System and method for administering health care cost reduction

Abstract

A system and method for the efficient administration of health care plans, particularly as to the reduction and/or elimination of avoidable medical costs for select individuals who participate in the plan, is disclosed. Existing health care data is processed to determine an indication as to the relative desirability of an intervention in a plan participant's health care regimen. The data is also processed to determine the status of one or more flags, each of which potentially indicates the relative desirability of an intervention in a plan participant's health care regimen. A predictive model is used to determine the status of a flag relating to the likelihood of an insurance plan participant making a disability claim within a certain period of time. The information relating to desirability of an intervention in a plan participant's health care regimen, as well as a plan participant's medical information and claim history, is presented to case managers and/or health care providers in a user-friendly format.

What we claim is: 
     
         1 . A method for administering reductions in health care costs for those participants in a health insurance plan for whom future health care costs may be reduced through intervention (“intervention candidates”) comprising computer implemented steps of:
 extracting from a database participant data for each of a plurality of participants in the health insurance plan, the participant data comprising claims data representing at least one past claim, the past claim being one of a medical claim and a pharmacy claim, wherein: (a) the claims data representing the medical claim represents one or more of a procedure physically performed on or in connection with the participant, and a diagnosis of a disease or condition physically afflicting the participant, and (b) the claims data representing the pharmacy claim represents at least in part a drug physically administered to the participant; 
 executing a predictive model program using the participant data to generate an output, the predictive model program comprising computer executable instructions for determining a likelihood of occurrence of at least one predetermined future event, the event associated with utilization of health care services, the predictive model having been created using historical claims data from a sample of individuals, the predictive model program being stored on a non-transitory computer readable medium of at least one information server connected to the database; 
 determining, from the output of the execution of the predictive model program, via the at least one information server, a first score for an intervention candidate using the participant data, which first score reflects a predicted utilization of future health care services; 
 determining, via the at least one information server, a second score for the intervention candidate using the participant data, which second score is a function of the extent of the intervention candidate's prior consumption of a plurality of different predetermined health care services over a predetermined time interval, the second score reflecting relative desirability of intervention in a health care regimen of the intervention candidate; 
 comparing, via the at least one information server, the first score against a first threshold value and the second score against a second threshold value to identify at least one intervention candidate eligible for intervention and generating a result of such comparison and; 
 presenting a graphical user interface for providing to a select individual electronic access to a health care history of the at least one eligible intervention candidate and the result of the comparison, the graphical user interface including a display of historical information based at least in part on the participant data associated with the at least one eligible intervention candidate and adapted to facilitate intervention in the health care regimen of the at least one eligible intervention candidate based on the result of the comparison. 
 
     
     
         2 . The method of  claim 1 , wherein the second score is determined by adding a plurality of values, each value representing the intervention candidate's consumption of at least one of the plurality of different predetermined health care services. 
     
     
         3 . The method of  claim 2 , wherein one of the plurality of values is selected from the group consisting of: a value representing a number of medical specialists that treated the candidate, a value representing a number of inpatient admissions, a value representing a number of chronic diseases for which the candidate was treated, a value representing a number of prescriptions for unique drugs, a value representing an amount of medical claims allowed, and a value representing a number of emergency room visits without admission in a hospital. 
     
     
         4 . The method of  claim 1  wherein at least one of the plurality of different predetermined health care services is selected from the group consisting of:
 a unique drug prescription; 
 an instance of an inpatient admission; 
 an existence of a chronic disease or condition; 
 a unique medical specialty consultation; 
 an allowed medical claim exceeding a predetermined monetary threshold; and 
 an emergency room visit. 
 
     
     
         5 . The method of  claim 1  wherein the second score is determined based on a weighted matrix of values, each value associated with a corresponding scaling factor and representing the intervention candidate's consumption of at least one of the plurality of different predetermined health care services. 
     
     
         6 . The method of  claim 5  wherein one of the plurality of values in the matrix is selected from the group consisting of: a value representing a number of medical specialists that treated the candidate, a value representing a number of inpatient admissions, a value representing a number of chronic diseases for which the candidate was treated, a value representing a number of prescriptions for unique drugs, a value representing an amount of medical claims allowed, and a value representing a number of emergency room visits without admission in a hospital. 
     
     
         7 . The method of  claim 1 , wherein the step of generating a result includes generating a first result that indicates whether the first score exceeds the first threshold value, a second result that indicates whether the second score exceeds the second threshold value, and a composite result that represents both the first and second results. 
     
     
         8 . The method of  claim 1 , wherein the graphical user interface facilitates intervening by displaying the result of the comparison that causes a health care provider to contact the at least one eligible intervention candidate in order to recommend a change in the at least one eligible intervention candidate's health care regimen. 
     
     
         9 . The method of  claim 1  wherein the at least one information server is configured for generating a plurality of flags, wherein each flag has a status that represents the participant data associated with the intervention candidate. 
     
     
         10 . The method of  claim 9 , wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan. 
     
     
         11 . The method of  claim 1 , wherein the second score further indicates the potential for health care cost reduction of the intervention candidate as determined relative to other participants in the health insurance plan. 
     
     
         12 . A method for administering reductions in health care costs comprising:
 storing in a database health information relating to a plurality of health insurance plan participants;   identifying from stored health information candidates for whom health care costs may be reduced through intervention (“intervention candidates”);   generating a plurality of flags for each intervention candidate, wherein each flag has a status that represents a health condition of an intervention candidate and wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan;   storing the health information and flags for each intervention candidate in an separate database; and   permitting select individuals to retrieve and display via a graphical user interface each intervention candidate's health information and flags as stored in the separate database.   
     
     
         13 . The method of  claim 12  wherein the disability flag is determined from an output of a predictive model comprising computer executable instructions stored on a non-transitory computer readable medium and configured to determine a likelihood of an occurrence of a future disability claim by the intervention candidate based on the participant data. 
     
     
         14 . The method of  claim 13  wherein the output of the predictive model is selected from the group consisting of:
 (a) a binary prediction indicator whether the intervention candidate is likely to have at least one medically based disability claim within a predetermined time period; and 
 (b) a numerical indicator of probability that the intervention candidate will have the at least one medically based disability claim within the predetermined time period. 
 
     
     
         15 . The method of  claim 13  wherein the predictive model employs logistic regression. 
     
     
         16 . A method for administering reductions in health care costs for those participants in a health insurance plan for whom future health care costs may be reduced through intervention (“intervention candidates”) comprising computer implemented steps of:
 extracting from a database participant data for each of a plurality of participants in the health insurance plan, the participant data comprising claims data representing at least one past claim, the past claim being one of a medical claim and a pharmacy claim, wherein: (a) the claims data representing the medical claim represents one or more of a procedure physically performed on or in connection with the participant, and a diagnosis of a disease or condition physically afflicting the participant, and (b) the claims data representing the pharmacy claim represents at least in part a drug physically administered to the participant; 
 determining, via an information server connected to the database, an action score for the intervention candidate using the participant data, which action score is a function of the extent of the intervention candidate's prior consumption of a plurality of different predetermined health care services over a predetermined time interval, the action score reflecting relative desirability of intervention in a health care regimen of the intervention candidate; 
 comparing, via the information server, the action score against a threshold value to identify at least one intervention candidate eligible for intervention and generating a result of such comparison and; 
 presenting a graphical user interface for providing to a select individual electronic access to a health care history of the at least one eligible intervention candidate and the result of the comparison, the graphical user interface including a display of historical information based at least in part on the participant data associated with the at least one eligible intervention candidate and adapted to facilitate intervention in the health care regimen of the at least one eligible intervention candidate based on the result of the comparison. 
 
     
     
         17 . The method of  claim 16 , wherein the action score is determined by adding a plurality of values, each value representing the intervention candidate's consumption of at least one of the plurality of different predetermined health care services. 
     
     
         18 . The method of  claim 17 , wherein one of the plurality of values is selected from the group consisting of: a value representing a number of medical specialists that treated the candidate, a value representing a number of inpatient admissions, a value representing a number of chronic diseases for which the candidate was treated, a value representing a number of prescriptions for unique drugs, a value representing an amount of medical claims allowed, and a value representing a number of emergency room visits without admission in a hospital. 
     
     
         19 . The method of  claim 16  wherein at least one of the plurality of different predetermined health care services is selected from the group consisting of:
 a unique drug prescription; 
 an instance of an inpatient admission; 
 an existence of a chronic disease or condition; 
 a unique medical specialty consultation; 
 an allowed medical claim exceeding a predetermined monetary threshold; and 
 an emergency room visit. 
 
     
     
         20 . The method of  claim 16  wherein the action score is determined based on a weighted matrix of values, each value associated with a corresponding scaling factor and representing the intervention candidate's consumption of at least one of the plurality of different predetermined health care services. 
     
     
         21 . The method of  claim 20  wherein one of the plurality of values in the matrix is selected from the group consisting of: a value representing a number of medical specialists that treated the candidate, a value representing a number of inpatient admissions, a value representing a number of chronic diseases for which the candidate was treated, a value representing a number of prescriptions for unique drugs, a value representing an amount of medical claims allowed, and a value representing a number of emergency room visits without admission in a hospital. 
     
     
         22 . The method of  claim 16  further comprising:
 executing a predictive model program using the participant data to generate an output, the predictive model program comprising logic to determine a likelihood of occurrence of at least one predetermined future event, the event associated with utilization of health care services, the logic having been created using historical claims data from a sample of individuals, the predictive model program being stored on the information server; 
 determining, from the output of the execution of the predictive model program, via the information server, a predicted utilization score for an intervention candidate using the participant data, which score reflects a predicted utilization of future health care services; and 
 evaluating the predicted utilization score to assist in identifying the at least one eligible intervention candidate. 
 
     
     
         23 . The method of  claim 16  wherein the information server is configured for generating a plurality of flags, wherein each flag has a status that represents the participant data associated with the intervention candidate. 
     
     
         24 . The method of  claim 23 , wherein one of the plurality of flags represents the likelihood that an intervention candidate will claim disability under a disability insurance plan.