METHOD OF OPTIMIZING HEALTHCARE SERVICES CONSUMPTION

• US 20140249843A1
• 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:
  US14/278,750
• Publication Number:
  US 20140249843A1
• 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 healthcare consumers 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 source and storing in a database information comprising healthcare consumer data,

wherein healthcare consumer data comprises at least the healthcare consumers'"'"' names, addresses, healthcare consumer identification numbers, ages and genders;

wherein the healthcare consumer data is for at least 9800 healthcare consumers,

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

C. electronically receiving from an external source healthcare information comprising healthcare data relating to healthcare service events,

wherein healthcare data relating to the healthcare service events comprises at least a diagnosis and a procedure code,

and wherein storing healthcare data relating to the healthcare service events is repeated for each new healthcare service event;

D. storing in a database the received healthcare information comprising healthcare data relating to healthcare service events,

E. accessing stored healthcare data associated with each healthcare consumer;

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

wherein determining whether an individual healthcare consumer suffers from one or more chronic conditions includes reviewing the diagnosis and procedure code associated with the individual healthcare consumer,

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

G. storing in a database an indication of healthcare consumers who suffer from one or more chronic conditions;

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

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

J. determining whether the individual healthcare consumer 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 healthcare consumer has satisfied the predetermined set of MACRs associated with a chronic condition is repeated at least once every calendar quarter; and

K. using an electronic communication device to instruct healthcare consumers 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 at least one of the healthcare service events corresponds to a submitted medical claim.

3. The method according to claim 1, wherein the healthcare data comprises healthcare claims data.

4. A method of optimizing healthcare services consumption of healthcare consumers 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 source and storing in a database information comprising healthcare consumer data,

wherein healthcare consumer data comprises at least the healthcare consumers'"'"' names, addresses, healthcare consumer identification numbers, ages and genders;

wherein the healthcare consumer data is for at least 9800 healthcare consumers,

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

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

wherein the healthcare data relating to the healthcare service events comprises at least a diagnosis, a procedure code and a prescribed drug type,

and wherein storing healthcare data relating to the healthcare service events is repeated for each new healthcare service event;

D. accessing stored healthcare data associated with each healthcare consumer;

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

wherein determining whether an individual healthcare consumer suffers from one or more chronic conditions includes reviewing the diagnosis, procedure code and prescribed drug type associated with the individual healthcare consumer,

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

F. storing in a database an indication of healthcare consumers 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 healthcare consumer'"'"'s one or more chronic conditions each time a healthcare consumer is identified with a chronic condition and storing said association in a database as part of the healthcare consumer data;

I. determining whether the individual healthcare consumer 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 healthcare consumer has satisfied the predetermined set of MACRs associated with a chronic condition is repeated at least once every calendar quarter; and

J. using an electronic communication device to instruct healthcare consumers 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.

5. The method according to claim 4, wherein at least one of the healthcare service events corresponds to a submitted medical claim.

6. The method according to claim 4, wherein the healthcare data comprises healthcare claims data.

7. A method of optimizing healthcare services consumption of healthcare consumers 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 source and storing in a database information comprising healthcare consumer data,

wherein healthcare consumer data comprises at least the healthcare consumers'"'"' names, addresses, healthcare consumer identification numbers, ages and genders;

wherein the healthcare consumer data is for at least 9800 healthcare consumers,

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

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

wherein the healthcare data relating to the healthcare service events comprises at least a diagnosis and a procedure code,

and wherein storing healthcare data relating to the healthcare service events is repeated for each new healthcare service event;

D. accessing stored healthcare data associated with each healthcare consumer;

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

wherein determining whether an individual healthcare consumer suffers from one or more chronic conditions includes reviewing the diagnosis and procedure code associated with the individual healthcare consumer,

and wherein analyzing healthcare data is repeated daily;

F. storing in a database an indication of healthcare consumers 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 healthcare consumer'"'"'s one or more chronic conditions each time a healthcare consumer is identified with a chronic condition and storing said association in a database as part of the healthcare consumer data;

I. determining whether the individual healthcare consumer 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 healthcare consumer has satisfied the predetermined set of MACRs associated with a chronic condition is repeated at least once every calendar quarter; and

J. using an electronic communication device to instruct healthcare consumers 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.

8. The method according to claim 7, wherein at least one of the healthcare service events corresponds to a submitted medical claim.

9. The method according to claim 7, wherein the healthcare data comprises healthcare claims data.

10. A method of optimizing healthcare services consumption of healthcare consumers 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 source and storing in a database information comprising healthcare consumer data,

wherein healthcare consumer data comprises at least the healthcare consumers'"'"' names, addresses, healthcare consumer identification numbers, ages, and genders,

wherein the healthcare consumer data is for at least 9800 healthcare consumers,

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

C. electronically receiving from at least one external 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, a medical procedure code and a prescribed drug type,

and wherein storing healthcare claims data is repeated daily,

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

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

wherein determining whether an individual healthcare consumer suffers from one or more chronic conditions includes reviewing the diagnosis, medical procedure code and prescribed drug type associated with the individual healthcare consumer,

and wherein determining whether individual healthcare consumers suffer from one or more chronic conditions and storing any said indication is repeated daily;

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 healthcare consumer'"'"'s one or more chronic conditions each time a healthcare consumer is identified with a chronic condition and storing said association in a database as part of the healthcare consumer data;

H. determining whether the individual healthcare consumer 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 healthcare consumer has satisfied the predetermined set of MACRs associated with a chronic condition is repeated daily; and

I. using an electronic communication device to instruct healthcare consumers 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.

11. The method according to claim 10, wherein healthcare consumer data is transferred from an external source maintained by an employer.

12. The method according to claim 10, wherein healthcare consumer data is transferred from an external source maintained by a healthcare plan provider.

13. The method according to claim 10, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external source maintained by a healthcare service provider.

14. The method according to claim 10, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external source maintained by a PPO.

15. The method according to claim 10, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external source maintained by a healthcare quality management firm.

16. The method according to claim 10, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external source maintained by a pharmacy.

17. The method according to claim 10, wherein healthcare claims data relating to submitted healthcare claims is transferred from an external source maintained by a pharmacy benefit manager.

18. The method according to claim 10, wherein the electronic communication device comprises a telephone.

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