Method of optimizing healthcare services consumption

• US 7,711,577 B2
• Filed: 12/06/2002
• Issued: 05/04/2010
• Est. Priority Date: 12/06/2002
• Status: Active Grant

• Current Assignee: Quality Healthcare Intermediary LLC
• Original Assignee: Key Benefit Administrators, Inc.
• Inventors: Cook, David B., Dust, Larry R.
• Primary Examiner(s): Morgan; Robert W
• Assistant Examiner(s): NGUYEN, TRAN N
• Application Number:
  US10/313,370
• Publication Number:
  US 20040111291A1
• Time in Patent Office: 2,706 Days
• Field of Search: 705/2, 705/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• 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 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

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, including the steps of:

(A) assessing a healthcare situation of an employer who provides healthcare benefits to a population of patients consisting of employees of the employer and family members of the employees, the assessing step including the steps of

(i) using a computing device to execute software to access a database containing data relating to the employer, the patients, and providers who service the patients,

(ii) identifying a plurality of non-overlapping geographic regions,

(iii) associating with the computer an address of each patient with a geographic region,

(iv) associating with the computer a location of each provider with a geographic region, and

(v) aggregating with the computer the geographic regions associated in steps (iii)-(iv) above into a health economic zone (HEZ), wherein the HEZ encompasses only the aggregated geographic regions;

(B) using a computing device to transform past healthcare claims data generated by the patients and stored in the database into data representing a first group of patients likely to generate expensive healthcare claims relative to other patients in the population;

(C) using a computing device to transform past practice patterns data generated by the providers in the HEZ who provide services to the patients and stored in the database into data representing a first group of providers who provide high quality, cost efficient healthcare services; and

(D) responding to a healthcare request from a patient by determining whether the provider associated with the request is in the first group of providers, and when the provider is not in the first group of providers, using an electronic communication device to contact the patient before the patient consumes the requested services from the provider to urge the patient to obtain the requested services from a provider in the first group of providers.

2. The method of claim 1, wherein the step of transforming past practice patterns data includes the step of rating providers who service the patients in the population, the rating step including the steps of:

determining a cost efficiency index for each provider based on claim information stored in the database by

determining an average cost (AC1) for completed episodes of healthcare associated with the provider, an episode of healthcare being a healthcare consumption sequence including all healthcare services consumed by a patient of the particular provider for a particular healthcare problem,

determining an average cost (AC2) for similar episodes of healthcare treated by other providers who provide the same specialty service as the provider, and

dividing AC1 by AC2; and

determining whether the cost efficiency index is less than a first predetermined threshold.

3. The method of claim 2, wherein the rating step further includes the steps of:

determining a service rating for each provider based on claim information stored in the database by

determining a number (N1) of preventative care services ordered by the provider for treatment of a plurality of chronic conditions,

determining a number (N2) of preventative care services required to satisfy a predetermined set of preventative care services corresponding to the plurality of chronic conditions, and

dividing N1 by N2;

determining a typical service rate for other providers who provide the same specialty service as the provider; and

determining whether the service rate for the provider is greater than a second predetermined threshold that represents a percentage of the typical service rate.

4. The method of claim 3, wherein the rating step further includes the steps of:

determining a practice patterns challenge rate for each provider based on claim information stored in the database by

determining a total number (T1) of undesirable practice characteristics associated with the provider, the undesirable practice characteristics being at least one of inappropriately ordered procedures, procedures performed too frequently, services requiring medical review, upcoding, invalid coding, and vague coding,

determining a typical number (T2) of undesirable practice characteristics associated with other providers who provide the same specialty service as the provider, and

dividing T1 by T2; and

determining whether the practice patterns challenge rate is less than a third predetermined threshold.

5. The method of claim 4, wherein the rating step further includes the step of associating an indication that a provider is a quality service provider (QSP) when the provider has a cost efficiency index that is less than the first predetermined threshold, a service rating that is greater than the second predetermined threshold, and a practice patterns challenge rate that is less than the third predetermined threshold.

6. The method of claim 5, wherein the rating step further includes the steps of:

associating an indication that a QSP is an A level QSP when the claim information stored in the database includes at least a predetermined number of completed episodes of healthcare associated with the QSP; and

associating an indication that a QSP is a B level QSP when the claim information stored in the database does not include at least a predetermined number of completed episodes of healthcare associated with the QSP.

7. The method of claim 1, wherein the assessing step further includes the steps of:

accessing data in the database relating to healthcare costs of healthcare consumers in the HEZ and healthcare consumers in a larger geographic area that includes the HEZ; and

comparing the healthcare costs of consumers in the HEZ with the healthcare costs of the consumers in the larger geographic area to provide the employer with information about a relative cost of providing healthcare benefits to the population.

8. The method of claim 7, wherein the comparing step further includes the steps of:

determining a total cost (TC1) of all allowed healthcare charges for a specialty service consumed by consumers in the HEZ over a time period;

determining a total number (TN1) of consumers in the HEZ;

dividing TC1 by TN1 to determine an average cost (AC1) for the specialty service per consumer in the HEZ over the time period;

determining a total cost (TC2) of all allowed healthcare charges for the specialty service consumed by consumers in the larger geographic area over the time period;

determining a total number (TN2) of consumers in the larger geographic area;

dividing TC2 by TN2 to determine an average cost (AC2) for the specialty service per consumer in the larger geographic area over the time period; and

outputting a comparison of AC1 to AC2.

9. The method of claim 1, wherein the assessing step further includes the steps of:

accessing data in the database relating to healthcare costs of the patients in the population and healthcare costs of healthcare consumers in the HEZ; and

comparing the healthcare costs of the patients in the population with the healthcare costs of the consumers in the HEZ to provide the employer with information about a relative cost of providing healthcare benefits to the population.

10. The method of claim 9, wherein the comparing step further includes the steps of:

determining a total cost (TC1) of all allowed healthcare charges for a specialty service consumed by the patients in the population over a time period;

determining a total number (TN1) of patients in the population;

determining a total cost (TC2) of all allowed healthcare charges for the specialty service consumed by consumers in the HEZ over the time period;

determining a total number (TN2) of consumers in the HEZ;

dividing TC2 by TN2 to determine an average cost (AC1) for the specialty service per consumer in the HEZ over the time period;

multiplying AC1 by TN1 to determine an expected cost (EC1) for the specialty service over the time period for a number of consumers in the HEZ equaling TN1; and

outputting a comparison of TC1 to EC1.

11. The method of claim 9, wherein the comparing step further includes the steps of:

determining a total cost (TC1) of all allowed healthcare charges for a specialty service consumed by the patients in the population over a time period;

determining a total number (TN1) of patients in the population who consumed the specialty service during the time period;

determining a total cost (TC2) of all allowed healthcare charges for the specialty service consumed by consumers in the HEZ over the time period;

determining a total number (TN2) of consumers in the HEZ who consumed the specialty service during the time period;

dividing TC2 by TN2 to determine an average cost (AC1) per consumer of the specialty service in the HEZ over the time period;

multiplying AC1 by TN1 to determine an expected cost (EC1) for the specialty service over the time period for a number of consumers in the HEZ equaling TN1; and

outputting a comparison of TC1 to EC1.

12. The method of claim 1, wherein the step of transforming past practice patterns data includes the steps of:

comparing practice patterns of a particular provider who services the patients in the population with practice patterns of other providers who provide the same specialty service; and

outputting a report depicting results of the comparing step.

13. The method of claim 12, wherein the comparing step further includes the steps of:

identifying episodes of healthcare associated with the particular provider, each episode being a healthcare consumption sequence including all healthcare services consumed by a patient of the particular provider for a particular healthcare problem;

comparing the episodes of healthcare associated with the particular provider with similar episodes of healthcare associated with the other providers; and

providing an indication, based on the step of comparing the episodes of healthcare, of a characteristic of the particular provider'"'"'s practice relative to the other providers'"'"' practices, the characteristic being at least one of inappropriately ordered procedures, procedures performed too frequently, services requiring medical review, upcoding, invalid coding, and vague coding.

14. The method of claim 1, wherein the assessing step further includes the step of comparing a healthcare index (HI1) of consumers in the HEZ with a healthcare index (HI2) of consumers in a larger geographic region that includes the HEZ, HI1 being an average of individual healthcare indices of consumers in the HEZ, and HI2 being an average of individual healthcare indices of consumers in the larger geographic region, the individual healthcare indices being computed using Episode Risk Group scores representing at least age, sex, and health condition of the consumers.

15. The method of claim 1, wherein the assessing step further includes the step of comparing a healthcare index (HI1) of the patients in the population with a healthcare index (HI2) of consumers in the HEZ, HI1 being an average of individual healthcare indices of the patients in the population, and HI2 being an average of individual healthcare indices of consumers in the HEZ, the individual healthcare indices being computed using Episode Risk Group scores representing at least age, sex, and health condition of the consumers.

16. The method of claim 1, further including the step of outputting a report including a listing of chronic conditions and an indication of a rate at which patients in the population suffering from a listed chronic condition satisfy minimum annual care requirements associated with the chronic condition.

17. The method of claim 1, wherein the step of transforming past healthcare claims data includes the step of outputting a report representing a risk stratification of patients in the population, the report listing the patients in order of their associated healthcare indices and including a predicted cost for each patient, the healthcare indices being computed using Episode Risk Group scores representing at least age, sex, and health condition of the patients, and the predicted cost being the product of the healthcare index of the listed patient and an average cost per risk point of consumers in the HEZ.

18. The method of claim 1, further including the steps of:

periodically accessing the database to determine from the data relating to the patients whether patients in the first group suffer from one or more chronic conditions;

determining whether the patients suffering from one or more chronic conditions have obtained healthcare services that satisfy a predetermined set of minimum annual care requirements (MACR) associated with the one or more chronic conditions and stored in the database; and

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

19. The method of claim 1, wherein the step of responding to healthcare requests includes the step of conducting a first set of intervention actions when the patient uses a provider other than a provider in the first group of providers, the first set of intervention actions corresponding to a first degree of involvement of a healthcare quality management representative in the provision of the requested services.