COMPUTER SYSTEM AND METHOD FOR GENERATING HEALTHCARE RISK INDICES USING MEDICATION COMPLIANCE INFORMATION

• US 20100228570A1
• Filed: 05/24/2010
• Published: 09/09/2010
• Est. Priority Date: 10/22/2003
• Status: Active Grant

• Current Assignee: Express Scripts Strategic Development, Inc. (The Cigna Group)
• Original Assignee: Medco Health Solutions Incorporated (The Cigna Group)
• Inventors: Fulop, George, Andrews, Kurtis W., Qian, Qingshan, Bradbury, Keith J., Boscarino, Joseph A., McGuigan, Kimberly A., Maldonato, Debra A.
• Granted Patent: US 8,762,164 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

A healthcare risk index is generated using a patient or individual'"'"'s pharmacy claims. The index may be used to explain and predict variation in pharmacy-related costs and variation in total healthcare costs or utilization. In particular, the index is generated by first examining the individual'"'"'s pharmacy claims to identify any chronic conditions possessed by the individual. Similarly, the individual'"'"'s pharmacy claims are examined to identify any compliance medications prescribed to the individual. The chronic condition information is used to generate a chronic condition score by summing regression coefficients for each chronic condition possessed by the individual. Likewise, the compliance medication information is used to generate a compliance medication score by summing products of regression coefficients for each compliance medication prescribed to the individual with associated medication supply weights. From there, a modified chronic condition score is generated by multiplying the chronic condition score by an overall chronic condition regression coefficient. The modified chronic condition score may then be further modified by subtracting a no-claims weight from the chronic condition score in cases where the individual has no pharmacy claims. Finally, the risk index may be determined by summing the modified chronic condition score and the compliance medication score.

Claims

1. A computer implemented method for generating a risk index for an individual using said individual'"'"'s pharmacy claims, said method comprising the steps of:

(1) generating, by a computer, a raw risk index indicative of at least one of said individual'"'"'s medical costs, acute medical conditions, and variation in medical costs, by using said pharmacy claims; and

(2) modifying, by the computer, said raw risk index in accordance with a compliance medication score indicative of said individual'"'"'s compliance with prescribed pharmaceuticals, to thereby generate said risk index.

2. The method of claim 1, wherein said compliance medication score is determined by summing a total supply of a compliance medication prescribed to said individual and multiplying by a regression coefficient.

3. The method of claim 2, wherein said regression coefficient is generated from a log transform.

4. The method of claim 2, wherein said regression coefficient is generated from a square-root transform.

5. The method of claim 1, wherein said compliance medication score represents said individual'"'"'s compliance for an associated compliance medication.

6. The method of claim 1, wherein said pharmacy claims are obtained from the pharmacy claims database managed by at least one of a managed care organization, a pharmacy benefits manager, or a human resources department.

7. The method of claim 1, further comprising the step of determining variation in at least one of estimated total healthcare costs and utilization by the patient.

8. The method of claim 1, wherein if said individual has no pharmacy claims, an indicator relating to said patient'"'"'s compliance with a prescribed medication is set to indicate that there was no use of said prescribed medication.

9. A computer system for generating a risk index for an individual using said individual'"'"'s pharmacy claims, said system comprising:

means, by a computer, for generating a raw risk index indicative of at least one of said individual'"'"'s medical costs, acute medical conditions, and variation in medical costs, by using said pharmacy claims; and

means, by the computer, for modifying said raw risk index in accordance with a compliance medication score indicative of said individual'"'"'s compliance with prescribed pharmaceuticals, to thereby generate said risk index.

10. The system of claim 9, further comprising means for determining said compliance medication score by summing a total supply of a compliance medication prescribed to said individual and multiplying by a regression coefficient.

11. The system of claim 10, wherein said regression coefficient is generated from a log transform.

12. The system of claim 10, wherein said regression coefficient is generated from a square-root transform.

13. The system of claim 9, wherein said compliance medication score represents said individual'"'"'s compliance for an associated compliance medication.

14. The system of claim 9, wherein said pharmacy claims are obtained from the pharmacy claims database managed by at least one of a managed care organization, a pharmacy benefits manager, or a human resources department.

15. The method of claim 9, further comprising means for determining variation in at least one of estimated total healthcare costs and utilization by the patient.

16. The method of claim 9, further comprising, when said individual has no pharmacy claims, an indicator relating to said patient'"'"'s compliance with a prescribed medication that is set to indicate that there was no use of said prescribed medication.

17. A computer implemented method for generating a risk index for an individual using said individual'"'"'s medical information, said method comprising the steps of:

(1) generating, by a computer, a raw risk index indicative of at least one of said individual'"'"'s medical costs, acute medical conditions, and variation in medical costs, by using said medical information; and

(2) modifying, by the computer, said raw risk index in accordance with a compliance medication score indicative of said individual'"'"'s compliance with prescribed pharmaceuticals, to thereby generate said risk index.

18. The method of claim 17, wherein said compliance medication score is determined by summing a total supply of a compliance medication prescribed to said individual and multiplying by a regression coefficient.

19. The method of claim 18, wherein said regression coefficient is generated from a log transform.

20. The method of claim 18, wherein said regression coefficient is generated from a square-root transform.

21. The method of claim 17, wherein said compliance medication score represents said individual'"'"'s compliance for an associated compliance medication.

22. The method of claim 17, wherein said medical information is obtained from the medical information database managed by at least one of a managed care organization, a pharmacy benefits manager, health benefits manager or a human resources department.

23. The method of claim 17, further comprising the step of determining variation in at least one of estimated total healthcare costs and utilization by the patient.

24. The method of claim 17, wherein if said individual has no pharmacy claims, an indicator relating to said patient'"'"'s compliance with a prescribed medication is set to indicate that there was no use of said prescribed medication.