Year: 2025
Type: article
Abstract: Healthcare risk adjustment plays a pivotal role in ensuring equitable resource allocation and sustainable healthcare systems by estimating expected patient costs based on individual health needs. Traditional risk adjustment models, reliant on linear regression and retrospective claims data, suffer from limitations such as incomplete data, coding inaccuracies, time lags, and the omission of socioeconomic and behavioral factors, often leading to inequities in reimbursement and care delivery. This paper explores the transformative potential of advanced data analytics techniques like machine learning, decision tree-based algorithms, and deep learning in overcoming these shortcomings. By integrating diverse data sources, including electronic health records (EHRs), social determinants of health (SDoH), and patient-reported outcomes, these methods enhance predictive accuracy, enable personalized risk scoring, and support population segmentation and stratification. The paper also examines techniques for identifying rising-risk patients and preventing avoidable healthcare utilization through clustering and predictive modeling. However, challenges such as data quality, continuous model refinement, privacy, algorithmic bias, and interpretability must be addressed to fully realize these benefits. Through a comprehensive analysis, this study underscores the promise of analytics-driven risk adjustment in promoting fair reimbursement, optimizing resources, and advancing equitable, value-based care, while highlighting critical considerations for implementation
Author: Narendran Santhanam
Language: English
Subfield: Artificial Intelligence
Field: Computer Science
Domain: Physical Sciences
Open Access status: diamond
OpenAlex ID: W4409216600