System and method for management of health care services

• US 20030009355A1
• Filed: 03/20/2002
• Published: 01/09/2003
• Est. Priority Date: 03/21/2001
• Status: Active Grant

• Current Assignee: Company Acquisition LLC (Hillenbrand Incorporated)
• Original Assignee: Company Financial
• Inventors: Gupta, Amit K.
• Granted Patent: US 7,493,266 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management

Abstract

The present invention is a system and method for management of consumer services such as health care services which combines new financial structure for health insurance and health benefit plan, payment methods, health plan design, benefit development algorithms, unique procurement methods for health care benefits with and without application to an individual consumer'"'"'s personal state of health, and is integrated with financial services and asset management products, and benefits for an individual consumer'"'"'s future medical and/or retirement savings, for healthcare needs. The method and system employs a combination of the defined benefit and defined contribution approaches which combination is referred to herein as “defined-care.” Defined-care model or the healthcare asset management model has two primary components, one which is referred to herein as a “health management and retirement account”, and the other of which is an infrastructure “connected portal” that interfaces through a technology platform with the health management and retirement accounts and the account holders. The foundation of this infrastructure according to the present invention is a technology platform across which a variety of processes are implemented. In the technology platform for the infrastructure of the present invention, the conventional processes and the new processes are integrated, thereby allowing a change to one process to be adopted by or otherwise accommodated by the other processes.

Claims

1. A system for managing health care assets with a plurality of management strategies comprising:

means for establishing an account for at least one individual;

means for determining an appropriate amount of a defined contribution to establish a health care asset for at least one individual in the account;

means for determining a proportion of the defined contribution to be allocated for certain mandatory health care benefits; and

means for offering the at least one individual a selection of optional health care benefits the cost of which may be offset in whole or in part by the amount of the defined contribution remaining in the account after the amount of the defined contribution to be allocated for the mandatory health care benefits is deducted.

2. The system of claim 1 further comprising means for providing the at least one individual with descriptive information and advice concerning the optional health care benefits.

3. The system of claim 1 further comprising means for permitting the at least one individual to invest a proportion of the amount in the account.

4. The system of claim 1 further comprising means for accessing the account over the Internet.

5. The system of claim 1 wherein the means for determining an appropriate amount of the defined contribution includes determining certain mandatory health care benefits for each of the plurality of consumers based on the population group and individual health risk level associated with each of the plurality of consumers.

6. A system for managing health care comprising:

means for communicating between at least one consumer of health care services and other stakeholders in health care services, the other stakeholders including at least one health care benefits plan and insurer, at least one health care provider, at least one contributor of a defined contribution to the at least one consumer;

the means for communication further comprising;

means for insuring compliance with government regulation or other rules affecting items in the group including the administration of health care benefits, the provision of health care services, and the management of data concerning consumers of health care benefits and health care transactions associated with the same;

means for determining eligibility of the at least one consumer for a particular health care service to be provided by the at least one health care provider; and

means for processing claims on behalf of the at least one consumer for payment of or reimbursement for the particular health care service provided by the at least one health care provider.

7. The system of claim 6, wherein the means for communication further includes means for paying the at least one health care provider at the time of delivery of the particular health care service.

8. The system of claim 6, wherein the means for communicating is implemented via a network configured as an Intranet between the at least one consumer and the other stakeholders.

9. The system of claim 6, wherein the means for communicating is implemented via a network configured to interface over the Internet between the at least one consumer and the other stakeholders.

10. The system of claim 6, wherein the at least one consumer of health care services is an employee and the at least one contributor of a defined contribution to the at least one consumer is the employee'"'"'s employer.

11. A computer program product comprising for use with a system for managing health care comprising:

a computer usable medium, having program code embodied in the medium for causing the computer system to interface over a communications medium such as the Internet or another network between at least one consumer of health care services and other stakeholders in health care services, the other stakeholders including at least one health benefits plan, at least one health care services provider, wherein the program code;

recognizes a total health care asset amount corresponding to and unique to the at least one consumer;

allocates a proportion of the total health care asset amount for certain mandatory health care benefits;

determines the cost of the mandatory health care benefits;

permits the at least one consumer to select from optional health care benefits;

calculates the cost of any optional health care benefits selected; and

deducts the cost of the mandatory health care benefits from the total health care asset amount and, if there is a remainder, queries the at least one consumer as to whether the remainder or a portion thereof should be applied to the cost of any optional health care benefits selected.

15. The method of claim 14 wherein said health trust fund includes an individual trust fund for each of said one or more employees and further comprising the step of:

establishing an individual health care savings account for each of said one or more employees, said individual health care savings account being funded with a dividend based on each of said one or more employees'"'"' use of said individual trust fund.

16. The method of claim 15 further comprising the steps of:

receiving employee health information from said one or more employees;

determining an individual health risk level from said employee health information; and

determining a defined care pathway for each of said one or more employees from said employee health information,

wherein said dividend is further based on said one or more employees following said defined care pathway.

17. The method of claim 15 further comprising the step of:

determining supplementary benefits for said one or more employees, wherein a cost for said supplementary benefits being offset in whole or in part by said individual health care savings account.

18. The method of claim 17 wherein said supplementary benefits include one or more care packages selected from the group consisting of medical, dental and vision.

19. The method of claim 17 wherein said supplementary benefits include one or more prevention packages selected from the group consisting of medical, dental and vision.

20. The method of claim 17 wherein said supplementary benefits include value-added benefit packages.

21. The method of claim 17 wherein said supplementary benefits include one or more health reward programs.

22. The method of claim 14 further comprising the steps of:

determining an occupational injury risk level; and

determining benefits for said occupational injury risk level.

24. The system of claim 23 wherein said health trust fund includes an individual trust fund for each of said one or more employees and further comprising means for establishing an individual health care savings account for each of said one or more employees, said individual health care savings account being funded with a dividend based on each of said one or more employees'"'"' use of said individual trust fund.

25. The system of claim 24 further comprising:

means for receiving employee health information from said one or more employees;

means for determining an individual health risk level from said employee health information; and

means for determining a defined care pathway for each of said one or more employees from said employee health information,

wherein said dividend is further based on said one or more employees following said defined care pathway.

26. The system of claim 24 further comprising:

means for determining supplementary benefits for said one or more employees, a cost for said supplementary benefits being offset in whole or in part by said individual health care savings account.

27. The system of claim 24 further comprising:

means for determining an occupational injury risk level; and

means for determining benefits for said occupational injury risk level.

29. The method of claim 28 further comprising the step of:

insuring compliance with government regulation or rules affecting said health care benefits or optional health care benefits.

30. The method of claim 28 wherein said HMRA is funded with one or more contributions selected from the group consisting of employer up-front contributions at a beginning of a year;

employer incentive dividend at an end of the year and employee contribution from pre or post tax dollars.

31. The method of claim 28 wherein said mandatory health care benefit is catastrophic insurance from an insurance company with a high-deductible health plan policy.

32. The method of claim 31 wherein the high-deductible health plan policy has a deductible of at least $1000 for a single coverage or $2000 for family coverage.

33. The method of claim 28 wherein said mandatory health care benefit is catastrophic insurance from a re-insurance or property/casualty insurance provider with a health plan policy underwritten with a stop-loss at a predetermined high-deductible amount.

34. The method of claim 33 wherein the high-deductible amount is at least $1000 for a single coverage or $2000 for family coverage.

35. The method of claim 28 wherein said integrated health care technology platform further includes determining a defined care integrated pathway for said one or more employees;

and

determining a plan for providing said health care of said one or more employees based on said defined care integrated pathway.

36. The method of claim 35 wherein said defined care integrated pathway is determined by employee information entered at said employee interface.

37. The method of claim 36 wherein said defined care integrated pathway is designed by information from one or more of reference information, clinical information, medical board information and news information.

38. The method of claim 35 wherein said defined care integrated pathway determines access to health care services for diagnosis, treatment and/or prevention of health conditions.

39. The method of claim 37 wherein payment for said health care services are made through said HMRA.

40. The method of claim 28 wherein said employee interface is a web site and further comprising the step of:

said one or more employees accessing one or more of health information, benefit information, financial information and information of said HMRA from said web site.

41. The method of claim 28 wherein said integrated health care technology platform includes an employer interface, said employer interface is a web site and further comprising the step of:

said employer accessing one or more of a carrier for said mandatory health care benefits;

a defined integrated pathway or optional value-added benefits.

12. A method of managing the health care assets of a plurality of consumers of health care services comprising:

maintaining a database containing statistical information that permits characterization of consumers of health care services into population groups based on factors in the group including sex, age and occupation and that permits characterization of a consumer'"'"'s individual health risk level based on factors in the group including personal risk factors and prior and existing medical conditions;

acquiring information about each of the plurality of consumers;

determining, using the database, a total defined contribution amount to be allocated in an account for each of the plurality of consumers;

determining certain mandatory health care benefits for each of the plurality of consumers based on the population group and individual health risk level associated with each of the plurality of consumers;

determining the cost of the mandatory health care benefits and calculating the difference between the total defined contribution amount and the mandatory health care benefits to identify a defined contribution remainder in each of the plurality of consumers'"'"' accounts;

offering each of the plurality of consumers optional health care benefits for purchase;

if a consumer selects an optional health care benefit, determining the cost of the optional health care benefit;

calculating, for a given optional health care benefit selected by each of the plurality of consumers, whether all or a portion of the cost of the optional health care benefit can be offset by the defined contribution remainder; and

reporting the result of the calculation to each of the plurality of consumers.

13. A method of establishing an infrastructure for the management of health care services comprising:

establishing a technology platform over which a plurality of consumers of health care services can communicate with contributors of defined contribution health care assets for the plurality of consumers and with other stakeholders in health care benefits, the other stakeholders including health care plans and health care providers;

administering the technology platform so that all entities which interface with it remain compliant with government regulations and other appropriate rules affecting the management of health care services; and

maintaining a database which receives and provides information to those in communication with the technology platform which information regards health care statistics relating to the plurality of consumers and the health care transactions of the plurality of consumers.

14. A method of management of health care services comprising:

receiving employee census information from one or more employees;

determining catastrophic care coverage for each of said one or more employees from said census information;

determining a health trust fund for funding said catastrophic care coverage for each of said one or more employees; and

funding said health trust fund up to a deductible of a high-deductible insurance policy with premium savings received by an employer purchasing said high-deductible insurance policy.

23. A system of management of health care services comprising:

means for receiving employee census information from one or more employees;

means for determining catastrophic care coverage for each of said one or more employees from said census information;

means for determining a health trust fund for funding said catastrophic care coverage for each of said one or more employees; and

means for funding said health trust fund up to a deductible of a high-deductible insurance policy with premium savings received by an employer purchasing said high-deductible insurance policy.

28. A method for managing health care comprising the steps of:

providing an employee interface to a uniform health management system;

establishing a health management and retirement account (HMRA) for one or more employees, said health management and retirement account providing funding of health care; and

providing an integrated health care technology platform for providing deliverance of said funding from said HMRA to a health care provider or insurance provider, establishing mandatory health care benefits and optional health care benefits for each of said one or more employees and providing administration of said funding, mandatory health care benefits and optional health care benefits.

42. A system for managing health care comprising:

means for providing an employee interface to a uniform health management system;

means for establishing a health management and retirement account (HMRA) for one or more employees, said health management and retirement account providing finding of health care; and

means for providing an integrated health care technology platform for providing deliverance of said funding from said HMRA to a health care provider or insurance provider, establishing mandatory health care benefits and optional health care benefits for each of said one or more employees and providing administration of said funding, mandatory health care benefits and optional health care benefits.

43. The system of claim 42 further comprising the step of:

means for insuring compliance with government regulation or rules affecting said health care benefits or optional health care benefits.

44. The system of claim 42 wherein said HMRA is funded with one or more contributions selected from the group consisting of employer up-front contributions at a beginning of a year;

employer incentive dividend at an end of the year and employee contribution from pre or post tax dollars.

45. The system of claim 42 wherein said mandatory health care benefit is catastrophic insurance from an insurance company with a high-deductible health plan policy.

46. The system of claim 45 wherein the high-deductible health plan policy has a deductible of at least $1000 for a single coverage or $2000 for family coverage.

47. The system of claim 42 wherein said mandatory health care benefit is catastrophic insurance from a re-insurance or property/casualty insurance provider with a health plan policy underwritten with a stop-loss at a predetermined high-deductible amount.

48. The system of claim 47 wherein the high-deductible amount is at least $1000 for a single coverage or $2000 for family coverage.

49. The system of claim 42 wherein said integrated health care technology platform further includes:

means for determining a defined care integrated pathway for said one or more employees; and

means for determining health care of said one or more employees based on said defined care integrated pathway.

50. The system of claim 49 wherein said defined care integrated pathway is determined by employee information entered at said employee interface.

51. The system of claim 50 wherein said mandatory health care benefits are determined from census information entered by one or more employees at said employee interface.

52. The system of claim 51 wherein said employee information for determining said defined care integrated pathway includes one or more of known personal risk factors, allergies, medications and medical conditions.

53. The system of claim 52 wherein said census information is stored in a first database and said employee information for determining said defined integrated pathway is stored in a second database.

54. The system of claim 53 wherein said first database and said second database are connected algorithmically or cryptographically to one another, said employee having sole authority for access and connectivity to said census information and said employee information for determining said defined care integrated pathway.

55. The system of claim 53 wherein said first and said second database provide compliance with government regulation or other rules affecting said system for managing health care.

56. The system of claim 49 wherein said defined care integrated pathway is designed by information from one or more of reference information, clinical information, medical board information and news information.

57. The system of claim 49 wherein said defined care integrated pathway determines access to health care services for diagnosis, treatment and/or prevention of health conditions.

58. The system of claim 57 wherein payment for said health care services are made through said HMRA.

59. The system of claim 42 wherein said integrated health care technology platform includes an employer interface, said employer interface is a website or software interface and said website software interface comprising means for said employer to access one or more of a carrier for said mandatory health care benefits;

a defined integrated pathway or optional value-added benefits.

60. The system of claim 42 wherein said employee interface is a website or software interface and said website comprising means for said one or more employees to access one or more of health information, benefit information, financial information and information of said HMRA from said web site.

61. The system of claim 60 wherein said website or software interface further provides an active health monitor to alert or remind said one or more employees of scheduled health care services.

62. The system of claim 42 wherein said integrated health care technology platform further comprises means for claims adjudication.

63. The system of claim 42 wherein said integrated health care technology platform further comprises means for providing reports on utilization of services by said one or more employees.

64. The system of claim 42 wherein said integrated health care technology platform further comprises data storage for storing payment transactions for said mandatory health care benefits and optional health care benefits.

65. The system of claim 42 wherein said integrated health care technology platform further comprises means for aggregating said employee census information from said one or more employees.

66. The system of claim 42 wherein said integrated health care technology platform provides an interface for submission of clean claims between said integrated healthcare technology platform and a healthcare provider.

67. The system of claim 66 wherein said interface for submission of clean claims provides compliance with government regulation or other rules affecting said system for managing health care.

68. The system of claim 42 wherein said integrated health care technology platform provides an interface for submission of manual claims between said integrated healthcare technology platform and a healthcare provider.

69. The system of claim 68 wherein said interface for submission of manual claims provides compliance with government regulation or other rules affecting said system for managing health care.

70. The system of claim 42 wherein said integrated health care technology platform includes means for determining an eligibility verification of said one or more employees at a point of care service provider.

71. The system of claim 42 further comprising:

a universal HMRA policy card associated with said HMRA, said HMRA policy card including means for providing payment of health care services.

72. The system of claim 71 wherein said means for providing payment of health care services is a payment network selected from the group consisting of:

a check clearance network, a credit card clearance network, ATM network, Internet network, private network and public network.

73. The system of claim 71 wherein said universal HMRA policy card further comprises means for storing data.

74. The system of claim 73 wherein said means for storing data stores data of medical information related to authentication and privileges assigned by said one or more employees for access to information by other health care stakeholders for receiving a service at a point-of-care service provider.

75. The system of claim 73 wherein said means for storing data stores data on said mandatory health care benefits and said optional health care benefits and administration of said mandatory health care benefits and said optional health care benefits.

76. The system of claim 73 wherein said means for storing data stores a medical record of said employee using said universal HMRA policy card.

77. The system of claim 42 wherein said integrated health care technology platform further comprises means for determining a future health risk liability for said one or more employees by means of evidence-based medicine technologies and information.

78. The system of claim 77 wherein said future health risk liability is used in determining a potential cost liability associated with meeting said future health risk liability by use of funds in said HMRA.

79. The system of claim 78 further comprising means for advising said one or more employees of an appropriate investment of contributions into said HMRA for meeting said potential cost liability.