System and method for management of health care services

Abstract

The present invention is a system and method for management of consumer services such as health care services which combines new financial structure for health insurance and health benefit plan, payment methods, health plan design, benefit development algorithms, unique procurement methods for health care benefits with and without application to an individual consumer's personal state of health, and is integrated with financial services and asset management products, and benefits for an individual consumer's future medical and / or retirement savings, for healthcare needs. The method and system employs a combination of the defined benefit and defined contribution approaches which combination is referred to herein as “defined-care.” Defined-care model or the healthcare asset management model has two primary components, one which is referred to herein as a “health management and retirement account”, and the other of which is an infrastructure “connected portal” that interfaces through a technology platform with the health management and retirement accounts and the account holders. The foundation of this infrastructure according to the present invention is a technology platform across which a variety of processes are implemented. In the technology platform for the infrastructure of the present invention, the conventional processes and the new processes are integrated, thereby allowing a change to one process to be adopted by or otherwise accommodated by the other processes.

Description

CROSS REFERENCE TO RELATED APPLICATIONS [0001]This application is a divisional of application Ser. No. 10 / 103,267, filed Mar. 20, 2002, which claims priority from provisional application Ser. No. 60 / 277,994, filed Mar. 21, 2001, which applications are incorporated herein by reference.BACKGROUND OF THE INVENTION [0002]1. Field of the Invention[0003]The invention relates generally to a new and improved automated system and method for facilitating management of individual benefits or assets, such as those of an employee or consumer of services, that is capable of interfacing with a variety of entities or “stakeholders” who will or who potentially will benefit, financially or in some other manner, for example, by the acquisition of goodwill. More particularly, the invention relates to a system which creates an infrastructure that is used to connect together consumers, employers, health care providers and health plans and their affiliates so as to combine the process of benefits manageme...

AI Technical Summary

Benefits of technology

[0011]Driven by the Internet, and the ability to access information anytime, anywhere, the e-consumer who is increasingly using the Web today for health information and assistance in informed decision making, is also looking for alternative ways to manage his or her health information, his or her health care benefits, and health coverage information. The e-consumer demands a system that is increasingly transparent, having experienced the opposite to this point with an HMO. This greater transparency, greater choice and freedom to access health care services, and more flexibility and portability of the health care benefits, will be ignited by the transition of defined benefit health plans to consumer-centric health plans. Consumer-centric health plans refers to a health plan which is consumer focused or directed to bring consumer decision making into the economics of health care.

[0012]The method and system employs a combination of the defined benefit and defined contribution approaches which combination is referred to herein as “defined-care.” The model of the present invention is referred to as a “defined-care model” or “healthcare asset management model”, as a replacement for the “managed care” model, and an alternative to the traditional “defined contribution” model. The infrastructure system which will encompass this new model for healthcare benefits, finance, and delivery will be referred to as a Universal Health Management (UHM) system, consistent with the consumer-centric health plans. Although is contemplated that a system and method according to the present invention could be effectively and efficiently employed with respect to a wide variety of benefits or assets, the system and method is described herein in the context of health care. Defined-care model or the healthcare asset management model has two primary components, one which is referred to herein as a “health management and retirement account”, and the other of which is an infrastructure “connected portal” that interfaces through a technology platform with the health management and retirement accounts and the account holders. The technology platform can be implemented using the Internet, an Intranet, enterprise resource planning software, or some combination thereof, and consumers and other participants in the infrastructure can interface with the infrastructure using the Internet, an Intranet, television, or some other appropriate communications medium. Through the vehicle of a health management and retirement account according to the present invention, consumers can be presented with a transparent system in which it is easy to understand and choose from the available benefits and that will prevent the consumer from inadvertently not selecting core health care benefits which are appropriate based on his or her population group or individual health risk characteristics. The core benefits will continue to be selected by the employers, with some combination of employee input, and include at the least catastrophic health insurance, with additional benefits such as healthcare provider network, prevention and wellness programs, and chronic illness case management programs.

[0015]The foundation of this infrastructure according to the present invention is a technology platform across which a variety of processes are implemented. Conventional processes traditionally have been performed outside of an infrastructure, such as claims processing as between insured employees or health care providers on the one hand, and health care plans or their financial services administrators or underwriters on the other hand. In the technology platform for the infrastructure of the present invention, the conventional processes and the new processes are integrated, thereby allowing a change to one process to be adopted by or otherwise accommodated by the other processes. Accordingly, the system and method of the invention can function smoothly and efficiently during change such as new or modified federal regulations affecting any or all of the stakeholders, thereby the expense and delay associated with achieving compliance with changes in the law can be minimized. Optionally, the technology platform includes a feature for determining a patient's eligibility for certain benefits either prior to a visit to the doctor or hospital or at the point of care (e.g., during the visit to the doctor's office or at the hospital's inpatient window), and a feature for prompt payment of healthcare services provided and / or pre-payment of services provided by healthcare providers / doctors when appropriate.

Problems solved by technology

Prior systems and methods of providing health care services and administering employee health care benefits have proven unsatisfactory in recent years for at least several reasons.

The fee-for-service model has fallen into disfavor with employers, the insured and the insurers, because the available systems and methods for management and oversight of the various implementations of the model are less than efficient, increasing costly and vulnerable to mismanagement and even fraud.

There is dissatisfaction with defined benefit plans from the point of view of the employee / patient, the employer and the providers, at a minimum.

The providers suffered financially in the transition from the fee-for-service system to the defined benefit model.

Moreover, complicated administrative procedures mandated by the defined benefit plans before a provider can provide certain services lead to inefficiencies, provider overhead expenses, and situations in which non-physicians effectively are making decisions about what is best for a patient.

The employee / patient is wary of defined benefit plans because the capitation model gives them concern that they may be denied a procedure that is otherwise indicated because of financial rather than medical reasons.

The providers are faced with practical and very real cost / benefit analysis decisions, which arguably impact the provider's ability to provide the level of care that would be in the best interest of each patient.

When employees / patients feel particularly aggrieved, the patients increasingly are bringing lawsuits against employers and health care plans.

Employers likewise are unhappy with defined benefit plans because the cost of the premiums and of administering the plans is ever escalating and the bottom-line outcome of the employers' investment is not totally satisfying to the employees.

Defined contribution health care has not been attractive to employees to date, however, because the terms of the health care plans are difficult to comprehend and are increasingly opaque in terms of benefits, services, providers and reimbursement protocols.

In practice, though, the benefits plans are too complicated and inscrutable that employees risk choosing a plan that will not give them the minimal coverage they ought to have, and the plans similarly are too obtuse as to give an individual insight as to how best to take advantage of the contribution.

In addition, these defined-contribution plans pose very high-deductibles for the employees / patients.

This will result overtime in a greater divide between healthier and ill employees, causing “adverse selection” and even greater health benefit cost increases in the future.

Such changes generally are costly and disruptive to the various entities involved and, if not implemented properly, can lead to non-compliance legal liability.

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