Process, knowledge, and intelligence management through integrated medical management system for better health outcomes, utilization cost reduction and provider reward programs

• US 7,996,241 B2
• Filed: 05/12/2008
• Issued: 08/09/2011
• Est. Priority Date: 05/12/2008
• Status: Expired due to Fees

• Current Assignee: ikaSystems Corporation (Blue Cross Blue Shield of Michigan)
• Original Assignee: ikaSystems Corporation (Blue Cross Blue Shield of Michigan)
• Inventors: Kokku, Sashidhar, Ankarfa, Bala, Johnson, Craig, Narahari, Madusudhana, Parvatham, Streesha, Zak, Solomon, James, Poladas, Duddala, Rudra
• Primary Examiner(s): GILLIGAN, CHRISTOPHER L
• Application Number:
  US12/118,768
• Publication Number:
  US 20090281826A1
• Time in Patent Office: 1,184 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: G06Q 30/02 Marketing; Price estimation or determination; Fundraising
• CPC Class Codes: G06Q 40/08 Insurance
• 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: G16Z 99/00 Subject matter not provided for in other main groups of this subclass

Abstract

Disclosed herein is a computer implemented method and system for rewarding health care providers using an integrated medical management system. A web application analyzes performance of the health care providers. The web application acquires information from integrated medical management system. The acquired information includes information of health care quality improvement analysis, disease and case based management, utilization analytics, physician profiling, authorizations management, lab and imaging information, and health risk assessment information. The web application determines performance indices for the health care providers based on the acquired information. The performance indices include a quality index, an economic index, and a relative value unit index of the health care providers. The web application analyzes the performance of the health care providers based on the performance indices. The analysis includes identifying health care providers eligible for a reward. The health care providers are then rewarded based on the analyzed performance.

Claims

1. A computer implemented method of rewarding health care providers in a health care organization using an integrated medical management system, comprising the steps of:

providing said integrated medical management system, wherein the integrated medical management system comprises a web application for analyzing performance of said health care providers;

acquiring information from a plurality of medical management systems using said web application;

determining performance indices for the health care providers based on said acquired information using the web application, comprising;

calculating quality indices of said health care providers, wherein said quality indices are based on one or more of predetermined health plan employer data and information set analysis, predetermined disease management analysis, and predetermined quality of healthcare measure;

calculating economic indices of said health care providers, wherein said economic indices are based on one or more of utilization analytics, physician profiling, and authorizations management of a health care provider compared to other health care providers in a health plan; and

calculating a relative value unit index, wherein said relative value unit index is based on utilization of relative value units;

analyzing said performance of the health care providers based on said determined performance indices, wherein said step of analyzing the performance comprises identifying the health care providers eligible for a reward; and

rewarding said identified health care providers based on said analyzed performance;

whereby said health care organization rewards the health care providers based on the performance of the health care providers.

2. The computer implemented method of claim 1, wherein the health care providers are one or more of primary care physicians, procedurally related group specialists, medically related groups specialists, provider networks, hospitals, and ancillary providers.

3. The computer implemented method of claim 1, wherein said medical management systems include a utilization analytics system, provider profiling system, an intelligent health care quality improvement system, a disease and case based management system, referrals and authorizations management system, and a health risk assessment system.

4. The computer implemented method of claim 1, wherein the acquired information from said medical management systems comprises intelligent health care quality improvement analysis information, disease and case based management information, utilization analytics information, physician profiling information, authorizations management information, lab and imaging information, and health risk assessment information.

5. The computer implemented method of claim 1, wherein the acquired information comprises information of members enrolled with the health care providers, wherein said member information comprises information of health plan benefits, medical claims, pharmacy claims, hospital information, allied health center information, authorizations and referrals information, lab and imaging information, disease conditions, and comorbid conditions of said members.

6. The computer implemented method of claim 1, further comprising a step of updating unobserved performed health care measures by the health care providers.

7. The computer implemented method of claim 1, further comprising a step of notifying the health care providers for performing health care measures.

8. The computer implemented method of claim 7, wherein the integrated medical management system automatically triggers different communication devices for said notification in absence of access of the web application by the health care providers.

9. The computer implemented method of claim 1, wherein the integrated medical management system receives medical information of members via different communication devices in absence of access of the web application by the health care providers.

10. The computer implemented method of claim 9, wherein the integrated medical management system associates said received information with the health care providers of said members and enables updation of the received information.

11. The computer implemented method of claim 1, wherein the step of analyzing the performance comprises a step of monitoring the performance of the health care providers using the web application.

12. The computer implemented method of claim 1, further comprising a step of generating reports on the performance of the health care providers using the web application.

13. The computer implemented method of claim 1, wherein said step of rewarding comprises offering a projected increase in reimbursements to the identified health care providers.

14. The computer implemented method of claim 1, further comprising a step of identifying ineffective health care providers, wherein said identified ineffective health care providers are provided recommendations for improvement on health care management.

15. A computer implemented system for rewarding health care providers in a health care organization based on performance of said health care providers, comprising:

an integrated medical management system, comprising;

a plurality of medical management systems;

a web application server comprising;

an information acquisition module for acquiring information from a plurality of medical management systems;

a performance index calculation module for determining performance indices for the health care providers, comprising;

a quality index module for determining quality indices of said health care providers, wherein said quality indices are based on one or more of predetermined health plan employer data and information set analysis, predetermined disease management analysis, and predetermined quality of healthcare measure;

an economic index module for determining economic indices of said health care providers, wherein said economic indices are based on one or more of utilization analytics, physician profiling, and authorizations management of a health care provider compared to other health care providers in a health plan; and

a relative value unit index module for calculating a relative value unit index, wherein said relative value unit index is based on utilization of relative value units;

a performance analysis module for analyzing and monitoring said performance of the health care providers; and

a pay for performance module for rewarding the health care providers based on said analyzed performance.

16. The computer implemented system of claim 15, wherein said integrated medical management system enables updation of medical information of members received via different communication devices.

17. The computer implemented system of claim 15, wherein said medical management systems comprise an utilization analytics system, an intelligent health care quality improvement system, a disease and case based management system, a provider profiling system, a referrals and authorizations management system, and a health risk assessment system.

18. The computer implemented system of claim 15, further comprising a user interface for enabling health care administrators to assign a predetermined weighted percentage value for said performance indices.

19. The computer implemented system of claim 15, wherein said information acquisition module acquires information comprising intelligent health care quality improvement analysis information, disease and case based management information, utilization analytics information, physician profiling information, authorizations management information, lab and imaging information, and health risk assessment information.

20. The computer implemented system of claim 15, wherein said web application server further comprises a health care measure updation module for updating unobserved performed health care measures.

21. The computer implemented system of claim 15, wherein said web application server further comprises a report generation module for generating reports on the performance of the health care providers.

22. The computer implemented system of claim 15, wherein said web application server further comprises a provider record database for storing said acquired information, updated health care measure information, generated reports, information of said performance indices, analyzed performance information of the health care providers, and reward information of the health care providers.

23. The computer implemented system of claim 15, wherein said web application server further comprises a notification engine for notifying the health care providers to perform health care measures.

24. A computer program product comprising computer executable instructions embodied in a non-transitory computer-readable medium, wherein said computer program product comprises:

a first computer parsable program code for acquiring information from a plurality of medical management systems;

a second computer parsable program code for determining performance indices for health care providers based on said acquired information, comprising;

a quality index module for determining quality indices of said health care providers, wherein said quality indices are based on one or more of predetermined health plan employer data and information set analysis, predetermined disease management analysis, and predetermined quality of healthcare measure;

an economic index module for determining economic indices of said health care providers, wherein said economic indices are based on one or more of utilization analytics, physician profiling, and authorizations management of a health care provider compared to other health care providers in a health plan; and

a relative value unit index module for calculating a relative value unit index, wherein said relative value unit index is based on utilization of relative value units;

a third computer parsable program code for analyzing performance of said health care providers based on said determined performance indices;

a fourth computer parsable program code for rewarding the health care providers based on said analyzed performance; and

a fifth computer parsable program code for intelligently associating medical information of members received via different communication devices with the health care providers.