Health care incentive apparatus and method

Abstract

An embodiment of the invention provides, among other things, a method for providing a cost modification of a health care item for a subject. In an example method, a request is received for a health care item from a point of purchase of the health care item. Cost adjustment data is received from at least one source. The cost adjustment data is used to determine a cost modification for the health care item. The cost modification is communicated to a point of purchase of the health care item.

What is claimed is: 
     
         1 . A method for adjusting a cost for a health care item purchased under a health care plan, the method comprising:
 receiving a request for the health care item; and   for at least one product option corresponding to the requested health care item:
 receiving a total cost for the product option; 
 receiving a cost distribution for the total cost, wherein the cost distribution comprises a health care plan cost and one of more of a co-payment amount, a co-insurance amount, or a deductible amount; 
 receiving a coupon amount related to the product option; 
 adjusting one or more of the co-payment amount, the co-insurance amount, or the deductible amount based on the coupon amount; 
 adjusting the cost distribution based on the adjusted one or more of the co-payment amount, co-insurance amount, or deductible amount; and 
 delivering the adjusted cost distribution for the product option to a recipient. 
   
     
     
         2 . The method of  claim 1 , wherein the adjusting the cost distribution is performed in real time. 
     
     
         3 . The method of  claim 1 , wherein the health care item is a pharmaceutical product; and
 wherein each of the at least one product option is one or more of the requested health care item and therapeutically equivalent options.   
     
     
         4 . The method of  claim 1 , wherein said delivering comprises:
 preparing an explanation of benefits (EOB), including the total cost and the adjusted cost distribution for the product option; and   sending the EOB to the recipient.   
     
     
         5 . The method of  claim 1 , further comprising:
 for at least one additional product option corresponding to the requested health care item:
 receiving a total cost and a cost distribution for the additional product option; and 
 delivering the cost distribution for the additional product option to the recipient. 
   
     
     
         6 . The method of  claim 5 , wherein the delivering adjusted cost distribution for the product option comprises:
 preparing an explanation of benefits (EOB) including the retrieved total cost and the adjusted cost distribution for the product option; and   sending the EOB to the recipient;   wherein the delivering the adjusted cost distribution for the additional product option comprises:   adding the received total cost and the cost distribution for the additional product option to the prepared EOB before the sending.   
     
     
         7 . The method of  claim 1 , wherein the receiving a cost distribution comprises receiving a health plan design;
 wherein the health plan design comprises the health plan cost and the one or more of the co-payment amount, the co-insurance amount, or the deductible amount.   
     
     
         8 . The method of  claim 7 , wherein the health care item comprises a pharmaceutical product;
 wherein the health care plan further comprises a formulary;   wherein the method further comprises:   selecting each of the at least one product option based on the formulary.   
     
     
         9 . The method of  claim 1 , wherein the request is received from a health care provider. 
     
     
         10 . The method of  claim 1 , wherein the request is received from a health care plan participant;
 wherein the request is sent from a point of purchase and/or a web portal.   
     
     
         11 . The method of  claim 1 , wherein the recipient is one of a health care plan participant, a health care provider, and a health care payor. 
     
     
         12 . A method for adjusting a cost for a health care item purchased under a health care plan, the method comprising:
 receiving a request for the health care item; and   for at least one product option corresponding to the requested health care item:
 receiving a total cost for the product option; 
 receiving a cost distribution for the total cost, wherein the cost distribution comprises a health care plan cost and one of more of a co-payment amount, a co-insurance, or a deductible amount; 
 receiving subject compliance data; 
 adjusting one or more of the co-payment amount, the co-insurance amount, or the deductible amount based on the compliance data; 
 adjusting the cost distribution based on the adjusted co-payment amount, co-insurance amount, or deductible amount; and 
 delivering the adjusted cost distribution for the product option to a recipient. 
   
     
     
         13 . The method of  claim 12 , wherein the subject compliance information comprises claims information, a medical record, and/or a personal health assessment. 
     
     
         14 . The method of  claim 12 , wherein the adjusting a cost distribution comprises:
 decreasing or increasing the co-payment, co-insurance, or deductible based on whether the subject compliance information indicates compliance with a health incentive.   
     
     
         15 . The method of  claim 12 , further comprising:
 retrieving subject eligibility data; and   wherein the adjusting a cost distribution is further based on the retrieved subject eligibility data.   
     
     
         16 . The method of  claim 12 , wherein said delivering comprises:
 preparing an explanation of benefits (EOB), including the retrieved total cost and the adjusted cost distribution for the product option, and a portion of retrieved subject compliance information; and   sending the EOB to the recipient.   
     
     
         17 . The method of  claim 12 , wherein the request is received from a health care plan participant;
 wherein the recipient is the health plan participant;   wherein the request is sent from a web portal;   further comprising:
 receiving additional subject compliance data from the health plan participant; 
 re-adjusting the cost distribution based on the additional subject compliance data; and 
 delivering the re-adjusted cost distribution to the health care plan participant. 
   
     
     
         18 . An apparatus for adjusting a cost for a health care item, the apparatus comprising a non-transitory computer-readable medium containing computer-readable instructions for causing a computer to perform a method comprising:
 receiving a request for the health care item;   receiving subject compliance data; and   for at least one product option corresponding to the requested health care item:
 receiving a total cost for the product option; 
 receiving a cost distribution for the total cost, wherein the cost distribution comprises a health care plan cost and one of more of a co-payment amount, a co-insurance amount, or a deductible amount; 
 receiving a coupon amount related to the product option; 
 adjusting one or more of the co-payment amount, the co-insurance amount, or the deductible amount based on the coupon amount and the subject compliance data; 
 adjusting the cost distribution based on the adjusted one or more of the co-payment amount, co-insurance amount, or deductible amount; and 
 delivering the adjusted cost distribution for the product option to a recipient. 
   
     
     
         19 . The apparatus of  claim 18 , wherein the adjusting one or more of the co-payment amount, co-insurance amount, or deductible amount is dynamic, and wherein the recipient is at a point of purchase for the health care item.