METHOD OF OPTIMIZING HEALTHCARE SERVICES CONSUMPTION

摘要

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.

主权项

1. A method of optimizing healthcare services consumption of healthcare consumers in a healthcare plan comprising:
A. providing at least one computing device maintaining one or more databases on a computer-readable media, the one or more databases being electronically coupled to one or more networks; B. electronically receiving from an external source and storing in a database information comprising healthcare consumer data,
wherein healthcare consumer data comprises at least the healthcare consumers' names, addresses, healthcare consumer identification numbers, ages and genders;wherein the healthcare consumer data is for at least 9800 healthcare consumers,and wherein storing healthcare consumer data is repeated for each healthcare consumer added to the healthcare plan; C. electronically receiving from an external source healthcare information comprising healthcare data relating to healthcare service events,
wherein healthcare data relating to the healthcare service events comprises at least a diagnosis and a procedure code,and wherein storing healthcare data relating to the healthcare service events is repeated for each new healthcare service event; D. storing in a database the received healthcare information comprising healthcare data relating to healthcare service events, E. accessing stored healthcare data associated with each healthcare consumer; F. analyzing the accessed healthcare data with the computing device and determining whether an individual healthcare consumer suffers from one or more chronic conditions,
wherein determining whether an individual healthcare consumer suffers from one or more chronic conditions includes reviewing the diagnosis and procedure code associated with the individual healthcare consumer,and wherein analyzing healthcare data is repeated at least once every calendar quarter; G. storing in a database an indication of healthcare consumers who suffer from one or more chronic conditions; H. accessing data representing a first group of healthcare service providers who provide high quality cost efficient healthcare services relative to other healthcare service providers; I. associating a predetermined set of minimum annual care requirements (MACRs) with each individual healthcare consumer's one or more chronic conditions each time a healthcare consumer is identified with a chronic condition and storing said association in a database as part of the healthcare consumer data; J. determining whether the individual healthcare consumer suffering from one or more chronic conditions has obtained healthcare services that satisfy the predetermined set of MACRs associated with the one or more chronic conditions,
wherein determining whether an individual healthcare consumer has satisfied the predetermined set of MACRs associated with a chronic condition is repeated at least once every calendar quarter; and K. using an electronic communication device to instruct healthcare consumers who have not obtained healthcare services that satisfy the predetermined set of MACRs to obtain additional healthcare services to satisfy the predetermined set of MACRs from a provider in the first group of healthcare service providers.