Researchers Submit Patent Application, “Healthcare Clinical Efficiency Claims Per Healthy Day Navigation Engine”, for Approval (USPTO 20230123221): Patent Application

2023 MAY 04 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- From Washington, D.C., NewsRx journalists report that a patent application by the inventors Grifno, Ken (The Colony, TX, US); McCallum, Jack (Benbrook, TX, US); McCallum, William (Fort Worth, TX, US); Roloff, Scott (Arlington, TX, US), filed on October 18, 2022, was made available online on April 20, 2023.

No assignee for this patent application has been made.

News editors obtained the following quote from the background information supplied by the inventors: “Medical and pharmacy claims-the input into the healthcare equation-are measured in dollars and cents. Until now the output-what is received in exchange for those healthcare dollars-has been measured in qualitative terms, such as what a provider did or didn’t do (compliance with HEDIS and clinical guideline checklists) and whether the patient “liked” the doctor or healthcare experience (scored by CAHPS and Press Ganey).

“What is needed is a way to quantify the output-the patient’s outcome-in dollars and cents too so that the inputs and outputs are in the same terms, enabling the ranking of Healthcare Items based on the outcomes that they achieved and the calculating of ROIs (Returns on Investment).”

As a supplement to the background information on this patent application, NewsRx correspondents also obtained the inventors’ summary information for this patent application: “The invention is a navigation engine that quantifies healthcare outcomes based on their risk-adjusted claims per healthy day during a year (or other period), combining cost and quality into a single dollar and cent value.

“The claims measure the cost of the healthcare, while the healthy days measure the quality.”

The claims supplied by the inventors are:

“1. A method in a computing environment for ranking Healthcare Items based on quantified outcomes they achieved, wherein said Healthcare Items comprise physicians and other healthcare providers, healthcare facilities, case managers, workers’ compensation adjusters, healthcare treatment patterns and/or practices, healthcare plans and/or programs, and healthcare provider networks, the method comprising: presenting a navigational interface on a computer screen for a user searching for a Healthcare Item for treating a particular root diagnosis, said navigational interface comprising: presenting on a single computer display screen groups of items with functionally labeled circles connected in a hierarchical order; organizing that order with a central circle branching off into a plurality of smaller circles, and from each of said plurality of smaller circles, branching off into a plurality of even smaller circles, with more detailed subsets of material presented in each circle as each of said circles hierarchically descend; displaying thumbnails of dashboards and/or reports available under a circle when the user hovers a cursor over it; opening a new computer display screen from which the user can access said dashboards and/or reports when the user clicks a circle, or alternatively accessing a particular dashboard and/or report directly when the user clicks on its thumbnail; organizing patients’ medical and/or pharmacy claims in tables with common identifiers linking each patient’s claims; identifying a corresponding root diagnosis for each patient’s claims; accumulating all of the organized claims by a corresponding attributable root diagnosis over an entire continuum of care, and then grouping those accumulated claims by a specified measurement period; organizing eligibility files for any applicable health plan or program in tables, and then determining through a common identifier whether each patient in the claims data participated in an applicable health plan or program for the entirety of each measurement period; determining a risk score for each patient using age, gender, health diagnoses, and drug prescriptions data contained in each patient’s corresponding claims; organizing the Healthcare Items whose outcomes are to be quantified under an appropriate circle in the navigation interface; allocating to each physician that filed a claim grouped with a patient’s root diagnosis with both: (1) that physician’s claims grouped with that root diagnosis, and (2) all downstream claims from direct and indirect referrals of the patient made by that physician to other healthcare providers; sorting overall categories of the Healthcare Items whose outcomes are being ranked into sub-categories and displaying sorted Healthcare Items in the sub-categories in the navigation interface, wherein healthcare providers are sorted into four sub-categories comprising: (1) primary care physicians (PCPs), (2) non-surgeon specialists, (3) surgeons, and (4) healthcare institutions; determining, per measurement period, risk-adjusted claims costs to treat a patient with a particular root diagnosis by: (1) combining all costs of a particular patient’s claims and downstream costs allocated to a provider or other Healthcare Item when treating that particular root diagnosis, and (2) dividing those total costs by the patient’s risk score; determining per measurement period the total risk-adjusted claims costs of each Healthcare Item whose outcomes are to be quantified to treat patients with a particular root diagnosis by: (1) combining all the claims costs allocated to that item when treating that particular root diagnosis (including downstream costs), and (2) dividing those combined costs by an average risk score of patients treated with that particular root diagnosis; identifying from the organized claims all unhealthy days of each patient attributable to that particular root diagnosis during the measurement period, wherein unhealthy days comprise those days that the patient spends in the healthcare system or at home in a non-functional state relative to that patient’s normal activities; allocating to each physician that filed a claim grouped with a patient’s root diagnosis both: (1) unhealthy days of that patient attributable to that physician’s claims, and (2) unhealthy days of that patient attributable to all downstream claims from direct and indirect referrals of that patient made by that physician to other providers; risk-adjusting the unhealthy days of that patient by dividing them by the patient’s risk score; determining healthy days for that patient by subtracting the risk-adjusted unhealthy days of that patient from the number of days in the measurement period; determining, per measurement period, the claims per healthy day for each Healthcare Item whose outcome is being quantified when treating a particular patient with a particular root diagnosis by taking the risk-adjusted claims costs of that patient allocated to that Healthcare Item and dividing by that patient’s number of healthy days, thereby providing that patient’s claims per healthy day; determining, per measurement period, an average claims per healthy day for each Healthcare Item whose outcome is being quantified when treating a particular root diagnosis by either: dividing the total risk-adjusted claims costs allocated to that Healthcare Item when treating that particular diagnosis by the total healthy days of all patients treated for that particular root diagnosis, or alternatively, dividing the average risk-adjusted claims per patient by the average number of healthy days per patient; ranking the Healthcare Items whose outcomes are being quantified for each root diagnosis based on each Healthcare Item’s overall average claims per healthy day over all specified measurement periods-from the best with lower or the lowest claims per healthy day to the worst with higher or the highest claims per healthy day; filtering the results displayed to the user via menus by variables comprising one or more of: (1) root diagnosis, (2) provider category, (3) geographic proximity, and (4) in-network versus out of network for the user; and filtering the results displayed to the user based on type of user: (1) for users that are a plan provider, a provider network, an employer or other administrative user, the navigation engine displays all data, including the overall average claims per healthy day for all the Healthcare Items whose outcomes are being quantified by root diagnosis, (2) for users that are PCPs and other physicians, case managers, workers’ compensation adjusters and other healthcare providers making patient referrals or choosing from several health treatment patterns and/or practices, a simplified search component of the navigation engine displays: (A) a list of surgeons, specialists and healthcare institutions with an overall average claims per healthy day for a particular root diagnosis better than a designated threshold, and/or (B) possible health treatment patterns and/or practices for that particular root diagnosis with an overall average claims per healthy day for a particular root diagnosis better than a designated threshold, and (3) for users that are patients and other individuals seeking healthcare treatment, a simplified user-facing search component of the navigation engine displays all providers with overall average claims per healthy day for a particular root diagnosis better than a designated threshold and/or displays overall average claims per healthy day for health treatment patterns and/or practices for that particular root diagnosis with overall average claims per healthy day better than a designated threshold.

“2. The method of claim 1, further comprising: comparing a Healthcare Item’s average risk-adjusted unhealthy days to average risk-adjusted unhealthy days of the Healthcare Item’s peer group, wherein said peer group comprises Healthcare Items whose outcome is being quantified and ranked, and determining an excess, if any, by which the Healthcare Item’s average risk-adjusted unhealthy days exceed the peer group’s average risk-adjusted unhealthy days; valuing any such excess risk-adjusted unhealthy days at the peer group’s average risk-adjusted claims cost per unhealthy day; and adding the resulting valued amount to the Healthcare Item’s average risk-adjusted claims as a “quality of life adjustment” when calculating the Healthcare Item’s average claims per healthy day.

“3. The method of claim 2, further comprising: determining from the organized claims data a risk score of a particular individual; and predicting the claims per healthy day of each Healthcare Item when treating that individual for a particular root diagnosis by multiplying the risk score of that individual by an overall average claims per healthy day for that particular root diagnosis of the Healthcare Item.

“4. The method of claim 3, further comprising: comparing predicted claims per healthy day for the individual with actual claims per healthy day achieved; employing regression analysis to modify the risk score and/or components or subsets thereof to provide a revised prediction of claims per health day, with modifying factors deployed as additional elements in the predicting step; and comparing the revised prediction to the actual claims per healthy day, and then adjusting the modifying factors in a loop of neural network and machine learning until the predicted claims per healthy day equals the actual claims per healthy day.”

For additional information on this patent application, see: Grifno, Ken; McCallum, Jack; McCallum, William; Roloff, Scott. Healthcare Clinical Efficiency Claims Per Healthy Day Navigation Engine. U.S. Patent Application Number 20230123221, filed October 18, 2022 and posted April 20, 2023. Patent URL (for desktop use only): https://ppubs.uspto.gov/pubwebapp/external.html?q=(20230123221)&db=US-PGPUB&type=ids

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