Site of Care Migration Engine

python
# Site of Care Migration Modeling
procedure_cost_matrix = {
    'colonoscopy': {
        'hospital_outpatient': 3200,
        'asc': 1100,
        'savings': 2100,
        'migration_eligible': True,
        'quality_score': 'equivalent'
    },
    'cataract_surgery': {
        'hospital_outpatient': 4800,
        'asc': 2100,
        'savings': 2700,
        'migration_eligible': True,
        'quality_score': 'superior_asc'  # ASC outcomes better
    },
    'mri_lumbar_spine': {
        'hospital': 2400,
        'freestanding_imaging': 850,
        'savings': 1550,
        'migration_eligible': True,
        'quality_score': 'equivalent'
    },
    'rheumatoid_arthritis_infusion': {
        'hospital': 4800,
        'office_based': 1600,
        'savings': 3200,
        'migration_eligible': True,
        'quality_score': 'equivalent'
    },
    'knee_arthroscopy': {
        'hospital_outpatient': 12500,
        'asc': 5200,
        'savings': 7300,
        'migration_eligible': True,
        'quality_score': 'equivalent'
    }
}

def calculate_migration_opportunity(claims_data, utilization_history):
    total_savings = 0
    migration_plan = []
    
    for procedure, costs in procedure_cost_matrix.items():
        if not costs['migration_eligible']:
            continue
        
        # Find historical utilization at high-cost sites
        hospital_claims = claims_data.filter(
            procedure_code=procedure,
            site_of_service='hospital_outpatient'
        )
        
        volume = len(hospital_claims)
        current_cost = volume * costs['hospital_outpatient']
        
        # Assume 70% migration success rate (member steering + network design)
        migrated_volume = volume * 0.70
        target_site = 'asc' if 'asc' in costs else 'freestanding_imaging'
        future_cost = (migrated_volume * costs[target_site]) + ((volume - migrated_volume) * costs['hospital_outpatient'])
        
        annual_savings = current_cost - future_cost
        total_savings += annual_savings
        
        migration_plan.append({
            'procedure': procedure,
            'current_volume': volume,
            'migrated_volume': migrated_volume,
            'annual_savings': annual_savings,
            'per_procedure_savings': costs['savings'],
            'quality_impact': costs['quality_score']
        })
    
    # Sort by savings opportunity
    migration_plan.sort(key=lambda x: x['annual_savings'], reverse=True)
    
    return {
        'total_annual_savings': total_savings,
        'pmpm_impact': total_savings / 12 / len(utilization_history),
        'top_opportunities': migration_plan[:10]
    }

# Example: 10,000 member population
claims = load_claims('2024')
result = calculate_migration_opportunity(claims, population=10000)

print("Total Annual Savings: {:,.0f}".format(result['total_annual_savings']))
print("PMPM Reduction: {:.2f}".format(result['pmpm_impact']))
print("\nTop 5 Opportunities:")
for opp in result['top_opportunities'][:5]:
    print("  {}: {:,.0f}/year ({} procedures)".format(
        opp['procedure'], opp['annual_savings'], opp['current_volume']))

markdown
# Site of Care Migration Roadmap

## Phase 1: Opportunity Sizing (Month 1-2)
├─ Claims analysis: identify procedures done at high-cost sites
├─ Volume by procedure: colonoscopy (140/year), MRI (280/year), infusion (520 sessions), etc.
├─ Cost differential modeling: $2.1M current spend → $1.25M if migrated (40% savings)
└─ **Baseline: $850K annual savings opportunity**

## Phase 2: Network Assessment (Month 3-4)
├─ ASC availability: 6 in-network ASCs within 15 miles
├─ Freestanding imaging: 4 centers with MRI, quality-accredited
├─ Office-based infusion: 2 rheumatology practices with infusion suites
└─ **Migration feasible for 85% of identified procedures**

## Phase 3: Plan Design (Month 5-6)
├─ Differential copays: $150 hospital vs. $50 ASC (3× incentive)
├─ Prior authorization: require pre-auth for hospital site unless medical necessity
├─ Center of Excellence program: 0% coinsurance at designated ASC/imaging centers
└─ **Member steering: financial + administrative nudges**

## Phase 4: Launch + Monitoring (Month 7+)
├─ Member communication: "Save $100+ by choosing lower-cost sites"
├─ Provider education: share site-of-care cost data with referring physicians
├─ Real-time steering: case management outreach when high-cost site scheduled
└─ **Target: 70% migration rate by Month 12**

## 12-Month Results
├─ Colonoscopy: 98 migrated to ASC (70% rate) = $205K saved
├─ MRI: 196 migrated to freestanding (70% rate) = $304K saved
├─ Infusion: 364 sessions migrated (70% rate) = $341K saved
└─ **Total Year 1 Savings: $850K (matches forecast)**