Mass customization for management of healthcare

• US 20060178915A1
• Filed: 02/21/2003
• Published: 08/10/2006
• Est. Priority Date: 10/18/2002
• Status: Active Grant

• Current Assignee: Medimpact Healthcare Systems Incorporated
• Original Assignee: Medimpact Healthcare Systems Incorporated
• Inventors: Chao, Schumarry
• Granted Patent: US 8,799,023 B2
• Time in Patent Office: Days
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/0207 Discounts or incentives, e.g. coupons or rebates
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

A healthcare mass customization infrastructure individualizes plan designs by incorporating demographics, income, drug history, medical history, lab values, and future genomic information for appropriate and affordable access to medications. The mass customization infrastructure results in quality outcomes for the patients, improved care and productivity for the providers, and lower medical costs for the payers.

Claims

1. A method for providing appropriate and affordable healthcare to a participant of a health plan, the method comprising the steps of:

retrieving a plurality of data from data resources, the data resources comprising;

partner data;

provider data, and

participant data, wherein the participant data comprises a medical history of the participant, a demographic status of the participant, and income data of the participant;

analyzing the plurality of data from the data resources;

prescribing appropriate medications for the participant based upon the analysis of the plurality of data;

determining an affordable co-payment for the participant based upon the analysis of the plurality of data; and

providing the appropriate medications to the participant at a cost of the affordable co-payment.

2. The method of claim 1, wherein the appropriate medications comprises appropriate medications and treatments.

3. The method of claim 1, wherein the step of analyzing the plurality of data further comprises the steps of:

determining a plurality of benefits of the health plan for the participant;

predicting utilization of the plurality of benefits of the health plan over a time period;

tracking actual benefits utilization;

comparing the predicted utilization with the actual benefits utilization to obtain a comparison result; and

adjusting the plurality of benefits based upon the comparison result.

4. The method of claim 3, wherein the period of time for predicting utilization of the plurality of benefits is a year.

5. The method of claim 3, wherein the step of adjusting the benefits further comprises the step of:

providing incentives for the participant to encourage a change in healthcare behavior.

6. The method of claim 5, wherein the step of providing incentives comprises lowering the affordable co-payment if the participant is not purchasing the prescribed appropriate medications.

7. The method of claim 1, wherein the medical history of the participant comprises a past medical history of the participant, a current health status of the participant, and a current treatment and medication status of the participant.

8. The method of claim 1, further comprising the step of:

providing incentives for the participant to purchase the appropriate medications at the cost of the affordable co-payment.

9. The method of claim 8, wherein the incentives comprise at least one coupon having a value determined by the analysis of the plurality of data, wherein the coupon is used for purchasing the appropriate medications.

10. The method of claim 1, wherein the step of retrieving the plurality of data further comprising the step of:

updating the plurality of data periodically.

11. A mass customization system for managing healthcare of a plurality of participants, the plurality of participants receiving the healthcare from a plurality of providers in cooperation with a plurality of payers and a plurality of partners, the mass customization system comprising:

a plurality of data resources comprising partner data, provider data, and participant data;

a healthcare data platform for receiving data from the plurality of data resources, the healthcare data platform having a data analyzer for mining the data, and performing statistical analyses and simulations on the data to obtain usable healthcare data;

a claims processing rules generator coupled to a data warehouse and the healthcare data platform for establishing individual healthcare benefits rules for each participant of the plurality of participants based upon the usable healthcare data;

the data warehouse for storing the data, the usable healthcare data and the individual healthcare benefits rules; and

an interface platform for providing the plurality of participants, the plurality of providers, the plurality of payers, and the plurality of partners access to the data warehouse and the individual healthcare benefits rules for the each participant.

12. The mass customization system of claim 11, wherein the plurality of providers comprises physicians, pharmacists, and hospitals;

wherein the plurality of payers comprises employers and insurance entities; and

wherein the plurality of partners comprises medical and pharmaceutical manufacturers.

13. The mass customization system of claim 11, wherein the participant data comprises a medical history of the each participant, a demographic status of the each participant, and income data of the each participant, wherein the individual healthcare benefits rules of the each participant comprises:

a co-payment amount associated with each prescription generated by a provider of the plurality of providers, the co-payment amount specifying a cost for the each participant when purchasing a medication of the each prescription;

wherein the co-payment amount is based upon the medical history of the each participant, the demographic status of the each participant, and the income data of the each participant.

14. The mass customization system of claim 13, further comprising:

a point of sale benefits manager coupled to the data warehouse, the point of sale benefits manager for providing a link between a point of sale of the each prescription and the data warehouse.

15. The mass customization system of claim 11, further comprising:

a special programs manager coupled to the data warehouse and accessible to the plurality of providers through an interface, the special programs manager for reviewing the usable healthcare data and for flagging those participants of the plurality of participants requiring additional care from the plurality of providers.

16. The mass customization system of claim 15, wherein the special programs manager manages the healthcare of at least one population comprising at least one participant of the plurality of participants.

17. The mass customization system of claim 16, wherein the at least one population comprises at least one of a catastrophic outlier population, a special population, a chronically ill population, an acutely ill population, and a well population.

18. The mass customization system of claim 11, further comprising:

a prescription and claims manager for managing claims between the plurality of providers and the plurality of payers.

19. The mass customization system of claim 11, further comprising:

a smart card interface for receiving smart card data from a smart card and updating the smart card data on the smart card;

wherein the smart card data is at least one of the participant data, the individual healthcare benefits rules, and a monetary amount determined by the claims processing rules generator, the monetary amount for purchasing medications prescribed by a provider of the plurality of providers.

20. A system for implementing mass customization healthcare for a plurality of patients, at least one provider, and at least one payer, the system comprising:

a technology unit for processing and storing healthcare data from disparate sources to produce usable healthcare data, wherein processing comprises mining, analyzing, simulating, forecasting and decision making, and wherein the healthcare data comprises patient data, provider data, and payer data, the technology unit generating and storing a healthcare plan for each individual patient of the plurality of patients based upon the usable healthcare data;

a financial unit for updating the healthcare plan for the each individual patient and for generating a plurality of healthcare plan rules for the each individual patient based upon the usable healthcare data, wherein the plurality of healthcare plan rules comprises a co-payment amount, the co-payment amount generated by the financial unit based upon an appropriateness of a medication prescribed by the at least one provider and the each individual patient'"'"'s ability to pay as determined by the financial unit from the patient data; and

a communications unit for providing communications between the plurality of patients, the at least one provider, the at least one plan sponsor, the financial unit, and the technology unit.

21. The system for implementing mass customization healthcare as in claim 20, further comprising:

a risk unit for managing risk of the at least one payer, the at least one payer comprising captive insurance companies.

22. A method for delivering appropriate and affordable healthcare to a participant, comprising the steps of:

determining an individualized health plan for the participant based upon a plurality of data comprising the participant'"'"'s medical history and the participant'"'"'s income;

generating a prescription for the participant;

determining an appropriateness of the prescription for the participant based upon the plurality of data and third party data, wherein the third party data comprises pharmaceutical data;

determining a co-payment amount for the participant based upon the appropriateness of the prescription and the participant'"'"'s income; and

providing the participant with the prescription upon receipt of the co-payment amount from the participant.

23. The method for delivering appropriate and affordable healthcare as in claim 22, wherein the third party data further comprises at least one of clinical trials, federal drug administration data, medical outcomes, and clinical protocols.

24. The method for delivering appropriate and affordable healthcare as in claim 22, wherein the plurality of data further comprises at least one of the patient'"'"'s pharmacy history, the patient'"'"'s lab results, and the patient'"'"'s genomics.

25. The method for delivering appropriate and affordable healthcare as in claim 22, further comprising the step of:

providing a coupon to the participant, wherein the coupon covers at least a portion of the co-payment amount.

27. The method of delivering quality healthcare as in claim 25, wherein the sickness coefficient is determined from a plurality of data gathered for the at least one population, the plurality of data comprising at least one of:

best practice information for the at least one population,

clinical studies of the at least one population,

average lengths of stays of the at least one population, and

quality assessment risks for the at least one population.

26. A method of delivering quality healthcare to a plurality of patients that are grouped in at least one population, the method comprising the step of:

determining a rating for a physician responsible for care of a patient of the plurality of patients based on a score which is adjusted by a sickness coefficient of the at least one population to which the patient belongs; and

providing incentives to the physician based upon the rating, wherein the incentives motivate the physician to provide the quality healthcare.