Health care administration method

• US 7,657,442 B2
• Filed: 07/08/2003
• Issued: 02/02/2010
• Est. Priority Date: 07/08/2003
• Status: Active Grant

• Current Assignee: Richard Merkin
• Original Assignee: Richard Merkin
• Inventors: Merkin, Richard
• Primary Examiner(s): O'Connor; Gerald J.
• Assistant Examiner(s): RANGREJ, SHEETAL
• Application Number:
  US10/615,640
• Publication Number:
  US 20050010436A1
• Time in Patent Office: 2,401 Days
• Field of Search: 705 2- 4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 50/30 for calculating health indices; for individual health risk assessment
• CPC Class Codes: G16H 70/20 relating to practices or guidelines

Abstract

Health care administration methods are disclosed that substantially conserve the utilization of health care resources available to care for a specified patient population. Initially, a patient population is generated whereby each patient therein is assigned a risk based upon a retrospective and postspective assessment of the patient. Once the patient population is generated, utilization management practices are implemented that restrict utilization of health care resources without adversely impacting clinical outcome or quality of care until such utilization of resources is deemed medically warranted. A network of health care providers and health care providing institutions administers health care to the population according to methods of the present invention based upon primary care decision making practices utilizing the most cost-effective management practices and minimizing the use of specialists and in-patient/out-patient services whenever applicable.

Claims

1. A method for administering health care to patients within a patient population such that utilization of health care resources available to care for said patients within said patient population are conserved, the method comprising the steps:

a) generating said patient population, said generation of said patient population comprising the steps;

i) receiving a request from an individual to become a patient within said patient population;

ii) obtaining information from said individual in step (i), wherein said information is obtained by an in-person interview and wherein said information comprises demographic information related to said individual comprising the individual'"'"'s age, sex, medical history and geographic vicinity pertaining to said individual'"'"'s residence as well as the number of emergency room visits, number of hospitalizations and readmissions, patient pharmacy records, and medication compliance, storing such information in electronic medical records embodied on a computer readable medium;

iii) evaluating said data submitted in step (ii) via a computer capable of interpreting said electronic medical records;

iv) enrolling said individual as a patient within said patient population; and

v) repeating steps (i)-(iv) for a multiplicity of individuals;

b) receiving a request from a patient within said patient population generated in step a) for medical services;

c) assessing said request made in step b) and determining whether said request substantiates a specified clinical event, wherein said assessment is made by a primary care physician;

d) electronically submitting only a single CPT code corresponding to a single, specified medical service to be rendered in response to the clinical event specified in step (c) via a data communications network;

e) evaluating the single code submitted in step (d) for clinical and financial appropriateness, wherein said evaluation is performed by a hospitalist or case manager that is other than the primary care physician, and wherein evaluating the single code submitted in step (d) comprises (i) evaluating the effectiveness or clinical importance of the service required to be rendered in relation to the code, (ii) evaluating whether the submitted code is applicable to those health care services that are covered by the patient'"'"'s health care, and (iii) evaluating whether the code is susceptible to duplicative and/or unbundled billing practice or otherwise provides any financial interest to the primary care physician;

f) electronically responding to said submission made in step (d) based upon said evaluation made in step (e), said response comprising either approval or disapproval to proceed with rendering the requested service corresponding to said code submitted in step (d) via a data communications network;

g) assessing said request made in step (b) and determining whether said request substantiates the utilization of either in-patient services, out-patient services, referral to a specialist, or combinations thereof, wherein said assessment is made by a primary care physician and the in-patient services, out-patient services and services from the specialist are to be performed by a physician other than the primary care physician;

h) electronically submitting only a single CPT code corresponding to a single, specified medical service to be rendered in response to the utilization requested in step (g) via a data communications network;

i) evaluating the single code submitted in step (h) for clinical and financial appropriateness, wherein said evaluation is performed by a hospitalist or case manager that is other than the primary care physician, and wherein evaluating the single code submitted in step (h) comprises (i) evaluating the effectiveness or clinical importance of the service required to be rendered in relation to the code, (ii) evaluating whether the submitted code is applicable to those health care services that are covered by the patient'"'"'s health care, and (iii) evaluating whether the code is susceptible to duplicative and/or unbundled billing practice or otherwise provides any financial interest to the primary care physician;

j) electronically responding to said submission made in step (h) based upon said evaluation made in step (i), said response comprising either approval or disapproval to proceed with rendering the requested service corresponding to the code submitted in step (h) via a data communications network; and

k) when the patient has a chronic condition, repeating steps (g)-(j) to continuously assess the utilization of the in-patient services, out-patient services, and services of the specialist to provide treatment of the chronic condition.

2. The method of claim 1 wherein in step (a), substep (iii), said evaluation comprises comparing said information submitted in step (a), substep (ii) with eligibility criteria, said eligibility criteria defining a standard by which said individuals are compared for acceptance as a patient within said patient population.

3. The method of claim 2 wherein step (a), substep (iii), further comprises assessing the current state of health of said individual and anticipated future health of said individual by retrospectively examining the individual'"'"'s prior medical history and prospectively examining the anticipated future medical needs of said individual.

4. The method of claim 1 wherein step (a), substep (iv), further comprises assigning a risk level to said patient.

5. The method of claim 4 wherein in step (a), substep (iv), said risk level assigned said patient is indicative of the anticipated utilization of resources said patient is projected to utilize while a member of said patient population.

6. The method of claim 5 wherein following step (a), substep (v), such process further comprises step:

(vi) periodically updating and reviewing information indicative of the health of said patients within said patient population and reassigning risk levels associated with said patients within said patient population.

7. The method of claim 6 wherein said reassigning of risk levels is performed every six months.

8. The method of claim 5 wherein step (a), sub step (iv) further comprises the step of charging a premium to said individual for becoming a member of said patient population.

9. The method of claim 8 wherein said premium corresponds to said risk level assigned to said patient.

10. The method of claim 1 wherein step (f) further comprises the step of determining whether to provide a reimbursement to said primary care physician for said services sought to be rendered in relation to said code submitted in step (c).

11. The method of claim 1 wherein in step (f) said disapproval of said services sought to be rendered in relation to said code submitted in step (c) is followed by the further step:

(a) repeating step (b)-(d).

12. The method of claim 1 wherein in step (c) said primary care physician is a member of a network of physicians contracted to render medical services on behalf of a health plan, health maintenance organization, or government sponsored health care program.

13. The method of claim 1 wherein in step (c), said code corresponds to a single medical service to be rendered exclusively by said physician.

14. The method of claim 1 wherein in step (a), substep (ii), said number of emergency room visits and number of hospitalizations and readmissions are determined with respect to the twelve month period preceding obtaining the information.

15. The method of claim 1 wherein step (a), substep (ii) further comprises obtaining information in relation to the current condition of any disease that said individual may have.

16. The method of claim 15 wherein said disease is hypertension.

17. The method of claim 15 wherein said disease is diabetes.

18. The method of claim 1 wherein the request for medical services in step (b) is in relation to the treatment of a chronic condition requiring continuous care.

19. The method of claim 18 wherein the chronic condition is selected from the group consisting of diabetes, cancer, and Alzheimer'"'"'s disease.

20. The method of claim 18 wherein each specified clinical event assessed in step (c) is submitted as a single code every single time the specified clinical event is required until the specified clinical event is no longer required.

21. A method for administering an integrated health care delivery system for providing comprehensive health care to a patients within a patient population such that utilization of health care resources available to care for said patients within said patient population are conserved, the method comprising the steps:

a) generating said patient population, said generation of said patient population comprising the steps;

i) receiving a request from an individual to become a patient within said patient population;

ii) obtaining information from said individual in step (i), wherein said information is obtained by an in-person interview and wherein said information comprises demographic information related to said individual comprising the individual'"'"'s age, sex, medical history and geographic vicinity pertaining to said individual'"'"'s residence as well as the number of emergency room visits, number of hospitalizations and readmissions, patient pharmacy records, and medication compliance, storing such information in electronic medical records embodied on a computer readable medium;

iii) evaluating said data submitted in step (ii) via a computer capable of interpreting said electronic medical records;

iv) enrolling said individual as a patient within said patient population; and

v) repeating steps (i)-(iv) for a multiplicity of individuals;

b) receiving a request from a patient within said patient population for medical services;

c) assessing said request made in step b) and determining whether said request substantiates the utilization of either in-patient services, out-patient services, referral to a specialist, or combinations thereof, wherein said assessment is made by a primary care physician;

d) electronically submitting only a single CPT code corresponding to a single, specified medical service to be rendered in response to the utilization requested in step (c) via a data communications network;

e) evaluating the single code submitted in step (d) for clinical and financial appropriateness, wherein said evaluation is performed by a hospitalist or case manager that is other than the primary care physician, and wherein evaluating the single code submitted in step (d) comprises (i) evaluating the effectiveness or clinical importance of the service required to be rendered in relation to the code, (ii) evaluating whether the submitted code is applicable to those health care services that are covered by the patient'"'"'s health care, and (iii) evaluating whether the code is susceptible to duplicative and/or unbundled billing practice or otherwise provides any financial interest to the primary care physician;

f) electronically responding to said submission made in step (d) based upon said evaluation made in step (e), said response comprising either approval or disapproval to proceed with rendering the requested service corresponding to said code submitted in step (c) via a data communications network; and

g) when the patient has a chronic condition, repeating steps (c)-(f) to continuously assess the utilization of the in-patient services, out-patient services, and services of the specialist to provide treatment of the chronic condition.

22. The method of claim 21 wherein in step (f) said disapproval of said services sought to be rendered in relation to said code submitted in step (c) is followed by the further step:

(a) repeating step (b)-(d).

23. The method of claim 21 wherein in step (a) said primary care physician is a member of a network of physicians contracted to render medical services on behalf of a health plan, health maintenance organization, or government sponsored health care program.