Method of optimizing healthcare services consumption

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.

What is claimed is: 
     
         1 . A method of optimizing healthcare services consumption, including the steps of:
 assessing a healthcare situation of a population of patients that reside and consume healthcare services in a geographic zone, the geographic zone consisting of a plurality of 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 information generated by the population into data representing a first group of patients from the population likely to have a higher consumption of healthcare services than 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 information about providers in the geographic zone into identification of a first group of providers in the geographic zone who provide high quality, cost efficient healthcare services relative to other providers in the geographic 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   communicating with patients to urge the patients to obtain the healthcare services from a provider in the first group of providers.   
     
     
         2 . The method of  claim 1 , wherein the assessing step includes the step of comparing costs associated with healthcare services in the geographic zone with costs of similar healthcare services in a geographic area that is larger than the geographic region. 
     
     
         3 . The method of  claim 1 , wherein the assessing step includes accessing information describing healthcare data of healthcare consumers in the geographic zone and healthcare consumers outside the geographic zone. 
     
     
         4 . The method of  claim 1 , wherein the step of using a computing device to transform healthcare information includes the step of identifying patients suffering from at least one illness. 
     
     
         5 . The method of  claim 1 , wherein the step of using a computing device to transform healthcare information includes the step of assigning a healthcare index to each patient based upon factors including age and gender of the patient. 
     
     
         6 . The method of  claim 1 , wherein the step of using a computing device to transform information about providers includes the steps of identifying episodes of healthcare for each of the providers in the geographic 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 geographic region. 
     
     
         7 . The method of  claim 1 , wherein the step of using a computing device to transform information about providers includes the steps of performing an individual calculation for each provider in the geographic 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. 
     
     
         8 . The method of  claim 7 , wherein the step of using a computing device to transform information about providers includes the steps of performing an individual analysis for each provider to determine the provider's service rating, and assigning a non-certified designation to each provider having a service rating that fails to satisfy a second predetermined condition. 
     
     
         9 . The method of  claim 8 , wherein the step of determining a service rating for each provider includes the step of evaluating the number and types of services ordered by each provider for the treatment of a illness. 
     
     
         10 . The method of  claim 8 , wherein the step of using a computing device to transform information about 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. 
     
     
         11 . The method of  claim 10 , wherein the step of using a computing device to transform information about providers includes the steps of 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. 
     
     
         12 . 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. 
     
     
         13 . The method of  claim 1 , wherein the prompting patients step includes the step of attempting to contact 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. 
     
     
         14 . The method of  claim 1 , further including the steps of ranking the other providers in the geographic 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. 
     
     
         15 . The method of  claim 14 , wherein the step of ranking the other providers includes the step of assigning a cost efficiency index to each of the other providers. 
     
     
         16 . The method of  claim 14 , wherein the step of ranking the other providers includes the step of evaluating a practice pattern characteristic of each of the other providers. 
     
     
         17 . The method of  claim 14 , wherein the step of communicating with patients includes the step of urging patients who have obtained services from a third group provider to obtain future services from a second group provider. 
     
     
         18 . The method of  claim 17 , wherein the step of communicating with patients 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. 
     
     
         19 . The method of  claim 18 , wherein the step of communicating with patients 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. 
     
     
         20 . A method of optimizing healthcare services consumption, including the steps of:
 assessing a healthcare situation of a population that resides and consumes healthcare services in a geographic region;   using a computing device to transform past healthcare data generated by the population into data representing a first group of patients likely to have a higher consumption of healthcare services than 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 of healthcare services to the patients into data representing a first group of providers in the geographic region who provide high quality, cost efficient healthcare services relative to other providers in the geographic region;   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;   determining whether a patient has obtained healthcare services from a provider not in the first group of providers; and   contacting the patient to urge the patient to obtain healthcare services from a provider in the first group of providers.   
     
     
         22 . A method of optimizing healthcare services consumption of a patient population, including the steps of:
 transforming using a computing device past data generated by the patients into data representing a first group of patients likely to have a higher consumption of healthcare services than other patients in the population;   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;   periodically determining 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   initiating a communication with a patient who has not obtained healthcare services that satisfy the predetermined set of MACR to instruct the patient to obtain additional healthcare services to satisfy the predetermined set of MACR from a provider in the first group of providers.   
     
     
         23 . A system for optimizing healthcare services consumption of a patient population, including:
 a first computing device;   a database coupled to the first computing device; and   at least one additional computing device coupled via a network to at least one of the first computing device and the database that provides past data generated by the patients and past practice patterns data of providers who provide services to the patients for storage in the database;   wherein the first computing device includes software having instructions which, when executed by the first computing device, causes the first computing device to
 transform the past data generated by the patients into data representing a first group of patients likely to have a higher consumption of healthcare services than other patients in the population, 
 transform the past practice patterns data into data representing a first group of providers who provide high quality, cost efficient healthcare services relative to other providers of the patients, 
 periodically determine whether patients in the first group suffer from one or more conditions, 
 determine whether the patients suffering from one or more conditions have obtained healthcare services that satisfy a predetermined set of minimum annual care requirements (MACRs) associated with the one or more conditions, and 
 generate a report identifying a patient who has not obtained healthcare services that satisfy the predetermined set of MACRs to prompt communication with the patient to instruct the patient to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of providers. 
   
     
     
         24 . 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.