Medicare Program Integrity & Healthcare Equity Analytics

National-scale framework identifying high-risk counties through ML-based modeling

$
Potential Annual Savings
$20.8-36.7B
Validated federal savings
✓
Model Accuracy
99.1%
High-risk county identification
⚠
High-Risk Counties
255
8% of 3,198 total counties
!
Underserved Beneficiaries
2.5M
Requiring immediate intervention
Medicare Beneficiaries Analyzed
29.5M
52% of total Medicare population
HRSA Concordance
98.4%
Federal designation alignment
Processing Time
18.4 hrs
vs months for manual review
Return on Investment
178-461%
Payback: 2.2-6.3 months

Geographic Distribution of 255 High-Risk Counties

89
(35%)
Southeast
52
(20%)
Southwest
48
(19%)
Midwest
38
(15%)
Northeast
28
(11%)
Northwest

State Healthcare Equity Index Distribution

Grade Score Range States Percentage
A 80-100 2 3.9%
B 70-79 12 23.5%
C 60-69 20 39.2%
D 50-59 12 23.5%
F <50 5 9.8%

Random Forest Model - Top 9 Risk Indicators

Vulnerability Score - 36.3%
Emergency Dept Utilization - 24.1%
Hospital Readmission Rate - 17.7%
Dual Eligibility % - 10.7%
Rural-Urban Classification - 5.3%
Provider Density - 3.2%
Preventable Hospitalizations - 1.8%
Standardized Spending - 0.7%
Demographic Diversity - 0.2%

Implementation Scenarios & ROI

Scenario Annual Savings ROI Payback
Conservative $20.8B 461% 2.2 months
Moderate $26.5B 347% 3.5 months
Aggressive $36.7B 178% 6.3 months
10-Year Cumulative Impact:
$208B - $367B
Potential Medicare Trust Fund extension: 1-2 years

State Performance Rankings

Top 5 Performing States

1. Utah84.7
2. Rhode Island83.7
3. Idaho76.6
4. Hawaii76.4
5. Montana75.1

Bottom 5 Performing States

47. Connecticut46.6
48. Vermont44.7
49. Maine42.5
50. Mississippi42.4
51. District of Columbia36.0

Critical Healthcare Disparities

Provider Shortage Impact
1,704
Counties with severe shortages (HPSA >15)
Affecting 20.4 million beneficiaries
Emergency Room Utilization
35% Higher
In underserved areas
Dual-eligible: 15% higher (812 vs 706/1,000)
Rural vs Urban Disparity
20 Points
Higher vulnerability score in rural areas
78.5 vs 58.2 average score
Spending Variation
64%
Per-beneficiary cost variation
$8,295 to $13,644 annually

Implementation Roadmap

Phase Timeline Scope Financial Impact
Phase I Years 1-2 Pilot Expansion: Medicare Advantage integration, sub-county analysis $10-15B annually
Phase II Years 3-5 National Rollout: All 3,198 counties, Medicaid pilots in 5 states $26.5B annually
Phase III Years 5+ Cross-Program Integration: Medicare, Medicaid, VA, TRICARE via APIs $36.7B annually

Medicare Program Integrity & Healthcare Equity Analytics Framework

Validated against federal benchmarks • 98.4% HRSA concordance • 99.1% model accuracy

Data source: CMS Medicare Geographic Variation Files, HRSA, AHRF, U.S. Census (2019-2024)