Pharmacy Risk Group Classification for Patient Health Assessment
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Solution Overview
Problem
Current health risk assessment methods for healthcare organizations are inadequate, particularly in situations where medical claims data are not available, leading to inaccurate risk adjustments and inefficient resource allocation.
Innovation Solution
A method utilizing pharmacy data to assign patients to unique drug classes, which are then grouped into pharmacy risk groups (PRGs) based on clinical and risk characteristics, combined with demographic data to provide a risk score, allowing for timely and accurate health risk assessment without relying on medical claims.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Measurement precision
If traditional health risk assessment methods are used, then medical claims data are required for accurate assessment, but this leads to delayed assessment and inability to assess patients without claims history
Solution Approach 1:
The patent extracts the essential risk assessment function from traditional medical claims data and implements it through pharmacy data alone. By taking out the dependency on comprehensive medical claims and using only pharmacy service data, the system achieves timely risk assessment without waiting for claims processing, while maintaining predictive accuracy through carefully selected pharmacy indicators.
Solution Approach 2:
The patent introduces pharmacy data as an intermediary substitute for medical claims data. Pharmacy services serve as a mediator that provides proxy information about patient health status and future medical needs. This intermediary approach allows risk assessment to proceed without direct access to medical claims, resolving the contradiction between data completeness and assessment timing.
2Measurement precision
If comprehensive medical claims data are used for risk assessment, then accurate risk adjustment is achieved, but this increases system complexity and data processing requirements
Solution Approach 1:
The patent extracts only the essential risk assessment function from complex medical claims data processing. By taking out and using only pharmacy service data, the system maintains risk adjustment accuracy while dramatically reducing system complexity. The approach extracts the core predictive signal from a simpler, more manageable data source.
Solution Approach 2:
The patent uses pharmacy data as a simpler, more accessible substitute for comprehensive medical claims data. Pharmacy data is easier to obtain, process, and maintain than full medical claims datasets. This disposable approach to data selection—using what is readily available and sufficient—reduces system complexity while maintaining assessment quality.
3Productivity
If pharmacy data alone is used for risk assessment, then timely assessment is enabled without medical claims, but data availability and completeness may be limited
Solution Approach 1:
The patent makes pharmacy data serve multiple functions simultaneously. Pharmacy services not only indicate medication usage but also serve as proxies for underlying health conditions, treatment intensity, and future medical needs. This multi-functionality allows pharmacy data alone to provide comprehensive risk assessment information, compensating for the absence of other data sources.
Solution Approach 2:
The patent changes the parameters used for risk assessment from traditional medical claims indicators to pharmacy-based indicators. By transforming the assessment methodology to rely on pharmacy service patterns, frequency, and types, the system maintains information completeness using a different but equally informative data parameter set.
Data Source
AI summary
A system and method for receiving demographic data on a patient and data on at least one pharmacy service prescribed for the patient; assigning a unique drug class to each pharmacy service; using the unique drug classes for ordering the pharmacy services according to a predetermined hierarchy of classes; and providing a risk score for the patient using the ordered pharmacy services.