System and method for administering health care cost reduction

• US 20050222867A1
• Filed: 03/31/2004
• Published: 10/06/2005
• Est. Priority Date: 03/31/2004
• Status: Active Grant

• Current Assignee: Aetna Incorporated (CVS Health Corporation)
• Original Assignee: Aetna Incorporated (CVS Health Corporation)
• Inventors: Underwood, Howard R., Kastenschmidt, Walter
• Granted Patent: US 7,693,728 B2
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A system and method for the efficient administration of health care plans, particularly as to the reduction and/or elimination of avoidable medical costs for select individuals who participate in the plan, is disclosed. Existing health care data is processed to determine an indication as to the relative desirability of an intervention in a plan participant'"'"'s health care regimen. The data is also processed to determine the status of one or more flags, each of which potentially indicates the relative desirability of an intervention in a plan participant'"'"'s health care regimen. A predictive model is used to determine the status of a flag relating to the likelihood of an insurance plan participant making a disability claim within a certain period of time. The information relating to desirability of an intervention in a plan participant'"'"'s health care regimen, as well as a plan participant'"'"'s medical information and claim history, is presented to case managers and/or health care providers in a user-friendly format

Claims

1. A method for administering reductions in health care costs for those participants in a health insurance plan for whom future health care costs may be reduced through intervention (“

intervention candidates”

) comprising;

determining a first score for an intervention candidate, which first score reflects the predicted utilization of future health care services;

determining a second score for the intervention candidate, which second score depends on the intervention candidate'"'"'s prior consumption of a plurality of predetermined health care services;

comparing the first score against a first threshold value and the second score against a second threshold value and generating a result of such comparison;

providing to select individuals access to the health care history of the intervention candidate and the result of the comparison; and

intervening in the health care regimen of the intervention candidate depending on the result of the comparison.

2. The method of claim 1, wherein the second score is determined by adding a plurality of values, each of which represents the intervention candidate'"'"'s consumption of a different health care service.

3. The method of claim 2, wherein one of the plurality of values represents the amount of medical claims allowed.

4. The method of claim 2, wherein one of the plurality of values is selected from the group consisting of:

a value representing the number of medical specialists that treated the candidate, a value representing the number of inpatient admissions, a value representing the number of chronic diseases for which the candidate was treated, a value representing the number of prescriptions for unique drugs, or a value representing the number of emergency room visits without admission in a hospital.

5. The method of claim 1, wherein the plurality of predetermined health care services includes one health care service selected from the group consisting of:

treatment by a medial specialists, inpatient admissions, treatment for a chronic diseases, prescriptions for unique drugs, and emergency room visits without admission in a hospital.

6. The method of claim 1, wherein the step of generating a result includes generating a first result that indicates whether the first score exceeds the first threshold value, a second result that indicates whether the second score exceeds the second threshold value, and a composite result that represents both the first and second results.

7. The method of claim 1, wherein the step of intervening in the health care regimen of a candidate occurs only if the result of comparison indicates that the first score exceeds the first threshold value and a second result that indicates whether the second score exceeds the second threshold value.

8. The method of claim 1, wherein the step of intervening includes causing a health care provider to contact a candidate in order to recommend a change in the candidate'"'"'s health care regimen.

9. The method of claim 8, wherein the recommendation includes that the candidate increase physical activity and cardiorespiratory fitness.

10. The method of claim 8, wherein the recommendation includes that the candidate switch prescriptions from a brand name drug to a generic drug.

11. The method of claim 8, wherein the recommendation includes that the candidate enter a substance abuse program.

12. The method of claim 8, wherein the recommendation includes that the candidate consult a mental health practitioner.

13. The method of claim 1 further including the step of generating a plurality of flags, wherein each flag has a status that represents health information of an intervention candidate.

14. The method of claim 13, wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan.

15. The method of claim 1, wherein the second score indicates the potential for health care cost reduction of the candidate as determined relative to other participants in the health insurance plan.

16. The method of claim 1, wherein the step of providing health care providers with access to the health care history is carried out by an Internet server that provides information that may be displayed on an Internet browser.

17. The method of claim 16, wherein the information that may be displayed on an Internet browser includes a plurality of flags, wherein each flag has a status that represents health information of an intervention candidate.

18. The method of claim 17, wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan.

19. A method for administering reductions in health care costs comprising:

storing in at least one database health information relating to a plurality of health insurance plan participants;

identifying from stored health information candidates for whom health care costs may be reduced through intervention (“

intervention candidates”

);

generating a plurality of flags for each intervention candidate, wherein each flag has a status that represents a health condition of an intervention candidate;

storing the health information and flags for each intervention participant in an separate database; and

permitting select individuals to retrieve and display via a graphical user interface each intervention candidate'"'"'s health information and flags as stored in the separate database.

20. The method of claim 19, wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan.