights to design, evaluate, and manage payment arrangements.
Refine network decisions
Identify efficient providers and support tiering, contracting, and network design.
Understand drivers of spend
Analyze cost variation across episodes of care, providers, and care patterns to inform medical economics strategy.
Reduce technical burden
Use episode grouper output without maintaining open-source grouper software internally.
Features
Configure analysis parameters
Select episode types, lines of business, and other settings to align with business objectives.
Use transparent grouping logic
Understand how episodes are built, including which services are captured and how episodes are attributed to providers.
Receive detailed outputs
Access provider attribution, cost breakdowns, and risk-adjusted comparisons for each episode.
Integrate with existing platforms
Extend MedInsight environments with episode-based performance insights for downstream analytics.
Streamline data onboarding
Use input formats aligned with Milliman Health Cost Guidelines—Grouper software to reduce implementation effort.
Apply episode-specific risk adjustment
Benchmark provider performance using models tailored to each episode and population.
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