Method of optimizing healthcare services consumption

• US 8,036,916 B2
• Filed: 05/04/2010
• Issued: 10/11/2011
• Est. Priority Date: 12/06/2002
• Status: Expired due to Fees

• Current Assignee: Quality Healthcare Intermediary LLC
• Original Assignee: Key Benefit Administrators
• Inventors: Cook, David B., Dust, Larry R.
• Primary Examiner(s): Gilligan; Luke
• Assistant Examiner(s): Nguyen; Tran
• Application Number:
  US12/773,334
• Publication Number:
  US 20100217625A1
• Time in Patent Office: 525 Days
• Field of Search: 705/2
• 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:

assessing a healthcare situation of an employer who provides healthcare benefits to a population of patients that reside and consume healthcare services in a health economic zone, the health economic zone consisting of a plurality of non-overlapping geographic regions, each of which includes at least one of a residential address of a patient in the population and a location of a provider who services patients in the population;

using a computing device to transform past healthcare claims generated by the population into data representing a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population;

periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements;

using a computing device to transform data representing past practice patterns of providers in the health economic zone into identification of a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone;

prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and

responding to healthcare requests from the population by determining whether patients submitting requests are seeking to obtain healthcare services from providers in the first group of providers, and for a patient requesting services from one of the other providers, communicating with the patient before the patient consumes the services from the provider to urge the submitting patient to obtain the requested healthcare services from a provider in the first group of providers.

2. The method of claim 1 wherein the step of identifying a first group of providers includes the steps of performing an individual calculation for each provider in the health economic zone to determine the provider'"'"'s cost efficiency index, and assigning a non-certified designation to each provider having cost efficiency index that fails to satisfy a first predetermined condition.

3. The method of claim 2 wherein the step of identifying a first group of providers includes the steps of performing an individual analysis for each provider to determine the provider'"'"'s service rate, and assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition.

4. The method of claim 3 wherein the step of identifying a first group of providers includes the steps of evaluating the practice patterns of each provider, and assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition.

5. The method of claim 4 wherein the step of identifying a first group of providers includes the steps of assigning a qualified designation to each provider having a cost efficiency index, a service rate, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively.

6. The method of claim 3 wherein the step of determining a service rate for each provider includes the step of evaluating the number and types of preventative care services ordered by each provider for the treatment of a chronic illness.

7. The method of claim 1 further including the steps of ranking the other providers in the health economic zone based on an analysis of the quality and cost efficiency of practice patterns associated with the other providers, dividing the ranking of providers into a second group of other providers having a common characteristic and a third group of other providers having a common characteristic, and determining the group into which the provider associated with the request falls.

8. The method of claim 7 wherein the step of responding to healthcare requests includes the step of urging the patient to use a second group provider if the associated provider is a third group provider.

9. The method of claim 8 wherein the step of responding to healthcare requests includes the step of conducting a first set of intervention actions if the patient uses a second group provider, the first set of intervention actions corresponding to a first degree of involvement of a healthcare quality management representative in the provision of services by the second group provider.

10. The method of claim 9 wherein the step of responding to healthcare requests includes the step of conducting a second set of intervention actions if the patient uses a third group provider, the second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management representative in the provision of services by the third group provider, the second degree of involvement being greater than the first degree of involvement.

11. The method of claim 7 wherein the step of ranking the other providers includes the step of assigning a cost efficiency index to each of the other providers.

12. The method of claim 7 wherein the step of ranking the other providers includes the step of evaluating a practice pattern characteristic of each of the other providers including one of procedures not appropriate for an associated diagnosis, procedures performed too frequently, upcoded procedures, invalid coding data, and procedures billed with non-specific diagnosis.

13. The method of claim 1 wherein the assessing step includes the step of comparing costs associated with healthcare services in the health economic zone with costs of similar healthcare services in a geographic area that is larger than the health economic zone.

14. The method of claim 1 wherein the assessing step includes accessing information describing healthcare claims of healthcare consumers in the health economic zone and healthcare consumers outside the health economic zone.

15. The method of claim 1 wherein the step of identifying a first group of patients includes the step of identifying patients suffering from at least one chronic illness.

16. The method of claim 1 wherein the step of identifying a first group of patients includes the step of assigning a healthcare index to each patient based upon factors including age and gender of the patient.

17. The method of claim 1 wherein the step of identifying a first group of providers includes the steps of identifying episodes of healthcare for each of the providers in the health economic zone and comparing characteristics of the episodes of healthcare with characteristics of similar episodes of healthcare associated with providers in a geographic area that is larger than the health economic zone.

18. The method of claim 1 wherein the prompting patients step includes the step of urging the patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services from providers in the first group of providers.

19. The method of claim 1 wherein the prompting patients step includes the step of contacting the providers of the patients who have not obtained healthcare services that satisfy the predetermined requirements in an effort to persuade the patients to obtain additional services.

20. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and administered by a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:

using a computing device to rank providers in the health economic zone based on an analysis of the quality and cost efficiency of practice patterns associated with the providers;

using the computing device to divide the ranking of providers into a first plurality of providers, a second plurality of providers, and a third plurality of providers;

responding to healthcare requests from patients by using the computing device to determine the plurality of providers into which the provider associated with the request falls;

using an electronic communication device to urge patients requesting to use a provider in the second plurality of providers to use a provider in the first plurality of providers;

using an electronic communication device to urge patients requesting to use a provider in the third plurality of providers to use a provider in the second plurality of providers;

conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider used by the patient if the used provider is in the second plurality of providers; and

conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the used provider if the used provider is in the third plurality of providers, the second degree of involvement being greater than the first degree of involvement.

21. The method of claim 20 further including the step of identifying a first group of patients likely to generate expensive healthcare claims relative to other patients based on data representing past healthcare claims generated by the patients.

22. The method of claim 21 further including the step of periodically determining whether patients in the first group of patients have obtained healthcare services that satisfy predetermined requirements.

23. The method of claim 22 further including the step of prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements.

24. A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:

for each healthcare provider in a health economic zone, using a computing device to perform an individual calculation based upon past claims information to determine a cost efficiency index;

assigning a non-certified designation to each provider having a cost efficiency index that fails to satisfy a first predetermined condition;

for each provider, using a computing device to perform an individual analysis based upon the past claims information to determine a service rate;

assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition;

using a computing device to evaluate practice patterns of each provider based upon the past claims information;

assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition;

assigning a qualified designation to each provider having a cost efficiency index, a service rate, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively; and

responding to a request from a patient for healthcare services by communicating with the patient to urge the patient to obtain the services from a provider having a qualified designation.

25. The method of claim 24 further including the step of identifying a first group of patients from the patient population likely to generate expensive healthcare claims relative to other patients in the population based on data representing past healthcare claims generated by the population.

26. The method of claim 25 further including the step of periodically determining whether patients in the first group of patients have obtained healthcare services that satisfy predetermined requirements.

27. The method of claim 26 further including the step of prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers having a qualified designation.

28. The method of claim 25 wherein the step of identifying a first group of patients includes the step of identifying patients suffering from at least one chronic illness.

29. The method of claim 25 wherein the step of identifying a first group of patients includes the step of assigning a healthcare index to each patient based upon factors including age and gender of the patient.

30. The method of claim 24 further including the step of assessing a healthcare situation of the employer by comparing costs associated with healthcare services provided by the providers in the health economic zone to costs of similar healthcare services provided by providers in a geographic area that is larger than the health economic zone.

31. The method of claim 24 further including the step of comparing demographic and wellness information relating to the patients to demographic and wellness information relating to other healthcare consumers in the health economic zone.

32. The method of claim 24 further including the steps of ranking the providers having a non-certified designation, dividing the ranking of providers into a first plurality of providers and a second plurality of providers, and determining the plurality of providers into which the provider associated with the request falls.

33. A method of optimizing health services consumption of patients in a healthcare plan administered within a geographic area, the method including the steps of:

using a computing device to rank providers located in the geographic area based on an analysis of the quality and cost efficiency of practice patterns associated with the providers;

using the computing device to divide the ranking of providers into a first level of providers and a second level of providers; and

responding to a healthcare request from a patient requesting services from a second level provider by accessing the ranking of providers to identify providers having a first level ranking located within a selectable distance from the patient, and contacting the requesting patient using an electronic communication device to urge the requesting patient to use one of the identified first level providers.

34. The method of claim 33 wherein the selectable distance is a radius originating at a location of the patient.

35. A method of optimizing healthcare services consumption, including the steps of:

assessing a healthcare situation of an employer who provides healthcare benefits to a population that resides and consumes healthcare services in a health economic zone;

using a computing device to transform past healthcare claims generated by the population into data representing a first group of patients from the population likely to generate expensive healthcare claims relative to other patients in the population;

periodically determining whether patients in the first group have obtained healthcare services that satisfy predetermined requirements;

using a computing device to transform data representing past practice patterns of the first group of providers and the other providers into identification of a first group of providers in the health economic zone who provide high quality, cost efficient healthcare services relative to other providers in the health economic zone;

prompting patients who have not obtained healthcare services that satisfy the predetermined requirements to obtain additional healthcare services to satisfy the predetermined requirements from providers in the first group of providers; and

responding to healthcare requests from the population by determining whether a patient submitting a request is seeking to obtain healthcare services from a provider in the first group of providers, and, if not, contacting the submitting patient to urge the submitting patient to obtain healthcare services for the request from a provider in the first group of providers.

36. A method of optimizing healthcare services consumption of patients in a healthcare plan, the method including the steps of:

using a computing device to rank individual healthcare providers based on historical claims data;

based on the individual rankings, using the computing device to identify a first group of providers, a second group of providers, and a third group of providers;

participating in the provision of healthcare services at a first level for patients choosing to obtain services from a provider in the second group; and

participating in the provision of healthcare services at a second level for patients choosing to obtain services from a provider in the third group, the second level corresponding to a greater degree of participation than the first level.

37. A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:

for each provider servicing the population, using a computing device to perform an individual assessment of past claims information to determine a cost efficiency index, a service rate, and a practice patterns challenge rate

using the computing device to assign a qualified designation to each provider having an acceptable cost efficiency index, service rate, and practice patterns challenge rate; and

performing an action after a request for healthcare services by a patient, the action being directed specifically to the requesting patient in an attempt to persuade the requesting patient to obtain the services from a provider having a qualified designation.

38. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:

(A) executing software to access data representing past practice patterns of the providers;

(B) using a computing device to rank each provider based on quality and cost efficiency characteristics of the past practice patterns associated with the provider;

(C) using the computing device to divide the ranking of providers into a first plurality of providers, a second plurality of providers, and a third plurality of providers;

(D) responding to requests for healthcare services from patients by determining the plurality of providers into which the provider associated with the request falls;

(E) when a patient requests to use a provider in the second plurality of providers, using an electronic communication device to contact the patient before the patient consumes the requested services to urge the patient to use a provider in the first group of providers;

(F) when a patient requests to use a provider in the third plurality of providers, using an electronic communication device to contact the patient before the patient consumes the requested services to urge the patient to use a provider in one of the first plurality of providers and the second plurality of providers;

(G) when a patient uses a provider in the second plurality of providers, conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider in the second plurality of providers; and

(H) when a patient uses a provider in the third plurality of providers, conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the provider in the third plurality of providers, the second degree of involvement being greater than the first degree of involvement.

39. A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer, including the steps of:

(A) transforming using a computing device past healthcare claims data generated by the patients into data representing a first group of patients likely to generate expensive healthcare claims relative to other patients in the healthcare plan;

(B) transforming using a computing device past practice patterns data of providers who provide services to the patients into data representing a first group of providers who provide high quality, cost efficient healthcare services relative to other providers of the patients;

(C) periodically determining whether patients in the first group suffer from one or more chronic conditions;

(D) 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

(E) 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.