Medical Concept Representation Learning from Claims Data and Application to Health Plan Payment Risk Adjustment

Abstract: Risk adjustment has become an increasingly important tool in healthcare. It has been extensively applied to payment adjustment for health plans to reflect the expected cost of providing coverage for members. Risk adjustment models are typically estimated using linear regression, which does not fully exploit the information in claims data. Moreover, the development of such linear regression models requires substantial domain expert knowledge and computational effort for data preprocessing. In this paper, we propose a novel approach for risk adjustment that uses semantic embeddings to represent patient medical histories. Embeddings efficiently represent medical concepts learned from diagnostic, procedure, and prescription codes in patients' medical histories. This approach substantially reduces the need for feature engineering. Our results show that models using embeddings had better performance than a commercial risk adjustment model on the task of prospective risk score prediction.