Methods for optimizing managed healthcare administration and achieving objective quality standards

Abstract

Healthcare is administered to members / enrollees of a healthcare plan according to objective quality standards. A patient population of eligible members / enrollees is identified and for each member / enrollee, medical information is aggregated via a web-based compilation of medical data from multiple sources that is continuously updated so as to provide an accurate, up-to-date and readily accessible compilation of a member / enrollee past diagnoses, healthcare history, medical procedures, medications and the like. Such member / enrollees are continuously tracked, on an individual basis, and monitored to ensure healthcare is delivered for a variety of specific medical conditions pursuant to objective health program quality criteria.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS[0001]Not ApplicableSTATEMENT RE: FEDERALLY SPONSORED RESEARCH / DEVELOPMENT[0002]Not ApplicableBACKGROUND[0003]In a managed care setting, whether it is for commercial or senior products, health insurance is offered individually, through an employer or through Medicare. In all cases, the patient's coverage often changes. Whether it is a change in benefits or moving out of the service area, providers often move in and out of a patient's ecosystem, which then causes disjointed and incomplete health information and assessment of the quality of care rendered. Along those lines, in our current state of healthcare, there is not enough incentive (funding) to measure every health quality measure to ensure optimal healthcare is administered to eligible recipients. There are variations in the collection and reporting of data as well as the categories that are measured between programs. For example, pay for performance programs tend to allow greater flexibi...

AI Technical Summary

Benefits of technology

The present invention describes a system and method for collecting and presenting comprehensive data about patients to healthcare providers to help them make better clinical decisions. This data helps providers understand their patients' medical condition better and ensures that all appropriate medical conditions are treated. The system is web-based and can be integrated with any EHR / EMR application to provide a complete history and overview of the patient condition. The technical effect of the invention is to improve the quality of healthcare and reduce the administrative burden of healthcare providers by categorizing each of their patients into the appropriate quality programs.

Problems solved by technology

Whether it is a change in benefits or moving out of the service area, providers often move in and out of a patient's ecosystem, which then causes disjointed and incomplete health information and assessment of the quality of care rendered.

Along those lines, in our current state of healthcare, there is not enough incentive (funding) to measure every health quality measure to ensure optimal healthcare is administered to eligible recipients.

For example, pay for performance programs tend to allow greater flexibility in the ability to capture supplemental data than some of the other programs but are far limited in the number of quality outcomes measured, especially for the high utilizing senior population.

With these varying programs, as well as many health plans introducing their own quality initiatives, it is almost impossible for providers to keep track of the appropriate health maintenance programs for their patient population and much less insure that quality care is being administered.

As a consequence, duplication and errors are more commonplace, causing the quality of care to be negatively impacted.

Moreover, managed care is typically restricted to a specific service area and typically incorporates a referral and utilization management process which thus further limits a continuum of care to be administered.

It has likewise not been enough to avoid hospital admissions and bend the cost curve.

Even though there are many tools in the marketplace, none understand the problem and provide the means to a solution.

Unfortunately, no such systems currently exist.

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