Method of optimizing healthcare services consumption

• US 8,489,420 B2
• Filed: 07/07/2011
• Issued: 07/16/2013
• Est. Priority Date: 12/06/2002
• Status: Expired due to Term

• Current Assignee: Quality Healthcare Intermediary LLC
• Original Assignee: Quality Healthcare Intermediary LLC
• Inventors: Dust, Larry R., Cook, David B.
• Primary Examiner(s): NGUYEN, TRAN N
• Application Number:
  US13/178,174
• Publication Number:
  US 20120010898A1
• Time in Patent Office: 740 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 a population of patients, the assessing step including the steps of

identifying a plurality of geographic regions,

associating with a computer an address of each patient with a geographic region,

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

aggregating with the computer the geographic regions into a geographic zone;

performing a computerized analysis of information about the health of the patients and stored in a database to identify a first group of patients likely to have a higher consumption of healthcare services than other patients in the population;

accessing a computerized analysis of information about the practices of the providers in the geographic zone that identifies a first group of providers who provide high quality, cost efficient healthcare services; and

initiating a communication with a patient who has obtained services from a provider who is not in the first group of providers before the patient consumes additional services from the provider to urge the patient to obtain the additional services from a provider in the first group of providers.

2. The method of claim 1, wherein the computerized analysis of information about the practices of the providers includes the step of determining a cost efficiency index for each provider based on data stored in the database by:

determining an average cost (AC1) for an episode of healthcare associated with the provider,

determining an average cost (AC2) for similar episodes of healthcare treated by other providers who provide the same service as the provider, and dividing AC1 by AC2.

3. The method of claim 2, further including the step of determining whether the cost efficiency index is less than a first predetermined threshold.

4. The method of claim 3, wherein the computerized analysis of information about the practices of the providers includes the steps of:

determining a service rating for each provider based on data stored in the database by determining a number (N1) of services ordered by the provider for treatment of a plurality of conditions, determining a number (N2) of preventative care services required to satisfy a predetermined set of preventative care services corresponding to the plurality of conditions, and dividing N1 by N2.

5. The method of claim 4, further including the steps of:

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

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

6. The method of claim 5, wherein the computerized analysis of information about the practices of the providers includes the steps of:

determining a practice patterns challenge rate for each provider based on data stored in the database by determining a total number (T1) of undesirable practice characteristics associated with the provider,

determining a typical number (T2) of undesirable practice characteristics associated with other providers who provide the same service as the provider, and dividing T1 by T2.

7. The method of claim 6, further including the step of determining whether the practice patterns challenge rate is less than a third predetermined threshold.

8. The method of claim 7, wherein the computerized analysis of information about the practices of the providers 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.

9. The method of claim 8, wherein the computerized analysis of information about the practices of the providers includes the steps of:

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

10. 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 geographic zone and healthcare consumers in a larger geographic area that includes the geographic zone; and

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

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

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

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

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

determining a total cost (TC2) of all allowed healthcare charges for the 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 service per consumer in the larger geographic area over the time period; and

comparing AC1 to AC2.

12. 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 geographic zone; and

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

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

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

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

dividing TC2 by TN2 to determine an average cost (AC1) for the service per consumer in the geographic zone 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 geographic zone equaling TN1; and

comparing TC1 to EC1.

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

determining a total cost (TC1) of all allowed healthcare charges for a 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 service during the time period;

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

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

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

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

comparing TC1 to EC1.

15. The method of claim 1, wherein the computerized analysis of information about the practices of the providers 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 service; and

outputting a report depicting results of the comparing step.

16. The method of claim 15, 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.

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

18. 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 geographic zone, 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 geographic, the individual healthcare indices being computed using data representing at least age, sex, and health condition of the consumers.

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

20. The method of claim 1, wherein the step of performing a computerized analysis of information about the health of the patients 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 data 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 geographic zone.

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

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

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

instructing 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.

22. A method of optimizing healthcare services consumption of patients receiving benefits administered by a healthcare quality management firm in a geographic region that corresponds to residences of the patients and locations of providers used by the patients, the method including the steps of:

receiving a ranking of providers in the geographic region based on an analysis of information about the practices of the providers

the ranking of providers including a first plurality of providers, a second plurality of providers, and a third plurality of providers;

using a computing device to determine which patients have obtained services from a provider in one of the second plurality of providers and the third plurality of providers;

attempting to communicate with patients who have obtained services from a provider in the second plurality of providers to urge the patients to obtain future services from a provider in the first plurality of providers;

attempting to communicate with patients who have obtained services from a provider in the third plurality of providers to urge the patients to obtain future services from 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 providers 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 providers in the third plurality of providers, the second degree of involvement being greater than the first degree of involvement.

23. The method of claim 22, further including the step of identifying a first group of patients likely to have a higher consumption of healthcare services than other patients based on data representing past healthcare data generated by the patients.

24. The method of claim 23, further including the step of periodically determining whether patients in the first group of patients have obtained healthcare services that satisfy predetermined requirements.

25. The method of claim 24, 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.

26. A method of optimizing healthcare services consumption by patients of a population, the method including the steps of:

for each healthcare provider in a geographic region, using a computing device to perform an individual calculation based upon past 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 information to determine a service rating;

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

using a computing device to evaluate practice patterns of each provider based upon the past 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 rating, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively; and

attempting to communicate with patients who have obtained healthcare services from a provider having a non-certified designation to urge the patients to obtain services from a provider having a qualified designation.

27. The method of claim 26, further including the step of identifying a first group of patients from the population likely to have a higher consumption of healthcare services than other patients in the population based on information about the past health of the patients in the population.

28. The method of claim 27, further including the step of periodically determining whether patients in the first group of patients have obtained healthcare services that satisfy predetermined requirements.

29. The method of claim 28, 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.

30. The method of claim 27, wherein the step of identifying a first group of patients includes the step of identifying patients suffering from at least one illness.

31. The method of claim 27, 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.

32. The method of claim 26, further including the step of comparing costs associated with healthcare services provided by the providers in the geographic region to costs of similar healthcare services provided by providers in a geographic area that is larger than the geographic region.

33. The method of claim 26, 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 geographic region.

34. A method of optimizing health services consumption of patients in 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 information about the practices of the providers;

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

identifying a patient who has received services from a second level provider;

accessing the ranking of providers to identify providers having a first level ranking located within a selectable distance from the patient; and

contacting the patient to urge the patient to use one of the identified first level providers.

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

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

receiving a computerized ranking of all healthcare providers who participate in the program based on historical data;

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

participating in the provision of healthcare services at a first level when a patient obtains services from a provider in the second subset; and

participating in the provision of healthcare services at a second level when a patient obtains services from a provider in the third subset, the second level corresponding to a greater degree of participation than the first level.

37. A method of optimizing healthcare services consumption by a population of patients, the method including the steps of:

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

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

38. A method of optimizing healthcare services consumption of patients in a geographic region that corresponds to residences of the patients and locations of providers used by the patients, the method including the steps of:

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

performing a computerized ranking of each provider based on quality and cost efficiency characteristics of the past practice patterns associated with the provider;

using a 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;

determining the plurality of providers into which a provider associated with a patient'"'"'s consumption of healthcare services falls;

when the provider of the determining step is in the second plurality of providers, initiating a communication with the patient to urge the patient to obtain services from a provider in the first group of providers;

when the provider of the determining step is in the third plurality of providers, initiating a communication with the patient to urge the patient to obtain services from a provider in one of the first plurality of providers and the second plurality of providers;

when a patient obtains services from a provider in the second plurality of providers, conducting a 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 provider in the second plurality of providers; and

when a patient obtains services from 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 representative 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 a population of patients who receive healthcare services from a group of healthcare providers as a benefit administered by an entity, including the steps of:

identifying a subset of patients from the population likely to have a higher consumption of healthcare services than other patients in the population by using a computing device to analyze information about the past health of the patients in the population;

accessing an identification of a subset of providers from the group of providers who provide high quality, cost efficient healthcare services relative to other providers in the group, the subset being identified by using a computing device to analyze information about the past practices of the providers in the group; and

attempting to contact patients in the subset of patients who have obtained healthcare services from providers not in the subset of providers to urge those patients to obtain future healthcare services from providers in the subset of providers.

40. The method of claim 39, further including the step of periodically determining whether patients in the subset of patients have obtained healthcare services that satisfy predetermined requirements.

41. The method of claim 40, further including the step of prompting patients in the subset of 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 subset of providers.

42. The method of claim 41, further including the step of contacting providers of the patients who have not obtained healthcare services that satisfy the predetermined requirements.

43. The method of claim 39, further including the step of identifying a geographic zone that consists of a plurality of geographic regions, each geographic region including at least one of a residential address of a patient in the population and a location of a provider in the group of providers.

44. The method of claim 43, further including the step of comparing costs of healthcare services provided to the population of patients in the geographic zone with the costs of similar healthcare services provided to patients not in the population of patients.

45. The method of claim 39, wherein the step of identifying a subset of patients includes the step of identifying patients suffering from at least one illness.

46. The method of claim 45, wherein the step of identifying a subset of patients includes the step of using the computing device to compute an individual healthcare index for each patient in the population.

47. The method of claim 39, further including the steps of

ranking the other providers based on an analysis of the quality and cost efficiency of practice patterns associated with the other providers, and

dividing the ranking into a second group of providers and a third group of providers, the second group having a higher ranking than the third group.

48. The method of claim 47, further including the step of attempting to contact patients in the subset of patients who have obtained healthcare services from a provider in the third group of providers to urge those patients to obtain future healthcare services from providers in the second group of providers.

49. The method of claim 39, wherein the information about the past health of the patients in the population includes past healthcare data.

50. The method of claim 39, wherein the information about the past practices of the providers in the group includes past practice patterns data.

51. The method of claim 39, wherein the entity includes at least one of an employer and a third party administrator.

52. The method of claim 39, wherein the identification of the subset of providers includes the steps of identifying episodes of healthcare for each of the providers in the group and comparing characteristics of the episodes with characteristics of similar episodes of healthcare associated with providers not in the group.

53. The method of claim 39, wherein the identification of the subset of providers includes the step of comparing practice-related characteristics of each of the providers in the group to a set of predetermined conditions.

54. A method of optimizing healthcare services consumption of a population of patients who receive services from providers, including the steps of:

performing a computerized analysis of information about the past health of the patients to identify a group of patients having a high likelihood of requiring healthcare services;

accessing a computerized analysis of information about the practices of the providers to identify a group of preferred providers; and

attempting to contact a patient in the group to urge the patient to obtain future services from a preferred provider.

55. A system for optimizing healthcare services consumption of a population of patients who receive services from providers, including:

a first computing device;

a database coupled to the first computing device; and

a second computing device coupled to the first computing device via at least one network;

wherein the first computing device receives patient information about the past health of the patients over the at least one network, stores the patient information in the database, and executes software which analyzes the patient information to identify a group of patients having a high likelihood of requiring healthcare services;

wherein the first computing device receives provider information about the practices of the providers, stores the provider information in the database, and receives via the at least one network an analysis of the provider information performed by the second computing device that identifies a group of preferred providers; and

wherein the first computing device generates at least one report identifying the group of patients and the preferred providers to facilitate attempts to contact a patient in the group to urge the patient to obtain future services from a preferred provider.

56. A system for optimizing healthcare services consumption by a population of patients, including:

a first computing device coupled to a database and configured to receive past information from a second computing device via a network, the past information including information about practices of healthcare providers who provide services to the patients;

wherein the first computing device further includes software having instructions which, when executed by the first computing device, cause the first computing device to

perform an individual assessment for each provider of past information to determine a cost efficiency index, a service rating, and a practice patterns challenge rate

assign a qualified designation to each provider having an acceptable cost efficiency index, service rating, and practice patterns challenge rate, and

perform an action after a patient obtains healthcare services, the action being directed specifically to attempt to persuade the patient to obtain future services from a provider having a qualified designation.

57. A system for optimizing healthcare services consumption of a population of patients who receive services from providers, including:

a first computing device;

a database coupled to the first computing device;

a second computing device coupled to the first computing device via at least one network; and

a third computing device coupled to the first computing device via the at least one network;

wherein the first computing device receives patient information about the past health of the patients over the at least one network, stores the patient information in the database, and executes software which analyzes the patient information to identify a group of patients having a high likelihood of requiring healthcare services;

wherein the first computing device receives provider information about the practices of the providers, stores the provider information in the database, and executes software which analyzes the provider information to identify a group of preferred providers; and

wherein the first computing device generates at least one report identifying the group of patients and the preferred providers to facilitate attempts to contact a patient in the group to urge the patient to obtain future services from a preferred provider.