Patent ID: 7693728
Filing Date: 2010-04-06
Classification: G06Q,G16H

Abstract:
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 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 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 predetermined health care services comprising: 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, the second score reflecting relative desirability of intervention in a health care regimen of the intervention candidate determined by adding a plurality of numerical values, each numerical value corresponding to a predetermined number of occurrences of one of the plurality of predetermined health care services; 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.