Methods for optimizing managed healthcare administration and achieving objective quality standards

Abstract

Healthcare is administered to members/enrollees of a healthcare plan according to objective quality standards. A patient population of eligible members/enrollees is identified and for each member/enrollee, medical information is aggregated via a web-based compilation of medical data from multiple sources that is continuously updated so as to provide an accurate, up-to-date and readily accessible compilation of a member/enrollee past diagnoses, healthcare history, medical procedures, medications and the like. Such member/enrollees are continuously tracked, on an individual basis, and monitored to ensure healthcare is delivered for a variety of specific medical conditions pursuant to objective health program quality criteria.

What is claimed is: 
     
         1 . A method for identifying the healthcare needs of a patient population and thereafter administering healthcare in response to said needs, the method comprising steps:
 a) identifying a patient population eligible to receive healthcare benefits;   b) compiling and aggregating healthcare information for each patient within said patient population identified in step a), said aggregation of said healthcare being compiled from data sources selected from the group consisting of each patient's prior insurance claims and encounters information, membership enrollment data of each patient, pharmacy data associated with each patient, laboratory findings for each patient, hospital admissions information for each patient, data from centers providing Medicare services, prior authorizations for medical treatment for each patient, and combinations thereof, said aggregation of healthcare information for each patient creating a patient profile, wherein said patient profile is stored to retrievable from computer readable media;   c) providing a set of standardized health quality measures that are operative to define benchmark standards of healthcare to be administered to said patients within said patient population identified in step a), said set of standardized health quality measures is selected from the group consisting of the CMS five-star quality rating system, NCQA standards, IHA Health Care Pay for Performance program, and combinations thereof;   d) evaluating said patient profiles created in step b) and comparing said profiles with said standardized health quality measures of step c), and identifying a sub-population of patients who have not received healthcare commensurate with said standardized health quality measures in step c);   e) administering healthcare to said sub-population identified in step d) commensurate with said standardized health quality measures set forth in step c); and   f) repeating steps d) and e) until at least 80% of said patient population identified in step a) have met the standardized health quality measures set forth in step c).   
     
     
         2 . The method of  claim 1  wherein step f) further comprises compiling healthcare information of said patients receiving treatment in step e) and updating said patient profile created for such patient in step b), said patient profile being updated via information stored and retrievable on computer readable media.