System and method for assessing healthcare risks

• US 9,058,629 B2
• Filed: 10/17/2003
• Issued: 06/16/2015
• Est. Priority Date: 10/17/2003
• Status: Active Grant

• Current Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Original Assignee: Optuminsight, Inc. (UnitedHealth Group Incorporated)
• Inventors: Dunn, Daniel L., Celebi, Dogu
• Primary Examiner(s): Le, Michelle L
• Application Number:
  US10/688,858
• Publication Number:
  US 20050086076A1
• Time in Patent Office: 4,260 Days
• Field of Search: 705 2- 4
• US Class Current: 1/1
• CPC Class Codes: G06Q 40/08 Insurance
• 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

Abstract

A system and method for receiving demographic data on a patient and data on at least one pharmacy service prescribed for the patient; assigning a unique drug class to each pharmacy service; using the unique drug classes for ordering the pharmacy services according to a predetermined hierarchy of classes; and providing a risk score for the patient using the ordered pharmacy services.

Claims

1. A computer-implemented method for assessing risk of insuring a healthcare patient;

the method comprising one or more computers performing the following;

receiving demographic data on a patient and prescription data for each prescription filled by the patient;

assigning the prescription data for each prescription to at least one risk group based upon at least one medical condition typically treated by the prescription;

storing risk data for the patient, wherein the risk data includes the risk groups for all prescription data of the patient; and

calculating a risk score for the patient based upon the risk data and the demographic data of the patient.

2. The method of claim 1, wherein the step of assigning the prescription data to at least one risk group comprises using national drug codes to classify each prescription.

3. The method of claim 2, wherein the step of assigning the prescription data to at least one risk group further comprises categorizing each national drug code classification into one of a number of pharmacy risk groups.

4. The method of claim 1, further comprising defining additional member risk markers based on patient age and other characteristics known to indicate that the patient belongs to a high risk category and using the additional member risk markers to calculate the patient'"'"'s risk score.

5. The method of claim 1, further comprising providing a clinical and demographic risk profile for the patient based on the patient'"'"'s age, gender and a mix of clinical and demographic risk profiles and using the patient'"'"'s clinical and demographic risk profile to calculate the patient'"'"'s risk score.

6. The method of claim 5, further comprising providing multiple patient risk markers for patients with pharmacy services that indicate multiple medical conditions.

7. The method of claim 1, wherein each risk group is assigned a numerical risk value based upon the patient'"'"'s demographic data, and the patient'"'"'s risk score is the sum of the numerical risk values of the risk groups in the patient'"'"'s risk data.

8. The method of claim 7, wherein the risk score is computed using predetermined weights and a patient'"'"'s patient risk marker profile.

9. The method of claim 3, wherein the pharmacy risk groups comprise patient risk markers.

10. An information processing system comprising:

a computer processor for;

receiving demographic data on a patient and prescription data for each prescription prescribed for the patient;

assigning the prescription data for each prescription to at least one risk group based upon at least one medical condition typically treated by the prescription;

storing risk data for the patient in an associated database, wherein the risk data includes the risk groups for all prescription data of the patient; and

calculating a risk score for the patient based upon the risk data and the demographic data of the patient.