U.S. patent application number 13/964780 was filed with the patent office on 2014-03-27 for providing transparent health care information to consumers.
This patent application is currently assigned to Aetna Inc.. The applicant listed for this patent is Aetna Inc.. Invention is credited to Roberta Downey, Wayne Gowdy, Ronald A. Williams.
Application Number | 20140088986 13/964780 |
Document ID | / |
Family ID | 38950356 |
Filed Date | 2014-03-27 |
United States Patent
Application |
20140088986 |
Kind Code |
A1 |
Gowdy; Wayne ; et
al. |
March 27, 2014 |
Providing Transparent Health Care Information to Consumers
Abstract
Systems and methods are described for providing consumers with
access to the discounted rates for health care procedures provided
by primary care physicians, specialist physicians and facilities.
Fee information for contracted providers is stored in a database
and is accessible to consumers via an online interface. Consumers
select query criteria for providers and are presented with actual
cost information pertaining to procedures prospectively rendered by
providers. Additional information, such as quality or efficiency of
providers, can also be presented. Information on multiple providers
can be obtained and presented in a comparative arrangement. The
presented information can be limited to providers within a
geographic region, within a cost range, within a quality range, or
other criteria.
Inventors: |
Gowdy; Wayne; (Tolland,
CT) ; Downey; Roberta; (Glastonbury, CT) ;
Williams; Ronald A.; (Farmington, CT) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Aetna Inc. |
Hartford |
CT |
US |
|
|
Assignee: |
Aetna Inc.
Hartford
CT
|
Family ID: |
38950356 |
Appl. No.: |
13/964780 |
Filed: |
August 12, 2013 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
11457449 |
Jul 13, 2006 |
8510124 |
|
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13964780 |
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Current U.S.
Class: |
705/2 |
Current CPC
Class: |
G06Q 40/04 20130101;
G06Q 10/10 20130101; G16H 40/63 20180101; G06Q 40/08 20130101 |
Class at
Publication: |
705/2 |
International
Class: |
G06Q 50/00 20120101
G06Q050/00; G06Q 50/22 20060101 G06Q050/22 |
Claims
1. A method for displaying cost information and quality information
in a user interface prior to a health care provider performing a
health service, the method comprising: receiving a selection of a
first health care provider that has a contractual relationship with
a health plan organization, wherein the contractual relationship
specifies a first monetary amount that the first health care
provider would charge for performing the health service and/or a
second monetary amount that the first health care provider would be
compensated by the health plan organization for performing the
health service; displaying, via an electronic user interface, cost
information for performing the health service, wherein the cost
information is based on the first monetary amount and/or the second
monetary amount under the contractual relationship; and displaying,
via the electronic user interface, quality information for the
first health care provider, wherein the quality information
includes indicia for at least one of: compliance of the first
health care provider with predetermined quality criteria, a
frequency of adverse reactions in past patients of the first health
care provider, rates that past patients of the first health care
provider subsequently have sought similar health care services,
datedness of procedures used by the first health care provider, and
comparison of the indicia to industry standards; wherein the cost
information and the quality information are displayed on the
electronic user interface prior to the first health care provider
performing the health service.
2. The method of claim 1, further comprising: receiving, via the
electronic user interface, consumer identity information; and
determining, via a health care computer system, that the consumer
identity information corresponds to a member of a health insurance
plan provided by the health plan organization.
3. The method of claim 1, further comprising: displaying, via the
electronic user interface, treatment cost efficiency metric for the
first health care provider, wherein the treatment cost efficiency
metric is presented to the consumer prior to the first health care
provider performing the health service.
4. The method of claim 3, wherein the treatment cost efficiency
metric for the first health care provider is based on a total cost
of treatment of at least one health condition, wherein determining
the treatment cost efficiency metric comprises: grouping health
insurance plan claim data for the first health care provider into
an episode treatment group based on at least one of procedure codes
and diagnosis codes associated with the claim data for the first
health care provider; associating the claim data in the episode
treatment group with the at least one health condition; aggregating
costs for the claim data within the episode treatment group for
measuring the total cost of treatment from the first health care
provider of the at least one health condition; and calculating the
treatment cost efficiency metric for the first health care provider
as a percentile ranking among a plurality of health care providers
of the total cost of treatment of the at least one health
condition.
5. The method of claim 1, wherein the health plan organization
enters a contractual relationship with a second health care
provider that specifies a third monetary amount that the second
health care provider would charge for performing the health service
and/or a fourth monetary amount that the second health care
provider would be compensated by the health plan organization for
performing the health service; and wherein displaying the cost
information further comprises displaying the third monetary amount
and/or the fourth monetary amount prior to the second health care
provider performing the health service.
6. The method of claim 5, wherein the first and second monetary
amounts corresponding to the first health care provider are
presented in a comparative arrangement relative to the third and
fourth monetary amounts corresponding to the second health care
provider.
7. The method of claim 5, wherein the first and second health care
providers are within a specified geographic proximity to the
consumer.
8. The method of claim 1, wherein the health plan organization
enters a plurality of contractual relationships with a plurality of
health care providers to compensate the providers in predetermined
monetary amounts for performing the health service, each provider
in the plurality being located within a specified geographic
proximity; and wherein the cost information further comprises a
mathematical function of the predetermined monetary amounts.
9. The method of claim 1, wherein the contractual relationship
corresponds to a health plan provided by the health plan
organization, wherein the health plan is a consumer-directed health
plan.
10. The method of claim 9, wherein the health plan is a high
deductible health plan.
11. The method of claim 1, further comprising: displaying, via the
electronic user interface, a list of health services determined to
be provided with high frequency by the first health care
provider.
12. A computing device for presenting cost information and quality
information to a consumer, the computing device comprising: an
input interface for receiving a selection of a first health care
provider that has a contractual relationship with a health plan
organization, wherein the contractual relationship specifies a
first monetary amount that the first health care provider would
charge for performing the health service and/or a second monetary
amount that the first health care provider would be compensated by
the health plan organization for performing the health service; and
a display device configured to: display, via an electronic user
interface, cost information for performing the health service,
wherein the cost information is based on the first monetary amount
and/or the second monetary amount under the contractual
relationship, and display, via the electronic user interface,
quality information for the first health care provider, wherein the
quality information includes indicia for at least one of:
compliance of the first health care provider with predetermined
quality criteria, a frequency of adverse reactions in past patients
of the first health care provider, rates that past patients of the
first health care provider subsequently have sought similar health
care services, datedness of procedures used by the first health
care provider, and comparison of the indicia to industry standards;
wherein the cost information and the quality information are
displayed on the electronic user interface prior to the first
health care provider performing the health service.
13. The computing device of claim 12, wherein the computing device
is configured to receive consumer identity information and
determine that the consumer identity information corresponds to a
member of a health insurance plan provided by the health plan
organization.
14. The computing device of claim 12, wherein the display device is
further configured to: display, via the electronic user interface,
treatment cost efficiency metric for the first health care
provider, wherein the treatment cost efficiency metric is presented
to the consumer prior to the first health care provider performing
the health service.
15. The computing device of claim 14, wherein the treatment cost
efficiency metric for the first health care provider is based on a
total cost of treatment of at least one health condition, wherein
determining the treatment cost efficiency metric comprises:
grouping health insurance plan claim data for the first health care
provider into an episode treatment group based on at least one of
procedure codes and diagnosis codes associated with the claim data
for the first health care provider; associating the claim data in
the episode treatment group with the at least one health condition;
aggregating costs for the claim data within the episode treatment
group for measuring the total cost of treatment from the first
health care provider of the at least one health condition; and
calculating the treatment cost efficiency metric for the first
health care provider as a percentile ranking among a plurality of
health care providers of the total cost of treatment of the at
least one health condition.
16. The computing device of claim 12, wherein a second health care
provider enters a contractual relationship with the health plan
organization that specifies a third monetary amount that the second
health care provider would charge for performing the health service
and/or a fourth monetary amount that the second health care
provider would be compensated by the health plan organization for
performing the health service; and wherein the display device is
further configured to display the third monetary amount and/or the
fourth monetary amount prior to the second health care provider
performing the health service.
17. The computing device of claim 16, wherein the first and second
monetary amounts corresponding to the first health care provider
are presented in a comparative arrangement relative to the third
and fourth monetary amounts corresponding to the second health care
provider.
18. The computing device of claim 12, wherein the health plan
organization enters a plurality of contractual relationships with a
plurality of health care providers to compensate the providers in
predetermined monetary amounts for performing the health service,
each provider in the plurality being located within a specified
geographic proximity; and wherein the cost information further
comprises a mathematical function of the predetermined monetary
amounts.
19. The computing device of claim 12, wherein the display device is
further configured to display, via the electronic user interface, a
list of health services determined to be provided with high
frequency by the first health care provider.
20. A system for presenting cost information and quality
information to a consumer, the system comprising: a health plan
organization computer system; and a consumer computer system
configured to: receive a selection of a first health care provider
that has a contractual relationship with a health plan
organization, wherein the contractual relationship specifies a
first monetary amount that the first health care provider would
charge for performing the health service and/or a second monetary
amount that the first health care provider would be compensated by
the health plan organization for performing the health service; and
communicate with the health plan organization computer system in
order to display, via an electronic user interface, cost
information for performing the health service, wherein the cost
information is based on the first monetary amount and/or the second
monetary amount under the contractual relationship, and communicate
with the health plan organization computer system in order to
display, via the electronic user interface, quality information for
the first health care provider, wherein the quality information
includes indicia for at least one of: compliance of the first
health care provider with predetermined quality criteria, a
frequency of adverse reactions in past patients of the first health
care provider, rates that past patients of the first health care
provider subsequently have sought similar health care services,
datedness of procedures used by the first health care provider, and
comparison of the indicia to industry standards; wherein the cost
information and the quality information are displayed on the
electronic user interface prior to the first health care provider
performing the health service.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This patent application is a continuation of U.S. patent
application Ser. No. 11/457,449, filed Jul. 13, 2006, which is
incorporated herein in its entirety by this reference.
FIELD OF THE INVENTION
[0002] This invention relates generally to the field of health
insurance and more specifically to the area of price and
information transparency for contracted health care providers.
BACKGROUND OF THE INVENTION
[0003] Imagine a world without price tags. A consumer can buy a big
screen TV that he's had his eye on, but he would not know the price
until his credit card bill came in the mail. Although this seems
like a ridiculous proposition, it is exactly the world the average
American lives in when he or she seeks medical care. As reported in
the Wall Street Journal in February and June of 2005, knowing the
cost of a doctor's visit has long been a missing piece of the
health care decision-making process.
[0004] One previously unachievable approach is called "price
transparency." Through price transparency, consumers would be able
to know what they can expect to pay at the physician's office
before visiting the physician. However, in previous health care
systems, no health insurer has ever been able to provide this level
of detail to its members. The reasons for this have been
varied--contractual issues, complexities in the rates physicians
agree to accept from insurers, and concerns about consumers
shopping for health care on price alone.
BRIEF SUMMARY OF THE INVENTION
[0005] Embodiments of the invention provide consumers with online
access to the negotiated discounted rates for health care
procedures provided by primary care and specialist physicians. This
provides advantages by educating consumers about the actual costs
of medical care, responding to a need of the employer and broker
communities. Such embodiments are particularly valuable in the face
of the increased adoption of consumer-directed health plans, which
necessitate more detailed information than had previously been
available for health issues, health care quality, and average
pricing within specific geographies.
[0006] Using embodiments of the invention, consumers can research
what they can expect to pay at a doctor's office before going in
for a visit. The research can be conducted securely via a
password-protected interface to a query engine, such as a member
website. The query engine can access information on health
providers and health provider groups in conjunction with a health
insurance company or other health plan organization. Members can
search for a physician and, upon selecting a physician, can view
negotiated contracted rates. This provides advantages to members
who are selecting health care providers for services, and also to
members who may be choosing health care benefits at the beginning
of a plan year. By raising awareness about the costs of care, the
marketplace for consumers as health care decision-makers is
enhanced.
[0007] Embodiments of the invention provide information on overall
value, not just price alone. Quality and efficiency measures are
used and are in alignment with the Institute of Medicine's criteria
for efficiency and effectiveness.
[0008] In one aspect, a method is provided for providing a health
care consumer with information for a prospectively performed health
service, the method comprising entering a contractual relationship
with a health care provider to compensate the provider in a
predetermined monetary amount for performing a health service for
members of a health plan, providing an interface to the consumer
through which consumer identity information can be entered,
receiving the consumer identity information, determining that the
consumer is a member of the health plan, and presenting, for the
consumer, cost information for the prospectively performed health
service, the cost information comprising the predetermined monetary
amount and in accordance with the health plan.
[0009] In another aspect, a system is provided for use with a
health plan organization offering a health care plan and a health
care consumer subscribing to the health care plan, the system for
providing the health care consumer with cost information for a
first health service, the first health service providable by any of
one or more health service providers in a collection of providers,
each provider in the collection having a contractual relationship
with the health plan organization, the system comprising a database
containing cost information for health services provided by one or
more providers in the collection, the cost information comprising
the amount the provider will charge for rendering health services
under the contractual relationship, query specifying means for
specifying query criteria to be queried of the database, query
receiving means for receiving query criteria and for querying the
database, and presentation means for presenting to the consumer
cost information for the first health service, said cost
information obtained from the database according to the specified
query criteria and according to the consumer's subscription to the
health care plan.
[0010] In yet another aspect, a method is provided for obtaining
information for a health care service prospectively to be rendered
by a health care provider, the health care provider under a
contractual relationship with a health plan organization, the
method comprising transmitting consumer identity information, the
identity information corresponding to a health care plan offered by
the health plan organization, specifying, via a user interface,
query criteria for provider-related information, transmitting a
query comprising the specified criteria to a database for the
health plan organization, receiving, from the database and in
response to the query, information relating to the health care
provider, the information comprising a monetary amount for which
the health care provider would be compensated for performing the
health service according to the consumer's health plan and under
the contractual relationship.
BRIEF DESCRIPTION OF THE DRAWINGS
[0011] While the appended claims set forth the features of the
present invention with particularity, the invention and its
advantages are best understood from the following detailed
description taken in conjunction with the accompanying drawings, of
which:
[0012] FIG. 1 is a diagram of a system used to provide health care
provider information to consumers, in accordance with an embodiment
of the invention;
[0013] FIGS. 2-8 are screenshots illustrating exemplary user
interfaces for presenting health care provider information, in
accordance with an embodiment of the invention;
[0014] FIG. 9 is an exemplary presentation of price information for
a health care provider, in accordance with an embodiment of the
invention;
[0015] FIG. 10 is an exemplary presentation of comparative data
between health care providers, in accordance with an embodiment of
the invention;
[0016] FIG. 11 is an exemplary presentation of quality and
efficiency information for a provider, in accordance with an
embodiment of the invention; and
[0017] FIG. 12 is a flow diagram of a technique for presenting
health care cost information to a consumer, in accordance with an
embodiment of the invention.
DETAILED DESCRIPTION OF THE INVENTION
[0018] The following examples further illustrate the invention but,
of course, should not be construed as in any way limiting its
scope.
[0019] Turning to FIG. 1, an implementation of a system
contemplated by an embodiment of the invention is shown with
reference to an overall healthcare environment. A consumer
("subscriber" or "member") 102 is a member of a health plan 104 of
a health plan organization ("HPO") 106. Alternatively, the consumer
102 is a prospective member of a health plan 104. The member 102
may subscribe to the health plan 104 through, for example, his
employer. Alternatively, the member 102 may obtain benefits of the
health plan 104 through a subscriber (e.g., a spouse or child of a
subscriber can be a member of a health plan). The HPO 106 is
typically a health insurance company and the health plan 104 can be
one of a number of health insurance or related products, such as a
PPO, HMO, POS, or the like. The health plan 104 can also be a
consumer-directed health plan, such as a high deductible health
plan, health reimbursement arrangement (HRA), health savings
account (HSA) or the like. The member's 102 plan 104 covers various
health care services according to one of a variety of pre-arranged
terms, and details for the member 102 and the corresponding plan
104 are preferably stored in a member database 108. The terms of
the plan 104 can vary greatly from plan to plan according to: what
types of services are provided, where the services are provided, by
whom they are provided, the extent to which the patient is
personally responsible for payment, amount of deductibles, etc.
Generally, however, regardless of the specific plan subscribed to,
when a member 102 obtains health care services from a provider 110,
either the patient 102 or the provider 110 can submit a claim to
the HPO 106 for reimbursement or payment. For analysis purposes,
historical claim data is stored in a claims database 112.
[0020] A health care services provider 110 may have a contractual
relationship 114 with the HPO 106. Under the contract 114, the
provider 110 typically agrees to provide services to members 102 of
the HPO 106 at scheduled rates. The rates are stored in a fee
schedule 118, preferably stored in a fees database 120 maintained
by the HPO 106. By contracting with the HPO 106, the provider 110
generally increases the amount of business he receives from members
102, and members 102 generally receive a less expensive rate than
they would otherwise receive for a health service provided by the
provider 110, and at least a portion of the provider's 110
compensation is generally paid by the HPO 106. The actual amount of
out-of-pocket expense to be paid by a member 102 may vary according
to the terms of his health plan 104 (e.g., co-payments,
co-insurance or deductibles may apply), but will generally be at
most the contracted rate. Historically, these contracted rates have
been guarded fairly closely by HPOs 106. Consumers often would not
become aware of their charges until after they were billed for past
services. Moreover, different contracted providers may operate on
different fee schedules for the same health services without any
knowledge by the consumer.
[0021] In an embodiment of the invention, consumers 102 can obtain
cost information and other relevant data (quality information,
efficiency information, etc.) prior to the provision of any health
services by a provider 110. The consumer 102 uses a computing
device 122 to communicate via a network, such as the Internet 124,
with the HPO 106. An interface is preferably provided so the
consumer 102 can identify himself as a member of a health plan 104
of the HPO 106, and so the consumer 102 can research information on
providers 110 who prospectively may perform health services for the
consumer 102. Through the interface, a query is sent to a query
engine 126. The query engine 126 connects to one or more databases
of the HPO and obtains price information, provider quality
information, provider efficiency information, or other information
that may be useful to the consumer's 102 deciding on a provider of
health services.
[0022] FIGS. 2-8 illustrate a sample interface provided by an HPO
for presenting health care provider information, as used in an
embodiment of the invention. In FIG. 2, a login screen 202 is shown
whereby a member can enter a username 204 and password 206 in order
to obtain access to the system. Alternatively, or in addition,
non-members can access the system under particular circumstances.
In FIG. 3, basic member information is presented as obtained, for
example, from member and/or claims databases. Also presented in the
screen of FIG. 3 is an option to find health care providers 302. By
selecting this option, a member is presented with another screen as
shown in FIG. 4, where the member can choose the type of health
service provider or facility for which he would like more
information.
[0023] FIG. 5 illustrates the results of a query where the member
has requested information on "Specialists" 502 within a city 504
and state 506. Other search criteria, (e.g., providers within a
twenty mile radius of a specified zip code) are also available.
Basic information (e.g., name, specialty, address and phone
numbers) for contracted health services providers matching the
query criteria are presented in response to the query.
Additionally, an option 508 is presented for obtaining additional
details on particular providers. These additional details are
provided in a screen such as the one shown in FIG. 6, and
preferably include details such as the provider's education,
hospital affiliations, gender, or other information that may be of
value to consumers. An option 602 is further presented to view the
provider's contracted rates for provision of services to HPO
members. An option 604 is presented to view the provider's quality
and efficiency information.
[0024] When the option 602 is selected, the member is preferably
presented with one or more screens such as those shown in FIGS.
7-8. The screens contain one or more tables 702, 704, 706, 708.
Each table contains a group of categorized procedures, such as
Office Visits 702, Diagnostic Services 704, Minor Procedures 706,
Major Procedures 707 (births, Caesarean sections, shoulder surgery,
multiple bypass surgery, radiology procedures, etc.), or Other
Services 708. The procedures displayed are preferably unique to the
given specialty of the provider, so that the procedures displayed
for a cardiologist will differ from the procedures displayed for a
pediatrician, for example. For each procedure in a table, a rate
710 is shown. The rate 710 represents the amount that the provider
will be reimbursed for performing the corresponding procedure.
Depending on the member's health plan, he may pay less for these
services if any portion is to be paid by the HPO. The invention is
not limited to the interface as shown in FIGS. 7 and 8, however. In
some embodiments of the invention, the actual amount to be paid by
the member is presented. In some embodiments, only a selection of
possible procedures are presented via the interface (e.g., the 30
most frequently performed). The determination of which procedures
are to be presented can be made by a preferably quantitative
procedure, such as examining which procedure codes (CPT) appear
most frequently on previously submitted claims for the
specialty.
[0025] Turning to FIG. 9, an exemplary screen is shown whereby a
member can obtain cost information for a contracted health services
provider 902, in accordance with an embodiment of the invention. As
in FIGS. 7 and 8, a variety of health service procedures
performable by the provider 902 are listed in one column 904. The
listed procedures in the column 904 are preferably presented in a
nomenclature easily understandable to a layman, which may differ
from an actual formal description associated with a procedure's CPT
code. A second column 906 contains the negotiated contracted rate
the provider will be reimbursed for performing the procedure. A
third column 908 contains the actual cost the member would pay for
having the service performed by this provider. This actual cost can
differ from the contracted rate due to terms of the member's health
plan, which can be stored in one of the HPO's databases.
Differences may result from coinsurance, co-payments, satisfaction
of deductibles, etc.
[0026] In some embodiments of the invention, comparative
information is provided for multiple health service providers, as
illustrated in FIG. 10. In addition to the columns previously
described with respect to FIGS. 8 and 9, multiple columns are
presented for multiple health service providers to allow for
side-by-side comparison with respect to given procedures. For
example, the contracted rate for a procedure to be performed by
Doctor A may be less than the contracted rate for the same
procedure when performed by Doctor B. Such a direct comparison and
revelation of contracted rates has not been available in previous
systems. In some embodiments of the invention, the comparative
information in the table is sortable by selected criteria, which is
particularly useful if a number of providers are being
simultaneously compared.
[0027] In addition, a column 1002 is shown to provide a regional
average contracted rate for a given procedure, as used in some
embodiments of the invention. The regional average can be
calculated for the member based on a location specified in a query,
or based on his customer information stored in an HPO database. In
some embodiments, the size of the region can be customized on a
query-by-query basis (e.g., "within 10 miles"), or based on zip
code, or other geographic identifier.
[0028] Also shown in FIG. 10 are additional evaluation criteria
that may be useful to consumers making health care decisions. Such
criteria include quality metrics 1004 and efficiency metrics 1006.
The quality metrics 1004 can include, for example, whether a health
services provider has been recognized as an outstanding provider.
Doctors B and C in FIG. 10 are shown in the example to be
outstanding providers by the stars 1008 in their respective table
cells. The recognition can come from the HPO based on internal or
external metrics, or from outside parties such as certifying
agencies like AQA (Ambulatory Care Quality Alliance) or The
Leapfrog Group.
[0029] Another of the quality metrics 1004 is the rate of
readmission of a provider's patients for similar treatments. A
lower readmission rate may indicate to a prospective patient that
one provider provides a higher quality of care than another. A
period of time may be used (e.g., 30 days) to determine if patients
have been readmitted. Similarly, information regarding the number
or frequency of adverse effects in patients of the provider can be
used as a quality metric. Another of the quality metrics 1004 is
whether a provider uses the latest health care procedures, or
performs according to or in excess of industry standards. For
example, one metric can be whether an Ob/Gyn screens for cervical
cancer, or performs HIV tests, during routine examinations. Data
for such metrics can be obtained, for example, from past claim data
submitted with respect to the particular provider. Additionally,
other metrics can be used as proxies for quality, such as the
number of years of experience a provider has, the volume of the
number of patients using the provider, or the volume of the
services performed by the provider. In some embodiments of the
invention, survey data is included as a quality metric, such as
from a patient satisfaction survey or an industry peer survey.
[0030] Efficiency metrics 1006 can also be used and presented to
the member. Efficiency can measure, for instance, the total cost
for treatment of a particular medical condition. Because the
treatment may comprise multiple procedures and other expenses
(pharmaceutical, lab, hospitalization, etc.), such an efficiency
metric for a given provider can be of greater value to a
prospective patient than the costs of individual procedures, since
the sum total of all expected health care costs for that patient
may be less with one provider who is more efficient than another.
Efficiency metrics can be evaluated using past claim data submitted
with respect to providers. Claim data generally contains "procedure
codes" and "diagnosis codes". Claims can thus be grouped into
episodes of treatment, or ETGs ("episode treatment groups"), which
can further be associated into particular health conditions. By
aggregating the costs of claims within ETGs or conditions,
efficiency metrics can be computed and compared across
providers.
[0031] An additional example of a presentation of quality and
efficiency information to prospective consumers of a health care
provider is shown in FIG. 11.
[0032] In some embodiments of the invention, cost information is
provided not only for individual procedures, but for all
anticipated costs associated with a procedure. For example, a
prospective patient investigating the cost of having an outpatient
surgery is presented not only with the contracted rate from the
physician, but with contracted rates for the hospital or clinic
where the surgery is to be performed, an anesthesiologist who may
be required, associated laboratory fees for required testing, and
the like. In some embodiments, expected pharmaceutical costs are
also included. Such a "soup-to-nuts" pricing estimate may be of
tremendous value to prospective patients of elective or planned
surgeries, and can make use of existing evaluation tools that may
exist or be developed for individual components (e.g., tools for
comparing hospital costs). Additionally, in some embodiments of the
invention, prospective patients are presented with contracted rates
for a health service to be provided at one or more particular sites
of service. In this way, a prospective patient can compare the cost
of having a procedure performed at one site (e.g., a hospital)
versus another site (e.g., an outpatient clinic).
[0033] Turning to FIG. 12, a method is shown for providing cost
information to a prospective consumer of health services, in
accordance with an embodiment of the invention. A health plan
organization (HPO) enters a contractual relationship with a health
services provider at step 1202. The contract sets a schedule of
rates for which the provider is reimbursed for providing services
to patients who are members of the HPO. The HPO enrolls a consumer
as a member of one of its offered health plans at step 1204 and
provides him an interface at step 1206. At step 1208, the HPO
receives information from the consumer (e.g., a username and
password) and determines that the consumer is a member of a health
plan offered by the HPO at step 1210. The consumer is presented,
through the interface, with a selection options for querying about
provider and/or procedure data at step 1212. The query is received
at step 1214 and, in response, cost information is presented to the
consumer at step 1216.
[0034] All references, including publications, patent applications,
and patents, cited herein are hereby incorporated by reference to
the same extent as if each reference were individually and
specifically indicated to be incorporated by reference and were set
forth in its entirety herein.
[0035] The use of the terms "a" and "an" and "the" and similar
referents in the context of describing the invention (especially in
the context of the following claims) are to be construed to cover
both the singular and the plural, unless otherwise indicated herein
or clearly contradicted by context. The terms "comprising,"
"having," "including," and "containing" are to be construed as
open-ended terms (i.e., meaning "including, but not limited to,")
unless otherwise noted. Recitation of ranges of values herein are
merely intended to serve as a shorthand method of referring
individually to each separate value falling within the range,
unless otherwise indicated herein, and each separate value is
incorporated into the specification as if it were individually
recited herein. All methods described herein can be performed in
any suitable order unless otherwise indicated herein or otherwise
clearly contradicted by context. The use of any and all examples,
or exemplary language (e.g., "such as") provided herein, is
intended merely to better illuminate the invention and does not
pose a limitation on the scope of the invention unless otherwise
claimed. No language in the specification should be construed as
indicating any non-claimed element as essential to the practice of
the invention.
[0036] Preferred embodiments of this invention are described
herein, including the best mode known to the inventors for carrying
out the invention. Variations of those preferred embodiments may
become apparent to those of ordinary skill in the art upon reading
the foregoing description. The inventors expect skilled artisans to
employ such variations as appropriate, and the inventors intend for
the invention to be practiced otherwise than as specifically
described herein. Accordingly, this invention includes all
modifications and equivalents of the subject matter recited in the
claims appended hereto as permitted by applicable law. Moreover,
any combination of the above-described elements in all possible
variations thereof is encompassed by the invention unless otherwise
indicated herein or otherwise clearly contradicted by context.
* * * * *