“Systems and Methods for Mitigating Risk of a Health Plan Member” in Patent Application Approval Process (USPTO 20160275263)
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This patent application has not been assigned to a company or institution.
The following quote was obtained by the news editors from the background information supplied by the inventors: "A typical health care system includes a variety of participants, including doctors, hospitals, insurance carriers, and patients, among others. These participants frequently rely on each other for the information necessary to perform their respective roles because individual care is delivered and paid for in numerous locations by individuals and organizations that are typically unrelated. As a result, a plethora of health care information storage and retrieval systems are required to support the heavy flow of information between these participants related to patient care. Critical patient data is stored across many different locations using legacy mainframe and client-server systems that may be incompatible and/or may store information in non-standardized formats. To ensure proper patient diagnosis and treatment, health care providers often request patient information by phone or fax from hospitals, laboratories, or other providers. Therefore, disparate systems and information delivery procedures maintained by a number of independent health care system constituents lead to gaps in timely delivery of critical information and compromise the overall quality of clinical care. Since a typical health care practice is concentrated within a given specialty, an average patient may be using services of a number of different specialists, each potentially having only a partial view of the patient's medical status.
"One of the participants in a typical health care system is an insurance carrier. An insurance carrier can offer a variety of health plans to its customers, which can be individuals, corporate entities, or other organizations. The customer of the insurance carrier pays a fee to the insurance carrier periodically as a hedge against the risk of incurring future medical expenses. In some instances, insurance carriers can minimize the amount of future outlays for medical expenses to its customers via active patient management. In other words, it is in the best interests of the insurance carrier (and also the member) to be as healthy as possible so as to decrease future medical expenses.
"However, current approaches to active patient management are not very effective. First of all, certain health risks, such as chronic conditions, may be difficult for the insurance carrier to detect and attempt to actively manage. With chronic conditions, for example, the member's health degrades over time and thus the chronic condition may not be readily detected by the insurance carrier. Even if the chronic condition is detected and the insurance carrier attempts to engage with the member, the member may 'feel fine' and may not be willing to engage with the insurance carrier for health care management. For these reasons, among others, current approaches to active patient management have low engagement rates and therefore low efficacy.
"Accordingly, there remains a need in the art for systems and methods for mitigating risk of a health plan member that overcome the drawbacks and limitations of current approaches."
In addition to the background information obtained for this patent application, NewsRx journalists also obtained the inventors' summary information for this patent application: "Some embodiments of the disclosure provide systems and methods for attempting to mitigate risk of a health plan member. The method includes: receiving medical data related to the health plan member; computing a first score for the health plan member corresponding to predicated future financial health care costs for the health plan member based on the medical data; computing a second score for the health plan member corresponding to a clinical risk for the health plan member based on the medical data; computing a third score for the health plan member corresponding to a probability of a future acute care event for the health plan member within a threshold amount of time based on the medical data; assigning the health plan member to a risk tier based on the first, second, and third scores; and engaging the health plan member based on the risk tier and one or more engagement factors.
BRIEF DESCRIPTION OF THE DRAWINGS
"FIG. 1 is a conceptual diagram of a system with reference to an overall healthcare environment, according to one embodiment.
"FIG. 2 is a schematic diagram illustrating an overview of a system for mitigating risk of a health plan member, according to one embodiment.
"FIG. 3 is a conceptual diagram of a predictive model for categorizing patients in an effort to mitigate risk, according to one embodiment.
"FIG. 4 is a conceptual diagram illustrating a system for categorizing patients in an effort to mitigate risk, according to one embodiment.
"FIG. 5 is a flow diagram illustrating a method 500 for mitigating risk of a health plan member, in accordance with an embodiment of the disclosure.
"FIG. 6 is a flow diagram of assigning the health plan member to a risk tier based on first, second, and third scores, according to one embodiment.
"FIG. 7 is a flow diagram of method steps illustrating different engagement types based on risk tier, according to one embodiment.
"FIG. 8 is a flow diagram of method steps for engaging with a member based on risk tier and one or more engagement factors, according to one embodiment.
"FIG. 9 is a conceptual diagram illustrating calculating a priority of member within a particular risk tier, according to one embodiment."
URL and more information on this patent application, see: Pironti, Marc J.;
Keywords for this news article include: Patents, Hospital, Managed Care, Risk and Prevention.
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