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@mark64oswald/healthsim-agent
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SKILL.md

name healthsim-networksim
description NetworkSim provides provider network intelligence using real NPPES data (8.9M providers). Use this skill for ANY request involving: (1) provider search by specialty or location, (2) facility search (hospitals, nursing homes, clinics), (3) NPI validation, (4) network adequacy assessment against CMS/NCQA standards, (5) healthcare desert identification, (6) provider density analysis, (7) network roster generation, (8) hospital or physician quality metrics, (9) cross-product provider assignment, (10) pharmacy network analysis.

NetworkSim - Provider Network Intelligence & Analytics

Overview

NetworkSim provides provider network intelligence using real NPPES provider data (8.9M records), CMS facility data (60K+ facilities), and quality metrics integrated with PopulationSim demographics. Unlike synthetic generation, NetworkSim queries actual registered providers to enable:

  1. Provider Discovery: Search providers by specialty, location, credentials, quality
  2. Network Analysis: Assess adequacy against regulatory standards (CMS MA, NCQA, Medicaid)
  3. Healthcare Access: Identify deserts combining access gaps, health needs, and vulnerability
  4. Cross-Product Integration: Provide authentic providers for PatientSim, MemberSim, TrialSim

Key Differentiator: NetworkSim uses real NPPES registry data, not synthetic generation. Every NPI returned is a real, registered healthcare provider.

Quick Reference

I want to... Use This Skill Key Triggers
Provider Search
Find providers by specialty query/provider-search.md "find cardiologists", "search for PCPs", "providers in"
Search hospitals/facilities query/facility-search.md "hospitals in", "find nursing homes", "clinics near"
Find pharmacies query/pharmacy-search.md "pharmacies in", "retail pharmacy", "specialty pharmacy"
Validation & Roster
Validate an NPI query/npi-validation.md "is NPI valid", "validate NPI", "check NPI"
Generate network roster query/network-roster.md "create roster", "export providers", "network list"
Density & Coverage
Calculate provider density query/provider-density.md "providers per 100K", "density analysis", "HRSA benchmark"
Assess network coverage query/coverage-analysis.md "network coverage", "geographic coverage", "specialty gaps"
Quality Metrics
Filter by hospital quality query/hospital-quality-search.md "4-star hospitals", "high quality", "CMS ratings"
Filter by physician credentials query/physician-quality-search.md "MD only", "board certified", "credentials"
Advanced Analytics
Assess network adequacy analytics/network-adequacy-analysis.md "adequacy assessment", "CMS standards", "NCQA requirements"
Identify healthcare deserts analytics/healthcare-deserts.md "healthcare deserts", "underserved areas", "access gaps"
Synthetic Generation
Generate synthetic provider synthetic/synthetic-provider.md "generate a provider", "create physician"
Generate synthetic facility synthetic/synthetic-facility.md "generate hospital", "create facility"
Generate synthetic pharmacy synthetic/synthetic-pharmacy.md "generate pharmacy", "create pharmacy"
Generate synthetic network synthetic/synthetic-network.md "generate network", "create provider network"
Generate synthetic plan synthetic/synthetic-plan.md "generate plan", "create health plan"
Integration
Assign provider to encounter integration/provider-for-encounter.md "provider for patient", "attending physician"
Determine network status integration/network-for-member.md "in-network check", "network status"
Route prescription integration/pharmacy-for-rx.md "pharmacy for prescription", "dispense at"

Trigger Phrases

Provider Search

  • "Find [specialty] in [location]"
  • "Search for primary care providers in [county]"
  • "Show me cardiologists within 10 miles of [zip]"
  • "List all orthopedic surgeons in Texas"
  • "Find providers with NPI starting with [prefix]"

Facility Search

  • "Find hospitals in [county/state]"
  • "Show me 4-star hospitals in California"
  • "List nursing homes in [city]"
  • "Find trauma centers near [location]"
  • "Search for ambulatory surgery centers"

Validation & Roster

  • "Is NPI 1234567890 valid?"
  • "Validate this NPI: [number]"
  • "Create a network roster for [specialty] in [geography]"
  • "Export provider list to CSV"
  • "Generate directory of PCPs for [county]"

Density & Coverage

  • "What's the provider density in [county]?"
  • "Providers per 100K population in Texas"
  • "Compare density to HRSA benchmarks"
  • "Which specialties have gaps in [region]?"
  • "Assess geographic coverage for [state]"

Quality Filtering

  • "Show only 5-star hospitals"
  • "Find MD/DO providers only"
  • "Filter by board certification"
  • "High-quality providers in [area]"
  • "Premium tier hospitals"

Network Adequacy

  • "Assess PCP adequacy for California"
  • "Does this network meet CMS standards?"
  • "NCQA specialty coverage check"
  • "Provider-to-enrollee ratio analysis"
  • "Time/distance access assessment"

Healthcare Deserts

  • "Identify healthcare deserts in Texas"
  • "Show underserved counties"
  • "Find areas with low access + high disease burden"
  • "Critical shortage areas for primary care"
  • "Equity analysis for vulnerable populations"

Skill Inventory

Query Skills (9 skills)

Skill File Lines Purpose
Provider Search query/provider-search.md 450 Search 8.9M providers by specialty, location
Facility Search query/facility-search.md 380 Search hospitals, nursing homes, clinics
Pharmacy Search query/pharmacy-search.md 320 Search retail, specialty, mail pharmacies
NPI Validation query/npi-validation.md 280 Validate NPIs with Luhn checksums
Network Roster query/network-roster.md 350 Generate rosters in CSV/JSON/Excel
Provider Density query/provider-density.md 400 Calculate density vs HRSA benchmarks
Coverage Analysis query/coverage-analysis.md 380 Assess geographic/specialty coverage
Hospital Quality query/hospital-quality-search.md 320 Filter by CMS star ratings
Physician Quality query/physician-quality-search.md 290 Filter by credentials (MD/DO/NP/PA)

Analytics Skills (2 skills)

Skill File Lines Purpose
Network Adequacy analytics/network-adequacy-analysis.md 653 CMS/NCQA regulatory compliance
Healthcare Deserts analytics/healthcare-deserts.md 757 Access + health needs + vulnerability

Synthetic Skills (6 skills)

Skill File Lines Purpose
Synthetic Provider synthetic/synthetic-provider.md 400 Generate providers with valid NPI format
Synthetic Facility synthetic/synthetic-facility.md 350 Generate hospitals, ASCs, clinics
Synthetic Pharmacy synthetic/synthetic-pharmacy.md 320 Generate pharmacies with NCPDP IDs
Synthetic Network synthetic/synthetic-network.md 450 Generate complete network configurations
Synthetic Plan synthetic/synthetic-plan.md 380 Generate health plan structures
Synthetic Pharmacy Benefit synthetic/synthetic-pharmacy-benefit.md 350 Generate PBM configurations

Integration Skills (5 skills)

Skill File Lines Purpose
Provider for Encounter integration/provider-for-encounter.md 280 Assign providers to PatientSim
Network for Member integration/network-for-member.md 300 Network status for MemberSim
Pharmacy for Rx integration/pharmacy-for-rx.md 260 Pharmacy routing for RxMemberSim
Formulary for Rx integration/formulary-for-rx.md 290 Formulary checks for RxMemberSim
Benefit for Claim integration/benefit-for-claim.md 270 Benefit lookup for MemberSim

Reference Skills (7 skills)

Skill File Purpose
Network Types reference/network-types.md HMO, PPO, EPO, POS structures
Plan Structures reference/plan-structures.md Cost sharing, benefit design
Pharmacy Benefits reference/pharmacy-benefit-concepts.md PBM, formulary, tiers
Network Adequacy reference/network-adequacy.md CMS/NCQA standards
PBM Operations reference/pbm-operations.md Claims processing, rebates
Specialty Pharmacy reference/specialty-pharmacy.md Limited distribution, hubs
Utilization Management reference/utilization-management.md PA, step therapy, QL

Pattern Skills (5 skills)

Skill File Purpose
HMO Network patterns/hmo-network-pattern.md Closed network, gatekeeper model
PPO Network patterns/ppo-network-pattern.md Open access, tiered cost sharing
Tiered Network patterns/tiered-network-pattern.md Quality-based tier assignment
Specialty Distribution patterns/specialty-distribution-pattern.md Specialty mix by geography
Pharmacy Benefit patterns/pharmacy-benefit-patterns.md PBM network configurations

Output Types

ProviderSearchResult

Provider records from NPPES database:

{
  "npi": "1234567890",
  "entity_type": "individual",
  "name": {
    "last": "Johnson",
    "first": "Sarah",
    "credential": "MD, FACC"
  },
  "taxonomy": {
    "code": "207RC0000X",
    "classification": "Internal Medicine",
    "specialization": "Cardiovascular Disease"
  },
  "practice_location": {
    "address": "123 Medical Center Dr",
    "city": "Houston",
    "state": "TX",
    "zip": "77030",
    "county_fips": "48201"
  },
  "enumeration_date": "2015-03-15",
  "last_update": "2024-11-01"
}

AdequacyAssessment

Network adequacy evaluation against standards:

{
  "geography": {
    "type": "state",
    "code": "CA",
    "name": "California"
  },
  "standard": "CMS_MA",
  "assessment_date": "2025-01-15",
  "metrics": {
    "pcp_ratio": {
      "actual": 85.3,
      "required": 83.3,
      "adequacy_pct": 102.4,
      "status": "ADEQUATE"
    },
    "specialist_coverage": {
      "ncqa_13_specialties": 13,
      "covered": 13,
      "status": "COMPLETE"
    }
  },
  "overall_status": "COMPLIANT"
}

HealthcareDesert

Desert identification with severity scoring:

{
  "geography": {
    "fips": "48001",
    "county": "Anderson County",
    "state": "Texas"
  },
  "desert_type": "primary_care",
  "severity": "critical",
  "scores": {
    "access_gap": 0.85,
    "health_burden": 0.72,
    "social_vulnerability": 0.68,
    "quality_gap": 0.45,
    "composite": 0.73
  },
  "indicators": {
    "providers_per_100k": 12.3,
    "hrsa_benchmark": 60.0,
    "diabetes_prevalence": 0.142,
    "svi_percentile": 0.78
  },
  "intervention_priority": 1
}

NetworkRoster

Exportable provider roster:

{
  "roster_id": "ROSTER-CA-PCP-2025-001",
  "generated_at": "2025-01-15T10:30:00Z",
  "criteria": {
    "specialty": "Primary Care",
    "geography": "San Diego County, CA",
    "quality_filter": "MD/DO only"
  },
  "summary": {
    "total_providers": 2847,
    "by_taxonomy": {
      "207Q00000X": 1523,
      "207R00000X": 892,
      "363L00000X": 432
    }
  },
  "export_formats": ["csv", "json", "xlsx"]
}

Data Sources

Provider Data (network.providers)

Attribute Value
Source NPPES (National Plan and Provider Enumeration System)
Records 8,925,672
Update Frequency Monthly CMS releases
Coverage All active US healthcare providers with NPIs
County FIPS 97.77% coverage (3,213 of 3,286 counties)

Key Columns: npi, entity_type_code, last_name, first_name, credential, taxonomy_1-4, practice_state, practice_city, practice_zip, county_fips

Facility Data (network.facilities)

Attribute Value
Source CMS Provider of Services (POS) file
Records 77,302
Types Hospitals (01), SNFs (05), HHAs (07), Hospice (13)
Coverage All CMS-certified healthcare facilities

Hospital Quality (network.hospital_quality)

Attribute Value
Source CMS Hospital Compare
Records 5,421 hospitals
Metrics Overall rating (1-5 stars), mortality, readmission, safety

Physician Quality (network.physician_quality)

Attribute Value
Source CMS Physician Compare
Records 1,478,309 physicians
Metrics Quality measures, Medicare participation

AHRF County Data (network.ahrf_county)

Attribute Value
Source HRSA Area Health Resources File
Records 3,235 counties
Metrics Provider counts, hospital beds, health workforce

Regulatory Standards

CMS Medicare Advantage

Provider-to-Enrollee Ratios:

Specialty Ratio Example (10K enrollees)
Primary Care 1:1,200 8.3 providers minimum
OB/GYN 1:2,000 5.0 providers
Mental Health 1:3,000 3.3 providers
General Surgery 1:5,000 2.0 providers

Time/Distance Standards:

Geography Primary Care Specialists Hospitals
Urban (>50K) 10 miles 15 miles 15 miles
Suburban 20 miles 30 miles 30 miles
Rural (<10K) 30 miles 60 miles 60 miles

NCQA 13 Essential Specialties

Must have at least one contracted provider in each:

  1. Primary Care
  2. Cardiology
  3. Dermatology
  4. Endocrinology
  5. Gastroenterology
  6. General Surgery
  7. Neurology
  8. OB/GYN
  9. Ophthalmology
  10. Orthopedic Surgery
  11. Otolaryngology (ENT)
  12. Psychiatry
  13. Urology

HRSA Benchmarks

Metric Threshold Classification
PCPs per 100K <60 Health Professional Shortage Area
PCPs per 100K 60-80 Adequate
PCPs per 100K >80 Well-served

Performance Benchmarks

Query Type Target Actual Status
Provider search <100ms 13.8ms ✅ Excellent
NPI validation <50ms 18.8ms ✅ Excellent
Provider density <100ms 46.9ms ✅ Good
Network adequacy <300ms ~200ms ✅ Good
Healthcare deserts <500ms ~400ms ✅ Good
Cross-product JOIN <500ms ~300ms ✅ Good

Database: healthsim.duckdb (1.7 GB) Indexes: county_fips, taxonomy_1, practice_state

Cross-Product Integration

NetworkSim → PatientSim

Assign providers to clinical encounters:

-- Find cardiologist for heart failure patient
SELECT npi, first_name, last_name, credential
FROM network.providers
WHERE taxonomy_1 LIKE '207RC%'  -- Cardiovascular
  AND practice_state = 'TX'
  AND county_fips = '48201'     -- Harris County
LIMIT 1;

NetworkSim → MemberSim

Determine network status for claims:

-- Check if provider is in network
SELECT 
  CASE WHEN p.npi IS NOT NULL THEN 'IN_NETWORK' 
       ELSE 'OUT_OF_NETWORK' END as network_status
FROM network.providers p
WHERE p.npi = '1234567890';

NetworkSim + PopulationSim

Equity analysis combining provider access with vulnerability:

-- Provider access in vulnerable communities
SELECT 
    sv.county,
    sv.rpl_themes as svi_percentile,
    COUNT(DISTINCT p.npi) as provider_count,
    sv.e_totpop as population,
    ROUND(COUNT(DISTINCT p.npi) * 100000.0 / sv.e_totpop, 1) as per_100k
FROM population.svi_county sv
LEFT JOIN network.providers p ON sv.stcnty = p.county_fips
WHERE sv.rpl_themes > 0.75  -- Most vulnerable quartile
GROUP BY sv.county, sv.rpl_themes, sv.e_totpop
ORDER BY per_100k ASC;

Development Status

Phase 1: Data Infrastructure ✅

  • NPPES data import (8.9M providers)
  • Geographic enrichment (97.77% county FIPS)
  • Quality metrics integration (CMS Hospital Compare)
  • Test framework (18 tests passing)

Phase 2: Query Skills ✅

  • 9 query skills (provider, facility, pharmacy, NPI, roster, density, coverage, quality)
  • 4,069 lines documentation

Phase 3: Advanced Analytics 🎯 (Current)

  • Network adequacy analysis
  • Healthcare deserts identification
  • Specialty distribution analysis
  • Provider demographics analysis

Progress: 8 of 12 sessions complete (66%)

Validation Rules

NPI Validation

  • 10 digits exactly
  • Luhn algorithm checksum
  • Prefix 1 or 2 (individual vs organization)
  • Active status in NPPES

Taxonomy Validation

  • Valid NUCC taxonomy codes
  • Matches provider specialty claim
  • Primary taxonomy switch indicator

Geographic Validation

  • Valid state abbreviation (2 letters)
  • Valid county FIPS (5 digits)
  • ZIP code format (5 or 9 digits)

Related Documentation

Last Updated: December 28, 2025 Version: 2.0.0 Status: Active (Phase 3)