Computer system and method for generating healthcare risk indices using medication compliance information

• US 7,725,327 B2
• Filed: 10/22/2003
• Issued: 05/25/2010
• 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.
• Primary Examiner(s): Gilligan; C. Luke
• Assistant Examiner(s): Lubin; Valerie
• Application Number:
  US10/689,852
• Publication Number:
  US 20050091083A1
• Time in Patent Office: 2,407 Days
• Field of Search: None
• US Class Current: 705/2
• 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 chronic condition risk index for an individual using said individual'"'"'s pharmacy claims by a computer system, said method comprising the steps of:

(1) retrieving by the computer system said pharmacy claims from a pharmacy claims database, and processing by the computer system said pharmacy claims to identify any chronic conditions possessed by said individual;

(2) processing by the computer system said pharmacy claims to identify any compliance medications prescribed to said individual;

(3) generating a chronic condition score by summing regression coefficients for each chronic condition possessed by said individual;

(4) generating a compliance medication score by summing products of regression coefficients for each compliance medication prescribed to said individual with associated medication supply weights, or compliance;

(5) generating a modified chronic condition score by multiplying said chronic condition score by an overall chronic condition regression coefficient;

(6) further modifying said modified chronic condition score by subtracting a no-claims weight from said chronic condition score, if said individual has no pharmacy claims; and

(7) generating, by the computer system, said chronic condition risk index by summing said modified chronic condition score and said compliance medication score.

2. The method of claim 1, wherein said associated medication supply weights are determined by summing a total supply of an associated compliance medication prescribed to said individual.

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

4. The method of claim 1, wherein said no-claims weight indicates that said individual has not been diagnosed with a chronic condition.

5. The method of claim 1, wherein said no-claims weight indicates that said individual has not been prescribed any medications whatsoever.

6. The method of claim 1, wherein said no-claims weight is not applied if said individual has been prescribed a medication.

7. The method of claim 1, wherein said overall chronic condition regression coefficient accounts for variances in said chronic condition risk index.

8. 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.

9. The method of claim 1, further comprising the step of retrieving, by the computer system, patient information comprising patient eligibility data from at least one of a health insurer database and a pharmacy benefits database, and wherein said generating, by the computer system, said chronic condition risk index further comprises generating the chronic condition risk index responsive to the patient eligibility data.

10. The method of claim 1, further comprising the step of determining, by the computer system, using the chronic condition risk index clinical case identification with respect to the patient.

11. The method of claim 1, further comprising the step of determining, by the computer system, using the chronic condition risk index, and determining variation in at least one of estimated total healthcare costs and utilization by the patient.

12. The method of claim 1, further comprising the step of determining, by the computer system, using the chronic condition risk index, whether to generate comparable groups which may have differing rates of chronic illness and adjusting for factors including at least one of adverse and favorable selection into at least one health plans, programs and health-related interventions.

25. 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.

27. The computer implemented method of claim 1, wherein said generated chronic condition risk index is used in at least one of explaining and predicting variation in pharmacy-related costs and variation in total healthcare costs or utilization.

29. The computer implemented method of claim 1, further comprising determining at least one of pharmacy-related costs and total healthcare costs using said generated chronic condition risk index.

13. A computer system for generating a chronic condition risk index for an individual using said individual'"'"'s pharmacy claims, said computer system comprising processor and a memory medium storing instructions for controlling said processor, wherein said processor executes the instructions stored on said memory medium and performs the following functionality:

(1) retrieving by the computer system said pharmacy claims from a pharmacy claims database, and processing by the computer system said pharmacy claims to identify any chronic conditions possessed by said individual;

(2) processing by the computer system said pharmacy claims to identify any compliance medications prescribed to said individual;

(3) generating a chronic condition score by summing regression coefficients for each chronic condition possessed by said individual;

(4) generating a compliance medication score by summing products of regression coefficients for each compliance medication prescribed to said individual with associated medication supply weights, or compliance;

(5) generating a modified chronic condition score by multiplying said chronic condition score by an overall chronic condition regression coefficient;

(6) further modifying said modified chronic condition score by subtracting a no-claims weight from said chronic condition score, if said individual has no pharmacy claims; and

(7) generating, by the computer system, said chronic condition risk index by summing said modified chronic condition score and said compliance medication score.

14. The computer system of claim 13, wherein said associated medication supply weights are determined by summing a total supply of an associated compliance medication prescribed to said individual.

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

16. The computer system of claim 13, wherein said no-claims weight indicates that said individual has not been diagnosed with a chronic condition.

17. The computer system of claim 13, wherein said no-claims weight indicates that said individual has not been prescribed any medications whatsoever.

18. The computer system of claim 13, wherein said no-claims weight is not applied if said individual has been prescribed a medication.

19. The computer system of claim 13, wherein said overall chronic condition regression coefficient accounts for variances in said chronic condition risk index.

20. The computer system of claim 13, 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.

21. The computer system of claim 13, wherein said computer system retrieves said patient information comprising patient eligibility data from at least one of a health insurer database and a pharmacy benefits database, and wherein said generating, by the computer system, said chronic condition risk index further comprises generating the chronic condition risk index responsive to the patient eligibility data.

22. The computer system of claim 13, wherein said computer system determines using the chronic condition risk index clinical case identification with respect to the patient.

23. The computer system of claim 13, wherein said computer system determines using the chronic condition risk index, and determining variation in at least one of estimated total healthcare costs and utilization by the patient.

24. The computer system of claim 13, wherein said computer system determines using the chronic condition risk index whether to generate comparable groups which may have differing rates of chronic illness and adjusts for factors including at least one of adverse and favorable selection into at least one health plans, programs and health-related interventions.

26. The computer system of claim 13, 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.

28. The computer system of claim 13, wherein said generated chronic condition risk index is used in at least one of explaining and predicting variation in pharmacy-related costs and variation in total healthcare costs or utilization.

30. The computer system of claim 13, further comprising determining at least one of pharmacy-related costs and total healthcare costs using said generated chronic condition risk index.