METHOD OF OPTIMIZING HEALTHCARE SERVICES CONSUMPTION

• US 20140249842A1
• Filed: 05/15/2014
• Published: 09/04/2014
• Est. Priority Date: 12/06/2002
• Status: Abandoned Application

• Current Assignee: Quality Healthcare Intermediary LLC
• Original Assignee: Quality Healthcare Intermediary LLC
• Inventors: Dust, Larry R., Cook, David B.
• Application Number:
  US14/278,733
• Publication Number:
  US 20140249842A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06F 11/008 Reliability or availability analysis
• CPC Class Codes: G06F 11/0727 in a storage system, e.g. in a DASD or network based storage system drivers for digital recording or reproducing units G06F3/06; circuits for error detection or correction within digital recording or reproducing units G11B20/18; for distributed storage of data in networks, e.g. transport arrangements for network file system [NFS], storage area networks [SAN] or network attached storage [NAS], H04L67/1097
• CPC Class Codes: G06F 11/0751 Error or fault detection not based on redundancy power supply failures G06F1/30; network fault management H04L41/06
• CPC Class Codes: G06Q 10/00 Administration; Management
• CPC Class Codes: G06Q 10/063 Operations research, analysis or management
• CPC Class Codes: G06Q 10/0637 Strategic management or analysis, e.g. setting a goal or target of an organisation; Planning actions based on goals; Analysis or evaluation of effectiveness of goals
• CPC Class Codes: G06Q 30/0201 Market modelling; Market analysis; Collecting market data
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 20/00 ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance
• CPC Class Codes: G16H 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment

Abstract

A method of optimizing healthcare services consumption according to the invention includes the steps of assessing the healthcare situation of an employer providing healthcare benefits to a population, identifying a first group of patients from the population likely to generate expensive healthcare claims based on data representing past claims, periodically determining whether patients in the first group have satisfied certain predetermined healthcare requirements, identifying a first group of providers who provide high quality, cost efficient healthcare services based on the practice patterns of the providers, prompting patients who have not satisfied the predetermined healthcare requirements to obtain services from providers in the first group, and responding to healthcare requests from patients by determining whether the requesting patient is seeking services from a provider in the first group, and, if not, urging the patient to obtain such services from a provider in the first group.

Claims

1. A method of optimizing healthcare services consumption of patients in a healthcare plan comprising:

A. providing at least one computing device maintaining one or more databases on a computer-readable media, the one or more databases being electronically coupled to one or more networks;

B. electronically receiving from an external data source and storing in a database information comprising patient data,

wherein the patient data comprises at least the patients'"'"' names, addresses, patient identification numbers, ages, and genders,

wherein the patient data is for at least 9800 patients,

and wherein storing patient data is repeated for each patient added to the healthcare plan;

C. electronically receiving from an external data source and storing in a database healthcare information comprising healthcare claims data relating to submitted medical claims,

wherein healthcare claims data relating to submitted medical claims comprises at least a diagnosis, a procedure code and costs,

and wherein storing healthcare claims data relating to submitted medical claims is repeated for each newly submitted medical claim;

D. electronically receiving from an external data source and storing in a database healthcare information comprising healthcare claims data relating to submitted pharmaceutical claims,

wherein each healthcare claims data relating to submitted pharmaceutical claims comprises at least a type, quantity and dosage of a prescribed drug, and a pharmacy associated with the prescribed drug,

and wherein storing healthcare claims data relating to submitted pharmaceutical claims is repeated for each newly submitted pharmaceutical claim;

E. accessing stored healthcare claims data relating to submitted medical claims and submitted pharmaceutical claims associated with each patient;

F. analyzing the accessed healthcare claims data with the computing device to determine a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan,

wherein determining a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan includes reviewing an age, gender, diagnosis, previously performed procedures and treatment of the patients,

and wherein analyzing the accessed healthcare claims data is repeated at least once every calendar quarter;

G. storing in a database an indication of the patients likely to generate expensive healthcare claims;

H. accessing data representing a first group of healthcare service providers who provide high quality cost efficient healthcare services relative to other providers;

I. accessing patient data and associated healthcare claims data relating to submitted medical claims and submitted pharmaceutical claims from a database, determining whether an individual patient in the first group of patients suffers from one or more chronic conditions and storing an identification of any such chronic condition in a database as part of the patient data,

wherein determining whether an individual patient in the first group of patients suffers from one or more chronic conditions includes reviewing the diagnosis, previously performed procedures and treatment of the individual patient,

and wherein determining whether an individual patient in the first group of patients suffers from one or more chronic conditions is repeated at least once every calendar quarter;

J. associating a predetermined set of minimum annual care requirements (MACRs) with each individual patient'"'"'s one or more chronic conditions each time a patient is identified with a chronic condition and storing said association in a database as part of the patient data;

K. determining whether an individual patient suffering from one or more chronic conditions has obtained healthcare services that satisfy the predetermined set of MACRs associated with the one or more chronic conditions;

wherein determining whether an individual patient has satisfied the MACRs is repeated at least once every calendar quarter; and

L. using an electronic communication device to instruct patients who have not obtained healthcare services that satisfy the predetermined set of MACRs to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of healthcare service providers.

2. The method according to claim 1, wherein patent data is transferred from an external data source maintained by an employer.

3. The method according to claim 1, wherein patent data is transferred from an external data source maintained by a healthcare plan provider.

4. The method according to claim 1, wherein healthcare claims data relating to submitted medical claims is transferred from an external data source maintained by a healthcare provider.

5. The method according to claim 1, wherein healthcare claims data relating to submitted medical claims is transferred from an external data source maintained by a PPO.

6. The method according to claim 1, wherein healthcare claims data relating to submitted medical claims is transferred from an external data source maintained by a healthcare quality management firm.

7. The method according to claim 1, wherein healthcare claims data relating to submitted pharmaceutical claims is transferred from an external data source maintained by a pharmacy.

8. The method according to claim 1, wherein healthcare claims data relating to submitted pharmaceutical claims is transferred from an external data source maintained by a pharmacy benefit manager.

9. The method according to claim 1, wherein the electronic communication device comprises a telephone.

10. The method according to claim 1, wherein the electronic communication device comprises an email system accessed through at least one computer programmed interface.

11. A method of optimizing healthcare services consumption of patients in a healthcare plan comprising:

A. providing at least one computing device maintaining one or more databases on a computer-readable media, the one or more databases being electronically coupled to one or more networks;

B. electronically receiving from an external data source and storing in a database information comprising patient data,

wherein patient data comprises at least the patients'"'"' names, addresses, patient identification numbers, ages, and genders,

wherein the patient data is for at least 9800 patients,

and wherein storing patient data is repeated for each patient added to the healthcare plan;

C. electronically receiving from an external data source and storing in a database healthcare information comprising healthcare claims data relating to submitted medical claims,

wherein healthcare claims data relating to submitted medical claims comprises at least a diagnosis, a procedure code and costs,

and wherein storing healthcare claims data relating to submitted medical claims is repeated for each newly submitted medical claim;

D. accessing stored healthcare claims data relating to submitted medical claims associated with each patient;

E. analyzing the healthcare data relating to submitted medical claims with the computing device and determining a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan,

wherein determining a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan includes reviewing an age, gender, diagnosis, previously performed procedures and treatment of the patients,

and wherein analyzing the accessed healthcare claims data is repeated at least once every calendar quarter;

F. storing in a database an indication of the patients likely to generate expensive healthcare claims;

G. accessing data representing a first group of healthcare service providers who provide high quality cost efficient healthcare services relative to other providers;

H. accessing patient data and associated healthcare claims data relating to submitted medical claims from a database and determining whether an individual patient in the first group of patients suffers from one or more chronic conditions,

wherein determining patents who suffer from one or more chronic conditions is repeated at least once every calendar quarter;

I. associating a predetermined set of minimum annual care requirements (MACRs) with each individual patient'"'"'s one or more chronic conditions each time a patient is identified with a chronic condition and storing said association in a database as part of the patient data;

J. determining whether an individual patient suffering from one or more chronic conditions has obtained healthcare services that satisfy the predetermined set of MACRs associated with the one or more chronic conditions;

and wherein determining whether an individual patient has satisfied the MACRs is repeated at least once every calendar quarter; and

K. using an electronic communication device to instruct patients who have not obtained healthcare services that satisfy the predetermined set of MACRs to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of healthcare service providers.

12. The method according to claim 11, wherein method of optimizing healthcare services consumption of patients in a healthcare plan further includes:

electronically receiving from an external data source and storing in a database healthcare information comprising healthcare claims data relating to submitted pharmaceutical claims,

wherein healthcare claims data relating to submitted pharmaceutical claims comprises at least a type, quantity and dosage of a prescribed drug, and pharmacy associated with the prescribed drug,

and wherein storing healthcare claims data relating to submitted pharmaceutical claims is repeated for each newly submitted pharmaceutical claim;

accessing stored healthcare claims data relating to submitted pharmaceutical claims associated with each patient; and

analyzing the accessed healthcare claims data with the computing device and determining a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan,

wherein analyzing the accessed healthcare claims data is repeated at least once every calendar quarter;

13. A method of optimizing healthcare services consumption of patients in a healthcare plan comprising:

A. providing at least one computing device maintaining one or more databases on a computer-readable media, the one or more databases being electronically coupled to one or more networks;

B. electronically receiving from an external data source and storing in a database information comprising patient data,

wherein patient data comprises at least the patients'"'"' names, addresses, patient identification numbers, ages, and genders;

wherein the patient data is for at least 9800 patients,

and wherein storing patient data is repeated for each patient added to a healthcare plan;

C. electronically receiving from an external data source and storing in a database healthcare information comprising healthcare claims data relating to submitted medical claims,

wherein healthcare claims data relating to submitted medical claims comprises at least a diagnosis, a procedure code and costs,

and wherein storing healthcare claims data relating to submitted medical claims is repeated for each newly submitted medical claim;

D. accessing stored healthcare claims data relating to submitted medical claims associated with each patient;

E. analyzing the accessed healthcare claims data with the computing device and determining whether an individual patient suffers from one or more chronic conditions,

wherein determining whether an individual patient suffers from one or more chronic conditions includes reviewing the diagnosis, previously performed procedures and treatment of the individual patient,

and wherein analyzing the accessed healthcare claims data is repeated at least once every calendar quarter;

F. storing in a database an indication of the patients who suffer from one or more chronic conditions;

G. accessing data representing a first group of healthcare service providers who provide high quality cost efficient healthcare services relative to other healthcare service providers;

H. associating a predetermined set of minimum annual care requirements (MACRs) with each individual patient'"'"'s one or more chronic conditions each time a patient is identified with a chronic condition and storing said association in a database as part of the patient data;

I. determining whether an individual patient suffering from one or more chronic conditions has obtained healthcare services that satisfy the predetermined set of MACRs associated with the one or more chronic conditions,

wherein determining whether an individual patient has satisfied the MACRs is repeated at least once every calendar quarter; and

J. using an electronic communication device to instruct patients who have not obtained healthcare services that satisfy the predetermined set of MACRs to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of healthcare service providers.

14. A method of optimizing healthcare services consumption of patients in a healthcare plan comprising:

A. providing at least computing device maintaining one or more databases on a computer-readable media, the one or more databases being electronically coupled to one or more networks;

B. electronically receiving from an external data source and storing in a database information comprising patient data,

wherein patent data comprises at least a patient'"'"'s name, address, patient identification number, age, and genders,

wherein the patient data is for at least 9800 patients,

and wherein storing patient data is repeated for each patient added to a healthcare plan;

C. electronically receiving from at least one external data source and storing in a database healthcare claims data relating to submitted healthcare claims,

wherein healthcare claims data relating to submitted healthcare claims comprises at least a medical diagnosis, medical procedure code, drug type, quantity and dosage and associated charges,

and wherein storing healthcare claims data is repeated for each newly submitted healthcare claim,

D. retrieving stored healthcare claims data associated with each patient;

E. analyzing patient data and associated healthcare claims data with the computing device to determine whether an individual patient suffers from one or more chronic conditions and storing an indication of any such chronic condition in a database as part of the patient data,

wherein determining individual patients who suffer from one or more chronic conditions includes reviewing a diagnosis, previously performed procedures and treatment of the individual patients,

and wherein determining individual patients who suffer from one or more chronic conditions and storing any said indication is repeated at least once each calendar quarter;

F. accessing data representing a first group of healthcare service providers who provide high quality cost efficient healthcare services relative to other healthcare service providers;

G. associating a predetermined set of minimum annual care requirements (MACRs) with each individual patient'"'"'s one or more chronic conditions each time a patient is identified with a chronic condition and storing said association in a database as part of the patient data;

H. determining whether an individual patient suffering from one or more chronic conditions has obtained healthcare services that satisfy the predetermined set of MACRs associated with the one or more chronic conditions,

wherein determining whether an individual patient has satisfied the MACRs associated with a chronic condition is repeated at least once each calendar quarter; and

I. using an electronic communication device to instruct patients who have not obtained healthcare services that satisfy the predetermined set of MACRs to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of healthcare service providers.

15. The method according to claim 14, wherein patent data is transferred from an external data source maintained by an employer.

16. The method according to claim 14, wherein patent data is transferred from an external data source maintained by a healthcare plan provider.

17. The method according to claim 14, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external data source maintained by a healthcare provider.

18. The method according to claim 14, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external data source maintained by a PPO.

19. The method according to claim 14, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external data source maintained by a healthcare quality management firm.

20. The method according to claim 14, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external data source maintained by a pharmacy.

21. The method according to claim 14, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external data source maintained by a pharmacy benefit manager.

22. The method according to claim 14, wherein the electronic communication device comprises a telephone.

23. The method according to claim 14, wherein the electronic communication device comprises an email system accessed through at least one first computer programmed interface.