U.S. patent application number 15/984702 was filed with the patent office on 2018-09-20 for methods for improving the clinical outcome of patient care and for reducing overall health care costs.
The applicant listed for this patent is MedEncentive, LLC. Invention is credited to Jeffrey C. Greene.
Application Number | 20180268922 15/984702 |
Document ID | / |
Family ID | 47262344 |
Filed Date | 2018-09-20 |
United States Patent
Application |
20180268922 |
Kind Code |
A1 |
Greene; Jeffrey C. |
September 20, 2018 |
Methods for Improving the Clinical Outcome of Patient Care and for
Reducing Overall Health Care Costs
Abstract
System and method for reducing healthcare costs by improving
care and encouraging healthy behaviors. A web-based or telephonic
program using health plan sponsor funded financial incentives,
offered to patients and providers for declaring or demonstrating
adherence or providing a reason for non-adherence to performance
standards. Financial incentives are contingent upon patient's and
provider's agreement to allow the other to confirm or acknowledge
the other's declaration or demonstration of adherence or
non-adherence reason. Combining financial incentives with a set of
checks and balances motivates participation in the program and
adherence to the performance standards. Performance standards
include evidence-based treatment guidelines, information therapy,
wellness and prevention solutions, care management, and other
methods proven to control costs by improving behaviors and
healthcare. The system and method achieves improved health and more
affordable healthcare by aligning the interests of providers,
patients/consumers, and health plan sponsors in a win-win-win
arrangement.
Inventors: |
Greene; Jeffrey C.; (Norman,
OK) |
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Applicant: |
Name |
City |
State |
Country |
Type |
MedEncentive, LLC |
Oklahoma City |
OK |
US |
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Family ID: |
47262344 |
Appl. No.: |
15/984702 |
Filed: |
May 21, 2018 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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14923043 |
Oct 26, 2015 |
9977867 |
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15984702 |
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13492441 |
Jun 8, 2012 |
9171285 |
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14923043 |
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13166467 |
Jun 22, 2011 |
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13492441 |
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11596305 |
Dec 13, 2007 |
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PCT/US2005/015791 |
May 6, 2005 |
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13166467 |
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10841240 |
May 6, 2004 |
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11596305 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
G16H 10/60 20180101;
G06Q 10/10 20130101; G06Q 50/22 20130101; G06Q 10/087 20130101;
G06Q 30/0207 20130101; G16H 50/20 20180101; G16H 40/67 20180101;
G16H 10/20 20180101; G06F 19/34 20130101; G06F 19/328 20130101;
G06Q 50/20 20130101; G16H 40/20 20180101 |
International
Class: |
G16H 10/20 20180101
G16H010/20; G06Q 50/22 20180101 G06Q050/22; G06Q 50/20 20120101
G06Q050/20; G16H 10/60 20180101 G16H010/60; G06Q 10/10 20120101
G06Q010/10; G06Q 10/08 20120101 G06Q010/08; G06Q 30/02 20120101
G06Q030/02 |
Claims
1. A method for managing a patient's health and healthcare costs,
the method comprising: authenticating an electronic device to a
computer that stores a patient account record corresponding to a
patient identification; commanding the computer to generate and
transmit a unique patient webpage for display on the electronic
device using data from the patient account record; wherein the
patient webpage comprises an opportunity to earn a financial reward
associated with a medical service that is unique to the patient
account record, the opportunity comprising a healthcare provider
name and a patient diagnosis associated with a date of service, an
expiration date assigned to the opportunity by the computer, and a
patient session link to instruct the computer to generate and
display an information therapy prescription, a patient knowledge
exam, a patient declaration link, a patient agreement link, and a
patient rating link; displaying the information therapy
prescription at the electronic device; displaying the patient
knowledge exam on the electronic device, the knowledge exam
comprising a plurality of questions related to the information
therapy prescription and selected by the computer from a question
database; receiving input signals from the electronic device, the
signals comprising answers to the plurality of questions; creating
and displaying a new webpage when an incorrect answer is received
directing the patient to a question with the incorrect answer and a
portion of the information therapy prescription containing a
correct answer; activating the patient declaration link to transmit
a signal from the electronic device to indicate a patient
declaration of adherence or reason for non-adherence to the
information therapy prescription; receiving the signal from the
patient declaration link, the signal comprising an answer to the
patient declaration of adherence or reason for non-adherence to the
information therapy prescription; amending the patient account
record to indicate a patient declaration of adherence or reason for
non-adherence to the information therapy prescription; activating
the patient agreement link to transmit a signal used to amend the
patient account record to indicate a patient agreement to release
the patient's answers to the plurality of questions and the
declaration of adherence or reason for non-adherence to the
information therapy prescription and to the healthcare provider;
activating the patient rating link to transmit a signal indicative
of the patient's answers to the rating of the healthcare provider;
and thereafter, the computer authorizes disbursement of the
financial reward to the patient.
2. The method of claim 1 wherein the electronic device comprises an
Internet or application enabled device.
3. The method of claim 1 wherein authenticating the electronic
device to the computer comprises receiving the patient
identification and an authentication factor both corresponding to
the patient account record at the computer.
4. The method of claim 1 wherein the electronic device and the
computer communicate via the Internet.
5. The method of claim 1 wherein the patient web page comprises a
plurality of opportunities to earn financial rewards each
comprising an entry on the patient account record comprising the
healthcare provider name and the patient diagnosis associated with
a date of service, the expiration date of the opportunity assigned
by the computer, and the patient session link.
6. The method of claim 1 further comprising before displaying the
information therapy prescription and the knowledge exam on the
electronic device, the computer automatically processes the patient
account record to determine if the expiration date assigned by the
computer has passed, thereafter the computer does not authorize
disbursement of the financial reward to the patient if the computer
determines the expiration date has passed.
7. The method of claim 1 further comprising creating and sending an
electronic mail message or postal notice to the patient of the
opportunity to earn a financial reward associated with a medical
service before displaying the unique patient webpage.
8. The method of claim 7 wherein the electronic mail message
comprises an active link to the unique patient webpage.
9. The method of claim 1 further comprising the computer
establishing a threshold dwell time for the electronic device to
display the information therapy prescription and measuring the
dwell time, authorizing disbursement of the financial reward if the
measured dwell time meets or exceeds the threshold dwell time.
10. The method of claim 1 wherein the information therapy
prescription comprises an educational material selected by the
computer based on the patient diagnosis.
11. The method of claim 1 wherein the patient's rating of the
healthcare provider is aggregated with ratings from a plurality of
patients and transmitted by the computer to the healthcare provider
as a composite performance rating.
12. The method of claim 11 wherein the computer uses the composite
performance rating to determine a level of compensation to the
healthcare provider.
13. The method of claim 1 further comprising instructing a health
plan to disburse the financial reward to the patient.
14. The method of claim 12 further comprising instructing a health
plan to disburse the financial reward to the healthcare
provider.
15. A computer implemented method for managing health and
healthcare costs, comprising executing on a processor the steps of:
creating a financial reward opportunity record for a patient based
on a patient identifier and a medical diagnosis code associated
with a medical service rendered by a healthcare provider to the
patient received in a first electronic message; assigning a time
limit to the financial reward opportunity record; linking an
information therapy selected from an information therapy database
to the financial reward opportunity record; linking a randomly
selected query related to the information therapy from a plurality
of queries stored in a query database to the financial reward
opportunity record; receiving a second electronic message
comprising the patient identifier and requesting access to the
financial reward opportunity; in response to the second electronic
message, accessing the financial reward opportunity record to
create and transmit a patient session webpage comprising the
medical diagnosis code, the selected information therapy, the
query, and an active link to generate a third electronic message
comprising a patient declaration of adherence or reason for
non-adherence to the information therapy, a patient answer to the
query, and a patient agreement to release the patient answer and
the patient declaration of adherence or reason for non-adherence
transmitted to the healthcare provider; receiving and processing
the third electronic message to write the patient declaration of
adherence or reason for non-adherence, the patient answer, and the
patient agreement to release to a patient record and to confirm
receipt of the third electronic message prior to the time limit;
and thereafter authorizing disbursement of the financial reward to
the patient.
16. The method of claim 15 further comprising processing the
patient answer to the query and creating and displaying a new
webpage when the patient answer is incorrect, the new webpage
comprising the query for which the patient answer was given and at
least a portion of the information therapy containing a correct
answer to the query.
17. The method of claim 15 further comprising: receiving a
healthcare provider identification at the computer from a provider
electronic device; processing the healthcare provider
identification to create and transmit a healthcare provider webpage
for display on the provider electronic device, the healthcare
provider webpage comprising a plurality of fields to receive data
from a healthcare provider containing the patient identifier and
the medical diagnosis code; wherein the computer receives the
patient identification and the medical diagnosis code and generates
a healthcare provider prescription page for display on the provider
electronic device, the prescription page comprising plurality of
active links for the healthcare provider to select an offer of a
healthcare provider financial compensation, a healthcare provider
performance standard, a patient performance standard and
information therapy corresponding with the medical diagnosis code,
and an expiration date assigned to the offer by the computer; the
computer processes the data received from the prescription page and
generates a unique declaration page corresponding to the patient
identification and the medical diagnosis code comprising a
plurality of active links to receive and transmit data from the
provider electronic device to the computer comprising a healthcare
provider declaration of adherence or reason for non-adherence to
the healthcare provider performance standard, a healthcare provider
acknowledgment that the patient will rate or confirm the healthcare
provider declaration of adherence or reason for non-adherence, a
patient performance standard and information therapy prescription,
and an agreement to confirm and acknowledge the patient declaration
of adherence or reason for non-adherence; the computer receives the
data from the declaration page and automatically processes the data
to determine if the healthcare provider has declared adherence to
the healthcare provider performance standard or provided a reason
for non-adherence that corresponds to at least one reason for
non-adherence from plurality of preselected reasons for
non-adherence stored in a database at the computer; and the
computer issues a command signal to order disbursement of the
healthcare provider financial incentive to the healthcare provider
based upon authentication of the data received from the
prescription page and the healthcare provider declaration of
adherence or authorized reason for non-adherence, if the expiration
date has not passed.
18. The method of claim 17 further comprising processing data
received from the prescription page to generate the patient session
webpage.
19. The methods of claim 17 wherein the command signal is
transmitted to a health plan computer, and comprises an order to
disburse the service provider financial incentive comprising
monetary compensation to the service provider.
20. The method of claim 15 further comprising before transmitting
the patient session webpage, the computer automatically processes
the financial opportunity reward record to determine if the time
limit has passed, thereafter the computer does not authorize
disbursement of the financial reward to the patient if the computer
determines the time limit has passed.
Description
CROSS REFERENCE TO RELATED APPLICATION
[0001] This application is a continuation of U.S. patent
application Ser. No. 14/923,043, filed Oct. 26, 2015, now U.S. Pat.
No. 9,977,867, which is a continuation of U.S. patent application
Ser. No. 13/492,441, filed Jun. 8, 2012, now U.S. Pat. No.
9,171,285, which is a continuation-in-part of U.S. patent
application Ser. No. 13/166,467, filed Jun. 22, 2011, which is a
continuation of U.S. patent application Ser. No. 11/596,305, filed
Dec. 13, 2007, which is a 371 of PCT/US2005/015791 filed May 6,
2005, which is a continuation-in-part of U.S. patent application
Ser. No. 10/841,240, filed May 6, 2004, the contents of which are
incorporated herein by reference.
BACKGROUND OF THE INVENTION
[0002] A challenge confronting modern civilization is how to
provide healthcare to all the members of a society. When stated in
this way, the challenge transcends the issue of whether healthcare
is a right or a privilege. It even exceeds the questions about how
much healthcare and what quality of healthcare is a society to
receive. Moreover, the challenge is a matter of economic
reality--how can society afford universal healthcare coverage. When
all is said and done, and there has been lots said and done with
regard to this challenge, there are only a handful of consistencies
that define the challenge--and it is these consistencies that lead
us to the solution.
[0003] The following are the consistencies that frame the
challenge: [0004] Health Status of the Citizens--Obviously, a
society with a population of healthy versus unhealthy people is
better able to provide universal healthcare coverage. [0005]
Efficiency and Effectiveness of the Healthcare Delivery System--A
society with a healthcare system that delivers high quality
clinical outcomes for the least amount of resources is better able
to provide universal healthcare coverage than a society with a
healthcare system that is dysfunctional and delivers low quality
clinical outcomes. [0006] Affluence of the Society--Rich countries
are better able to provide universal coverage to its citizens than
poor countries. In fact, a country's affluence depends in large
part on the health status of its citizens.
[0007] Simply stated, a rich country with healthy people and an
efficient healthcare delivery system is in a much better position
to provide universal healthcare coverage than a poor country with
unhealthy people and a dysfunctional healthcare system. It follows
that a society increases its ability to provide universal coverage
by improving its economy, its citizen's health status and its
healthcare delivery system. So, the challenge can be distilled
further to the objective of improving a society's economy, public
health status and healthcare delivery system, and then maintaining
these factors at levels that allow the society to afford universal
healthcare coverage.
[0008] The United States presents an interesting combination of
factors that complicate the challenge. The U.S. is an affluent
country with declining public health, a largely dysfunctional
healthcare delivery system, and since 2008, a struggling economy.
Americans spend considerably more on healthcare per capita than
citizens of any other developed country, and yet Americans' life
expectancy and infant mortality rates rank toward the bottom of the
list of these countries. For decades, the growth rate of healthcare
expenditures in the U.S. has grown two to five times the rate the
economy at large, consuming an ever increasing segment of the
country's gross domestic production (GDP). Unlike other developed
countries that provide government-sponsored universal healthcare
coverage, the U.S. is the only country in which a majority of
citizens receive healthcare coverage through their employers or by
purchasing health insurance from a commercial insurer. Beginning in
the 1990s and continuing to the present, the number of Americans
without health insurance coverage or are under-insured has grown
because it is becoming increasingly unaffordable. Current estimates
place the number of uninsured at 45,000,000 to 47,000,000, which
represents an all-time high of 17.1% of the U.S. population as of
2011. At the same time, the annual cost of healthcare coverage for
a family of four exceeded $20,000 for the first time as of
2012.
[0009] Fueling this growth in healthcare costs and the uninsured is
the declining healthcare status of Americans. The U.S. is far and
away the most obese country on earth. According to the Center of
Disease Control and Prevention (CDC) latest survey for 2010, 35.7%
of American adults are obese. This compares with less than 15% in
1980, 24.2% for the next most obese country (Mexico), and 14.1% for
all developed countries. Obesity is a well-known cause of all sorts
of serious maladies that are expensive to treat such as diabetes,
heart disease, hypertension, and metabolic disease. It is also a
well-known fact that obesity can be prevented with better diet and
exercise. Studies clearly show that preventing and reversing
obesity along with other preventable health issues such as smoking,
poor medication adherence and health illiteracy at a moderate level
could save enough overall to provide funds to cover all the
uninsured and then some.
[0010] Complicating matters is the fact that the supply of U.S.
physicians to treat these diseases is also becoming an increasingly
critical problem. The number of people filling medical school slots
has not kept pace with the demand, especially for primary care
physicians. Currently, the United States ranks 43.sup.rd in the
world in the number of physicians per capita--and this shortage of
physicians is occurring just as the "baby-boomer" generation begins
to reach retirement age. The simple economic law of supply and
demand will only add inflationary pressure on an already
hyper-inflating situation.
[0011] Since the mid-1980s, several attempts have been made to
control healthcare costs. The attempted reforms only temporarily
slowed the escalation of healthcare costs during the mid to late
1990s, when health maintenance organizations (HMOs) incented
medical service providers to control healthcare utilization.
Successful lawsuits by patients that found HMOs rationed care and
the threat of federal legislation (Patients' Bill of Rights) caused
a dramatic decline in HMOs. Other approaches in which health plan
sponsors (health insurance companies, self-insured employers or
government programs) compensate medical service providers
(principally physicians) to improve the quality and efficiency of
healthcare quality in an attempt to bend the so-called cost curve
include: [0012] the pay-for-performance movement--a concept that
assumed improved care quality would lead to cost containment;
[0013] accountable care organizations (ACOS)--a concept that
essentially mirrors HMOs with a focus on improved quality to
prevent the suggestion of rationed care; [0014] patient-centered
medical homes (PCHMs)--a concept that uses primary care providers
and health information technology to coordinate better care; [0015]
the adoption of interconnected electronic health record (EHR)
systems to help make healthcare more effective and efficient.
[0016] Again, the reoccurring theme with each of these approaches
involves the health plan sponsor compensating medical service
providers to change their practice patterns in an attempt to bend
the cost curve. The other characteristic common to these approaches
is that patients (plan members) are not held accountable for their
health behaviors, and therefore, are left out of the equation.
[0017] Another movement attempting to resolve the issue of
healthcare coverage affordability involves approaches in which the
plan sponsor financially rewards the patient to improve his/her
health behaviors. Examples of this approach include: [0018]
wellness, prevention and care management programs--the patient
(plan member) earns financial rewards for participating in these
programs and/or for achieving specific health objectives; [0019]
high deductible consumer-driven health care plans--this approach
includes health savings and retirement accounts that are intended
to shift the financial responsibility for purchasing healthcare
services to the plan member, thus incenting the plan member to be
healthier and a discriminating healthcare shopper; [0020] disease
management--the plan sponsor hires nurses or coaches to encourage
patients with chronic conditions to be compliant with recommended
treatments; [0021] population health management--similar to disease
management, but includes other methods such as risk assessments,
predictive modeling, wellness and prevention to address the
complete population, not just chronically ill patients; [0022]
value-base benefit design (VBBD) or value-based insurance design
(VBID)--designed to lower the financial barriers to patients with
chronic conditions or use other financial incentives to encourage
patient compliance.
[0023] In addition to the plan sponsor financially rewarding plan
members for participation in these programs or for accomplishing
health objectives, the other characteristic common to these
approaches is that medical service providers are excluded from the
arrangement or have only a perfunctory role.
[0024] In essence, there have been two movements attempting to meet
the challenge making universal healthcare coverage affordable--one
in which plan sponsors financially incent medical service providers
(service providers and healthcare service providers) to change
their practice performance to the exclusion of the patient, and
another in which the plan sponsor financial incents patients to
improve their health behaviors to the exclusion of the medical
service provider. After decades of effort and countless attempts,
neither of these movements has succeeded in meeting the
challenge.
[0025] In 2010, the federal government passed the Patient
Protection and Affordable Care Act (PPACA or ACA) for the principal
purpose of reducing the number of uninsured Americans. A secondary
purpose of the law is to make healthcare less expensive to the
country can afford to provide universal coverage. The PPACA's
affordability provisions are primarily focused on improving the
efficiency and effectiveness of the country's healthcare delivery
system. Essentially nothing in the law addresses how to incent
Americans to improve their health habits to prevent and reverse
preventable conditions such as obesity. As a result, most experts
agree that the law cannot effectively resolve healthcare
affordability. Therefore, the goal of universal coverage cannot be
attained or sustained without either further crippling the U.S.
economy or by rationing care to Americans.
[0026] So back to the challenge, how can a society such as the U.S.
provide healthcare cover to its entire population when the country
can't effectively afford the cost of the current system with 17% of
its people uninsured? How can people be attracted to the medical
profession to alleviate the growing provider supply and demand
issue when the economic outlook for the profession seems so
gloomy?
[0027] The current invention is directed to improving the delivery
of healthcare and health behaviors by creating a system of
incentives that align the interests of healthcare's essential
stakeholders--healthcare service providers (principally
physicians), healthcare consumers/patients (health plan members),
and health plan sponsors (health insurers, self-insured employers,
health plans, and the government's Medicare and Medicaid programs)
in a win-win-win arrangement. Unlike other cost containment methods
that have consistently failed to recognize or accommodate for this
fundamental success criterion of stakeholder alignment, the present
invention provides an effective system to controlling healthcare
costs by "triangulating" the interests of the service provider, the
patient and the plan sponsor to improve the standard of care and
encourage healthy behaviors, which leads to better health.
[0028] The present invention is directed to a method and
information technology based system for simultaneously controlling
cost by improving the delivery of healthcare related services by
medical service providers and improving the health behaviors and
status of patients (health plan members) by directing health plan
sponsored financial rewards to both the healthcare service provider
and the patient for enhancing communication and co-decision-making
between medical service providers and patients, increasing the
knowledge of the patient about how to self-manage his or her
health, providing a system of "checks and balances" to measure and
motivate patient and medical service provider adherence to accepted
performance standards. As used herein the term "information
technology based" means telephonic, Internet, web-based, or other
computer based system for recording, storing, processing and
communicating information.
SUMMARY OF THE INVENTION
[0029] The present invention is directed to a method for improving
the delivery of healthcare services and the promotion of healthy
behaviors, simultaneous. The method comprises receiving a diagnosed
health condition of a patient and a claim for services rendered
from a service provider. A service provider performance standard is
sent to the service provider based on the received diagnosed health
condition. The service provider is queried to generate a service
provider declaration of adherence or a reason for non-adherence to
the service provider performance standard and a service provider
agreement to allow or an acknowledgment that the patient to confirm
or rate the service provider declaration of adherence or reason for
non-adherence. The diagnosed health condition, the service provider
performance standard, the service provider declaration of adherence
or the reason for non-adherence, and a patient performance standard
are transmitted to the patient. The patient is queried to generate
a patient demonstration of knowledge of the diagnosed health
condition, a patient declaration of adherence or reason for
non-adherence to a patient performance standard, and a patient
agreement to allow the service provider to confirm or acknowledge
the patient demonstration of knowledge and the patient declaration
of adherence or reason for non-adherence to the patient performance
standard. The patient demonstration of knowledge, the declaration
of patient adherence or reason for non-adherence to the patient
performance standard are transmitted or made available to the
service provider. The service provider is queried to generate a
service provider confirmation of the patient demonstration of
knowledge and the declaration of patient adherence or the reason
for non-adherence to the patient performance standard. The patient
is queried to generate a patient confirmation of the service
provider declaration of adherence or reason for non-adherence to
the service provider performance standard. The service provider
confirmation, the patient confirmation, the service provider
declaration of adherence or reason for non-adherence, and the
patient demonstration of knowledge, patient declaration of
adherence or reason for non-adherence are authenticated and payment
of the claim for services rendered and disbursement of a
performance-based incentive to the service provider and a
performance-based incentive to the service provider are authorized
based on authentication.
[0030] The present invention is further directed to an information
technology based, such as a web-based or telephonic method, for
managing healthcare delivery and for promoting healthy behavior.
The method comprises receiving a patient identification and at
least one diagnosis from a service provider through a web or
telephonic interface. The method further includes transmitting a
service provider performance standard, a patient performance
standard and patient educational articles to the service provider
corresponding with each diagnosis received from the service
provider through the web or telephonic interface. A service
provider declaration of adherence to the service provider
performance standard or a reason for non-adherence is received from
the service provider. An information therapy prescription of one or
more patient educational articles, a prescription of the patient
performance standard, and a rating of patient adherence to a
patient performance standard are received from the service
provider. Authorization from the service provider to allow the
patient to verify or rate the service provider declaration of
adherence to the performance standard or to express an opinion
about the reason for non-adherence, and to have the service
provider declaration of adherence to the service provider
performance standard or the reason for non-adherence that
authenticated and adjudicated. Disbursement of a performance-based
incentive to the service provider based upon verification by the
patient and authentication and adjudication of the service provider
declaration of adherence or the reason for non-adherence to the
performance standard is occurs upon receipt of verification by
patient.
[0031] The present invention further includes a system for managing
healthcare delivery and for promoting healthy behaviors. The system
comprises a healthcare services provider web-based or telephonic
interface, a patient web-based or telephonic interface, and a means
to automatically authenticating and adjudicating. The healthcare
services provider web-based or telephonic interface is adapted to
accept a patient identification and a diagnosis from a healthcare
services provider, to transmit a healthcare service provider
performance standard, a healthcare service provider agreement to
allow the patient to confirm or rate the healthcare service
provider declaration of adherence or the healthcare provider reason
for non-adherence to the healthcare provider performance standard,
a patient performance standard, and patient educational articles to
the healthcare services provider based upon the diagnosis, to
accept a healthcare service provider declaration of adherence or
reason for non-adherence to the healthcare service provider
performance standard, optionally to accept an after-the-fact
healthcare service provider rating of patient adherence to the
patient performance standard, to accept a healthcare service
provider information therapy prescription of one or more of the
patient educational articles to the patient, and to accept
healthcare service provider verification of a patient declaration
of adherence to the patient performance standard. The patient
web-based or telephonic interface is adapted to provide the patient
with the healthcare service provider performance standard, the
patient performance standard, the information therapy prescription,
and a patient agreement to allow the service provider to confirm or
rate a patient declaration of adherence or reason for non-adherence
to the patient performance standard and a patient answer to a query
regarding the information therapy prescription, to provide at least
one query to the patient regarding the information therapy and the
patient performance standard, to receive at least one answer to the
at least one query regarding the information therapy and the
agreement to allow the service provider to confirm or rate the
patient declaration of adherence or reason for non-adherence to the
patient performance standard and the patient answer to the query
regard the information therapy prescription, to accept the patient
declaration of adherence or reason for non-adherence to the patient
performance standard, to accept the patient agreement answer to
allow the service provider to confirm or rate the patient
declaration of adherence or reason for non-adherence to the patient
performance standard and the patient answer to the query regard the
information therapy prescription, to accept a patient verification
of the service provider declaration of adherence or reason for
non-adherence to the service provider performance standard. The
means for automatically adjudicating and authenticating the service
provider declaration of adherence, the patient declaration of
adherence, the service provider agreement to allow the patient to
confirm or rate the service provider, the patient agreement to
allow the service provider to confirm or rate the patient, the
patient verification of the healthcare service provider declaration
of adherence, and the healthcare service provider verification of
the patient declaration of adherence; for providing an
authorization for disbursement of a performance-based reward to the
patient and a performance-based reward to the services provides
upon adjudication and authentication.
BRIEF DESCRIPTION OF THE FIGURES
[0032] FIGS. 1 and 1A are a flow chart representing the medical
practitioner's (service provider's) portion of one embodiment of
the Program.
[0033] FIGS. 2 and 2A are a flow chart representing the patient's
portion of one embodiment of the Program.
[0034] FIG. 3 is a diagrammatic illustration of an Information
Therapy (Ix) Program embodiment of the method of the present
invention.
[0035] FIG. 4 is an illustrative representation of a webpage used
in the method and system of the present invention.
[0036] FIG. 5 is an illustrative representation of a webpage used
in the method of the present invention. The webpage shown
represents a step in the method of accepting a patient's member ID
or last name.
[0037] FIG. 6 is a representative webpage interface used to accept
a diagnosis from a service provider.
[0038] FIG. 7 is an illustrative webpage interface that may be used
in the present invention. The webpage of FIG. 7 is adapted to
accept multiple diagnoses from a service provider, if
necessary.
[0039] FIG. 8A is a webpage interface designed to guide the service
provider through the performance-based standards for a selected
diagnosis.
[0040] FIG. 8B is an alternative webpage interface designed to
guide the service provider through the performance-based standards
for a selected diagnosis.
[0041] FIG. 9A is an exemplary webpage of the present invention
illustrating the interactive nature of the present invention by
showing a menu of reasons for non-adherence upon deviation from the
performance standard.
[0042] FIG. 9B is an alternative exemplary webpage of the present
invention illustrating the interactive nature of the present
invention by showing a menu of reasons for service provider
non-adherence upon deviation from the performance standard.
[0043] FIG. 9C is an exemplary information therapy prescription
webpage.
[0044] FIG. 10 shows an initial "welcome page" on a patient side of
the present method.
[0045] FIG. 11 an internet webpage used to provide the patient with
health information about his/her diagnosis including EBM
treatments, recommended care, health maintenance, and/or other
performance standards.
[0046] FIG. 12A illustrates an exemplary webpage comprising a
questionnaire used to allow the patient to indicate his/her
knowledge or understanding of the health information provided by
the webpage shown in FIG. 11.
[0047] FIG. 12B is an exemplary webpage showing the patient's
options after giving an incorrect answer to a web-based test used
to test the patient's knowledge of the information therapy
prescribed by the service provider.
[0048] FIG. 13 is an exemplary webpage showing an inquiry of the
patient to share the patient's opinion as to how closely he or she
is following health recommendations.
[0049] FIG. 14 is an exemplary webpage used to allow the patient to
authorize release of the patient's responses to an information
therapy questionnaire to the patient's service provider.
[0050] FIG. 15 is an exemplary webpage used by the patient to rate
his or her service provider.
[0051] FIG. 16 is an exemplary voucher used to notify the patient
they have completed the information therapy process and earned a
financial reward.
DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0052] The current invention is often referred to as a healthcare
"pay-for-performance" or "P4P" program. Most P4P programs
exclusively reward or motivate medical providers (doctors and
hospitals). The current invention rewards both the medical provider
and the patient "interactively" in a manner that creates a
simultaneous benefit to the service provider, the patient, and the
purchaser/payer (health plan). The current invention may preferably
be described as an "alignment of interest" or "AOI" program because
it aligns the interest of the medical provider, the patient and the
health plan sponsor in a "win-win-win arrangement.
[0053] The current invention typically involves four (4) parties:
the medical service provider or practitioner (doctors); the patient
(consumer or health plan member); the party who underwrites the
cost or risk of the healthcare (purchaser or payer or employer or
insurer or government or health plan or health plan sponsor); and
the independent operator of the invention (referred to as an
intermediary or "Informediary")
[0054] The current invention also comprises the following elements:
a performance standard (or set of performance standards) for both
the medical provider and the patient that have been shown
(preferably by an independent and credible third party) to be
effective at improving healthcare and health in a manner that
controls healthcare costs; performance-based incentives that may
comprise financial rewards paid by the health plan to the medical
provider and patient; a web-based or telephonic system of checks
and balances that asks the medical provider and the patient to
independently and individually declare adherence or provide a
reason for non-adherence to the respective performance standard,
asks the medical provider and the patient to independently and
individually agree to allow the other party to confirm his/her
declaration of adherence or reason for non-adherence, and further
asks the service provider and patient to independently and
individually confirm each other's declaration of adherence or
reason for non-adherence; and a website (Website) operated by the
Informediary that comprises a set of proprietary Internet
applications that facilitates the system of checks and
balances.
[0055] In the current invention, the health plan disburses
performance-based financial rewards independently to the medical
provider and patient when the Informediary authenticates that the
medical provider and/or the patient have accessed the Website,
demonstrated or gained knowledge about the respective performance
standards, declared adherence or provided a reason for
non-adherence to the performance standards, agreed to allow the
other party to confirm his/her declaration of adherence or reason
for non-adherence, and confirmed (or denied) the adherence to the
performance standard by the other party.
[0056] The current invention is designed to "bolt on" to health
plans (including plans sponsored by health insurers, the
government's Medicare and Medicaid programs, and self-insured
employers) to improve health and healthcare in a manner that leads
to healthcare cost containment. In some respects, the current
invention creates a platform by which a three-way contract or
partnership can be established between the health plan, healthcare
service providers and patients, which is administered by the
intermediary. Accordingly, health plans are potential customers of
the current invention, while healthcare service providers and
patients are users. Other terms used to describe the result
achieved by the current invention include: "triangulation" and
"triangulation to reach a state of equilibrium;" "mutual
accountability," "mutual accountability partnership," and
"doctor-patient mutual accountability."
[0057] The Information Therapy (Ix) Program provided by the current
invention directs the health plan to financially reward healthcare
service providers (medical practitioners) and patients
"interactively" for controlling healthcare costs and utilization
through the incorporation of evidence-based medicine treatment
guidelines, information therapy, best clinical practices, and
healthy behaviors, which are collectively referred to as
performance standards of the Ix Program. The current invention is
delivered through a proprietary Internet Website where doctors
(medical practitioners) and patients read pertinent medical content
and respond to a series of questions to determine, declare,
acknowledge, confirm, and motivate compliance to performance
standards that have been shown to improve the standard of care and
the level of health, which in turn, lead to lower healthcare costs.
The invention is intended to compliment other quality improvement
and cost containment methods and initiatives such as: disease
management; consumer-driven healthcare; accountable care
organizations (ACOs); patient centered medical homes (PCMHs);
population health management including health risk assessment,
readiness to change, health screenings, wellness examinations,
wellness and fitness programs, smoking cessation, predictive
modeling; medical malpractice risk management; the adoption of
personal health records (PHRs), recommended hospital care
management programs; pre-authorization certification of expensive
procedures and tests; pharmacy benefit management including
electronic prescribing, therapeutic substitutions, and drug
interaction; electronic health monitoring devices; and the adoption
of electronic health (medical) record (EHR) systems and the related
meaningful use criteria.
[0058] Rewarding medical practitioners (physicians and hospitals)
in this fashion is commonly referred to as "pay-for-performance" or
"P4P." It is also referred to as "value-based" healthcare, in
contrast to "volume-based" healthcare. However, the current
invention's incentive system is unlike any other P4P program in
that financial rewards are paid by the health plan (healthcare
purchaser/payer) to both the medical provider (practitioner) and
the patient for voluntarily, individually and independently (or
dependently) declaring (or demonstrating) compliance to performance
standards (that are known to improve health and healthcare that
leads to reduced utilization and cost of healthcare services)
through the invention's Website, and also for agreeing to allow the
other party to individually and independently confirm (verify or
acknowledge) each other's (his/her) declaration (or demonstration)
of adherence to performance standards through the Website. In
effect, the current invention directs health plan sponsored
financial rewards to both medical practitioners and patients to
invoke powerful psychosocial motivators inherent to the
doctor-patient relationship by asking the medical practitioner and
the patient to voluntarily serve as each other's "judge and jury"
as to the other person's adherence to performance standards known
to improve health and healthcare. The innate desire by both the
medical practitioner and patient to please one another augments the
financial incentives to increase adherence to the performance.
Since the invention is accomplished through a proprietary Internet
Website that allows for an independent third party or a health plan
to authenticate and report the medical practitioner and patient's
"declarations and confirmations", a natural check and balance
(mutual accountability) is created that serves as a very effective
and efficient means (incentive) to shape the behaviors of the
medical practitioner (provider) and the patient, which again, is
above and beyond the invention's financial rewards. This process of
"declare and confirm" and "demonstrate and acknowledge" create
"checks and balances" that defines the terms "doctor-patient mutual
accountability" and "interactive" rewards and incentives. In the
present invention, the interests of the medical practitioner
(provider), the patient and the health plan (purchaser/payer) are
aligned in a "win-win-win" arrangement that define the terms
"triangulation to reach a state of equilibrium" and "mutual
accountability partnership."
[0059] More specifically, medical practitioners "win" by being
compensated for rendering a higher standard of care, by earning the
admiration of their patients, by enhancing their reputation and
image with their peers, and by the personal satisfaction of
providing superior care to their patients. Patients "win" by
earning financial rewards for demonstrating knowledge of and
compliance to healthy behaviors and rating their medical
practitioner's performance; by gaining knowledge, empowerment and
motivation to self-manage their health; by attaining the peace of
mind that their medical practitioners are rendering recommended EBM
care; and by achieving the satisfaction that their doctor is aware
of their health literacy and adherence to the performance standard.
Health plans "win" by gaining a means to better insure that they
are receiving greater value for their healthcare purchases, plus a
means to adjust both the size and nature of the rewards and
performance standards to improve healthcare and healthiness to
achieve cost savings that produce a return on investment. Because
of its unique aligning feature, the invention could be described as
an "alignment of interest" or "AOI" program as opposed to a P4P
program.
[0060] The current invention provides an I.sub.x (Ix) Program model
that rewards service providers (medical practitioners) financially
and in other ways when they adhere or provide a reason for
non-adherence to a performance standard such as considering an EBM
treatment guidelines, prescribing I.sub.x to their patients, and
agreeing to allow their patients to confirm or rate their adherence
or reason for non-adherence to the performance standard through a
medical practitioner Internet Website application. The rewards,
however, may comprise financial rewards or other rewards limited in
their type and nature by the imagination of the health plan
customer of the current invention. The same holds true for
performance standards. In addition to EBM treatment guidelines and
Ix prescriptions, a medical practitioner performance standard could
also be any service that is independently judged and validated to
be beneficial to the patient that can be structured interactively
through the invention's Website. Examples of these types of
performance standards include: patient-integrated pre-authorization
certification of expensive medical services; patient-integrated
hospital care management systems; drug therapy (pharmacy benefit)
management programs including e-prescription, therapeutic drug
substitution, automated drug interactions, and patient pharmacy
education with knowledge verification; the adoption and use of
personal health records; medical education programs; wellness and
fitness programs; social networking therapy programs; health risk
assessments; readiness to change interventions; compliance to
recommended treatments; use of automatic health monitoring devices;
hospitalization pre-admit and discharge education and adherence
programs; provider quality and cost education and transparency; and
adoption of health self-management programs. In effect, the health
plan can choose a specific health objective, such as prenatal care
with self-management testing that is confirmed by a licensed
obstetrician (who is compensated for the extra time and liability).
Then the health plan can specify an extra amount of financial
rewards, such as $200 for patient adherence against this
performance standard, whereas a normal patient financial reward may
be $25. The health plan's objective is to prevent health problems
for the mother and child, and the associated costs by using both a
financial reward and the psychosocial motivators inherent to the
doctor-patient relationship. This process illustrates just one of
countless ways a health plan can use the invention to target a
specific health or cost objective. It is referred to a
"precision-guided rewards and performance standards."
[0061] In the Ix program model of the current invention, the
process of a service provider, such as a medical practitioner,
physician, doctor, clinician, chiropractor, nurse, dentist, or
other health care service provider, accessing the Website to
"practice the method" (Ix Program or Program) by considering EBM,
prescribing Ix, and agreeing to allow the patient to confirm/rate
the doctor's performance can be initiated as a result of the
doctor's normal insurance claim filing. The receipt of a claim for
an applicable service, such as a patient office visit, prompts the
independent intermediary to send an email or fax notification to
the doctor. This "after-the-fact" notification directs the doctor
to access the Website to "practice the Program." In this example,
when the doctor successfully responds to the Website, the
independent intermediary notifies the health plan to compensate the
doctor for practicing the Program for the associated patient office
visit. This implies that the method facilitates timely and direct
physician (service provider) compensation for each patient
encounter on a per-occurrence-of-care basis. This method of
compensation is considered "Pavlovian" in that physicians receive
quick rewards that are directly tied to their performance. Other
incentive-based (P4P) programs that compensate physicians in an
indirect and untimely fashion, such as annual payments, are often
based on formulas designed to measure a variety of performance
criteria and judged by a third party. Physicians find these types
of incentive-based programs objectionable, especially when
compensation is based on complicated formulas or dependent on
patient performance or involve "cookbook medicine" or judge by
third parties that physicians do not trust.
[0062] In a preferred embodiment of the current invention, doctors
can initiate the process during the patient office visit on a
"real-time" basis through the medical practitioner (service
provider) Internet Website application. The doctor's appropriate
responses entered into the Website affect an immediate information
therapy prescription to the patient. The doctor's responses are
stored in the independent intermediary's Website database. When the
doctor files an insurance claim for an applicable medical
practitioner service (such as a patient office visit), the claim is
forwarded (typically through the health plan's administrator by
electronic means) to the independent intermediary. The claim is
then linked to the doctor's stored Website responses. The
independent intermediary then notifies the health plan to
compensate the doctor for practicing the program for the associated
patient office visit
[0063] As described earlier, the current invention can also be
initiated "after-that-fact" when the independent intermediary
identifies applicable medical practitioner services from the filing
of a claim for reimbursement. This triggers an e-mail notification
from the independent intermediary to the medical practitioner
(doctor). The doctor responds to the e-mail through the medical
practitioner Website. The medical practitioner's appropriate
responses can affect an automatic payment or reimbursement increase
to the medical practitioner (for practicing the Program) and an
information therapy prescription to the patient.
[0064] When the patient receives the Ix prescription by mail or
e-mail (or handed to the patient during the encounter by the
doctor), he/she is directed to a patient Website. There the patient
is asked to read evidence-based medical content and answer a series
of questions. These questions are designed to test the patient's
understanding of his/her condition, the recommended treatments and
healthy behaviors, and how best to self-manage his/her condition.
These questions also determine the patient's adherence or reason
for non-adherence to recommended treatment, agreement to allow
his/her doctor to confirm/acknowledge/rate his/her adherence or
reason for non-adherence to the recommended treatments and healthy
behaviors, and seek his/her impression of the doctor's care
relative to recommended care (treatments). As the patient answers
these questions, the patient scores points toward a financial
reward or refund of the patient's out-of-pocket medical expenses.
The patient's score and corresponding reward amount is
automatically transmitted by the independent intermediary to the
patient's health plan, which makes the disbursement of a
performance-based reward to the patient. As used herein,
"independent intermediary" may also include the patient's health
plan. In an alternative embodiment of this model of the invention,
the independent intermediary can disburse the performance-based
rewards to doctors and patients from funds supplied by the health
plan. The current invention provides for the automatic or optional
forwarding of the patient's actual responses by the independent
intermediary through the Website to the patient's doctor to support
subsequent care and as a means for the doctor to
confirm/acknowledge the patient's declaration or demonstration of
adherence to a performance standard. Alternatively, the
intermediary can post the patient's responses on a secured section
of the Website for the doctor to access for follow-up and
confirmation purposes.
[0065] The current invention has a number of built-in features that
are designed to achieve service provider (doctor) and patient
acceptance. One of these features addresses concerns doctors have
about being forced to practice "cookbook medicine." The current
invention allows and, in fact, encourages service providers
(medical practitioners/doctors/physicians/clinicians/healthcare or
medical service providers) to deviate from treatment guidelines
when it is appropriate in their judgment. The service provider
Website offers the doctor a menu of reasons to deviate or the
doctor can briefly describe a reason for non-adherence, provided
the doctor agrees to allow the patient to review/concur with the
reason for deviation/non-adherence. When the doctor provides a
reason for deviating from (non-adherence to) a guideline, the
intermediary stores that reason in the Website database to be
presented to the patient later in the process. When the patient
accesses the Website (which is described below), one of the
questions he/she is asked to answer is to rate or express an
opinion about the doctor's reason for deviating from a guideline.
As a result, the health plan is served (wins) by this feature of
the current invention because the doctor knows his/her reason for
deviation (or for that matter, declaration of guideline adherence)
will be rated/confirmed by the patient, which may cause the
patient's opinion of the doctor's care to be reinforced--or
diminished to the point the patient may refer the doctor to others
or seek care elsewhere. Doctors are aware that their patients are
gaining valuable information through the Program and doctors know
that their patients will expect care that is aligned with
evidence-based and/or recommended treatments. Doctors also become
aware that they are being rated by their patients against
evidenced-based and recommended care. Though this rating may or may
not directly impact an individual doctor's compensation on a
per-occurrence-of-care basis, most doctors do not want their
patients to think/learn they may be practicing inferior medicine,
nor do doctors want their aggregate patient rating to cause them to
be ranked poorly against their peers or to suffer negative
consequences because a poor aggregate rating or a low ranking may
be published. This check and balance aspect of the current
invention serves as an important incentive to encourage doctors to
be adherent to guidelines or to provide appropriate reasons for
deviation from a guideline. Doctors are served (win) by this
feature of the current invention because this check and balance
feature alleviates the concerns medical practitioners (doctors)
have about being forced to practice "cookbook medicine" and helps
doctors better communicate and educate their patients. Patients are
served (win) because the Program communicates their doctor's reason
for deviation so patients can understand that a particular
guideline does not necessary fit a specific medical condition. This
feature also helps the developers of guidelines and medical
researchers determine which guidelines are strongest and which ones
need further research and development.
[0066] Another feature of the current invention provides for the
efficient and effective dissemination of advancements in medicine
to service providers (medical practitioners) and serves as a means
(incentive system) to encourage doctors to adopt new and proven
advancements in medicine. This feature accomplishes these
objectives by highlighting new advancements in the decision-tree
guidelines or medical content presented in the medical practitioner
Website. The Website can require the medical practitioner to read
the highlighted guideline or content that contains research studies
or literature that supports the advancement. The medical
practitioner can also be required to answer a questionnaire or
indicate an acknowledgement or take a test about the medical
advancement in order for the medical practitioner to receive
compensation and/or to earn the higher rates of reimbursement
offered through the Program. The successful completion of the
questionnaire or test may earn the medical practitioner credits
toward required continuing medical education (CME). The current
invention may also forward (electronically or otherwise) the
results of the questionnaire to the medical practitioner's
licensure board for accreditation purposes. Since the doctor is
already asked to declare adherence or provide a reason for
non-adherence to the guideline, adoption of medical advancements
can be accelerated.
[0067] Though the service provider and patient psychological
incentives (psychosocial motivators inherent to the doctor-patient
relationship) are interactive in that both parties are aware that
they will be asked to judge/acknowledge each other's
declaration/demonstration of adherence (or non-adherence) to
performance standards against their actual performance (adherence),
the current invention ideally (but not necessarily) separates the
financial reward provided to the medical practitioner from the
reward provided to the patient. Thus, the medical practitioner may
be paid for his/her time and effort independent (or dependent) to
how the medical practitioner's patients respond to their Ix or
adherence (non-adherence) to a patient performance standard.
Patients' performance-based rewards may also be independent (or
dependent) of the medical practitioners' participation/adherence,
prescribing information therapy or adherence to the medical
practitioner performance standards. In other words, the reward
strategies involving participant elections/Website choices of the
current invention have been purposely configured to create a
natural and beneficial check and balance between doctors and the
patients. This set of strategic checks and balances
("doctor-patient mutual accountability") solves the issues of
compliance monitoring and appropriate provider deviation from a
guideline that other incentive-based models cannot solve.
[0068] The current invention provides a method for delivering
healthcare services designed to lower healthcare costs by elevating
the standard of care and encouraging patients to lead healthier
lives through a web-based/telephonic interface, provider-patient
interactive incentive (reward) system. An application of the method
comprises the steps of receiving a claim for compensation for
medical services from a medical practitioner for medical treatment
of a patient covered by the invention's program. The claim includes
at least one applicable diagnosis code corresponding to at least
one applicable medical treatment (such as an office visit) rendered
to patient. If at least one diagnosis code of the submitted claim
corresponds to a medical diagnosis found in a database of
applicable medical diagnoses, then a notice is sent by the
independent intermediary, also known as an Informediary, to the
medical practitioner, directing the medical practitioner to
voluntarily access a Website operated by an Informediary. The
Website presents the medical practitioner with EBM treatment
guidelines or other pertinent medical content relating to the
medical diagnosis of the patient. In addition to rendering the
common/recommended medical treatment, the medical practitioner
prescribes Ix for said patient that provides the patient with
instructions concerning managing the medical condition/diagnosis
and living a healthy lifestyle. The medical practitioner may be
given the opportunity to rate the patient's compliance with the
prescribed information therapy, recommended treatments, and
instructions relating to a healthy lifestyle.
[0069] In another embodiment, the current invention provides a
method for delivering healthcare services through a
web-based/telephonic interface, interactive provider-patient
incentive (reward) system. One method of the current invention
comprises the steps of the Informediary receiving a claim for
compensation for medical services rendered by a medical
practitioner to a patient covered by the Program of the current
invention. The claim filed by the medical practitioner includes at
least one applicable diagnosis code corresponding to at least one
applicable medical treatment rendered to said patient. Upon receipt
by the Informediary, the claim is examined to determine if at least
one diagnosis code corresponds to an applicable medical diagnosis
found in a database of applicable medical diagnoses. If a
corresponding applicable medical diagnosis is present, then a
notice is sent by the Informediary to the medical practitioner. The
notice sent to the medical practitioner includes the instructions
necessary for accessing a medical practitioner Website. Once the
medical practitioner gains access to the Website, the medical
practitioner will have access to EBM treatment guidelines (if one
exists) relating to the medical diagnosis/diagnoses of the patient.
Thereafter, the medical practitioner declares/demonstrates
adherence or provides a reason for non-adherence to the EBM
treatment guideline (if one exists), agrees to allow the patient to
confirm/rate the medical practitioner's declaration/demonstration
of adherence or reason for non-adherence to the EBM treatment
guideline, and then prescribes educational material in the form of
information therapy to the patient relating to the medical
diagnosis/diagnoses through the Website application. The prescribed
information therapy includes instruction for the patient to
self-manage his/her medical condition, guidelines for healthy
behavior, and a means to assess/determine/test the patient's
understanding (health literacy) of the educational material.
Additionally and alternatively, the medical practitioner rates
patient adherence to the prescribed Ix and recommended treatments
and healthy behaviors. Following the prescription of Ix, the
Informediary automatically generates a notice to the patient
directing the patient to access the Website. Once the patient
accesses the Website, the Website provides the patient with the
means to access the educational material relating to his/her
medical diagnosis/diagnoses. The method further provides for the
monitoring of the patient's access of the medical information. The
Website further provides a knowledge exam/assessment/test designed
to measure patient comprehension of the medical diagnosis, how
his/her doctor (medical practitioner) should be treating the
diagnosis, and how the patient can/should self-manage his/her
condition. Provided that the patient takes the exam or declares
his/her understanding, the Website will automatically score the
knowledge exam and it will provide the patient with the option of
(or require) forwarding (posting for access) the knowledge exam or
declaration of understanding results to the medical practitioner.
The patient is also asked to indicate their personal adherence or
reason for non-adherence to recommended care and healthy behaviors,
to report their health status, to agree to allow his/her medical
practitioner to confirm/rate/acknowledge the patient's knowledge
exam/declaration and declaration/demonstration of adherence (or
reason for non-adherence) to recommended care and healthy
behaviors, and to rate their medical practitioner's performance
against the recommended care. Finally, the patient is provided with
the option of authorizing the compliance rating assigned by his/her
medical practitioner to the patient's health plan and/or employer
for the purpose of determining a financial or other types of
reward.
[0070] In a further embodiment of the current invention, the
patient is provided with the option of rating (or is required to
rate) the medical practitioner's adherence or reason for
non-adherence to EBM treatment guidelines or other accepted care
corresponding to the patient's diagnosis. Following review of the
prescribed Ix educational material, the patient is asked to rate
the medical practitioner's care against the Ix educational
material. This rating ideally does not, though it may, directly
affect that medical practitioner's reward or compensation on a
case-by-case basis. However, it does begin to build an overall
clinical performance rating for that medical practitioner. This can
be used to help individual medical practitioners measure their
performance against their peers. Poor ratings can be used in peer
review. This embodiment of the invention allows and encourages
medical practitioners the freedom to use their clinical judgment to
deviate from a guideline while receiving the maximum financial
reward, provided the medical practitioner selects or supplies a
reason for the deviation and agrees to allow the patient to concur
with/acknowledge/rate the medical practitioner's reason for
non-adherence. Preferably, the ratings provided by the medical
practitioner and the patient would be obscured from each other to
help protect the doctor-patient relationship with each party having
the option of releasing his/her rating to the other party.
[0071] Still further, the current invention provides a method for
delivering healthcare services through a web-based/telephonic
interface, interactive provider-patient incentive (reward) system.
The system of the current invention comprises a Website operated by
an Informediary and having a medical practitioner portion/section
and a patient portion/section. The medical practitioner's portion
is programmed to be accessed directly by the medical practitioner
during the patient encounter (the "real-time" method) or to receive
a claim submitted by the medical practitioner after the patient
encounter containing standard codes for the patient's diagnosis(es)
and medical services rendered by the medical practitioner (the
"after-the-fact" method). The Website compares the medical
diagnosis(es) entered by the medical practitioner directly into the
Website during the patient encounter or from a coded claim
submitted by the medical practitioner to a database of medical
diagnoses.
[0072] In the Ix program model of the current invention, the
process of a service provider accessing the Website to "practice
the method" (Ix Program or Program) by considering EBM, prescribing
Ix, and agreeing to allow the patient to confirm/rate the service
provider's performance can be initiated as a result of the doctor's
normal insurance claim filing. The receipt of a claim for an
applicable service, such as a patient office visit, prompts the
independent intermediary to send an email or fax notification to
the doctor. This "after-the-fact" notification directs the doctor
to access the Website to "practice the Program." In this example,
when the doctor successfully responds to the Website, the
independent intermediary notifies the health plan to compensate the
doctor for practicing the Program for the associated patient office
visit. This implies that the method facilitates timely and direct
physician (service provider) compensation for each patient
encounter on a per-occurrence-of-care basis. This method of
compensation is considered "Pavlovian" in that physicians receive
quick rewards that are directly tied to their performance. Other
incentive-based (P4P) programs that compensate physicians in an
indirect and untimely fashion, such as annual payments, are often
based on formulas designed to measure a variety of performance
criteria and judged by a third party. Physicians find these types
of incentive-based programs objectionable, especially when
compensation is based on complicated formulas or dependent on
patient performance or involve "cookbook medicine" or judge by
third parties that physicians do not trust.
[0073] In a preferred embodiment of the current invention, doctors
can initiate the process during the patient office visit on a
"real-time" basis through the medical practitioner (service
provider) Internet Website application. The doctor's appropriate
responses entered into the Website affect an immediate information
therapy prescription to the patient. The doctor's responses are
stored in the independent intermediary's Website database. When the
doctor files an insurance claim for an applicable medical
practitioner service (such as a patient office visit), the claim is
forwarded (typically through the health plan's administrator by
electronic means) to the independent intermediary. The claim is
then linked to the doctor's stored Website responses. The
independent intermediary then notifies the health plan to
compensate the doctor for practicing the program for the associated
patient office visit
[0074] As described earlier, the current invention can also be
initiated "after-that-fact" when the independent intermediary
identifies applicable medical practitioner services from the filing
of a claim for reimbursement. This triggers an e-mail notification
from the independent intermediary to the medical practitioner
(doctor). The doctor responds to the e-mail through the medical
practitioner Website. The medical practitioner's appropriate
responses can affect an automatic payment or reimbursement increase
to the medical practitioner (for practicing the Program) and an
information therapy prescription to the patient.
[0075] When the patient receives the Ix prescription by mail or
e-mail (or handed to the patient during the encounter by the
doctor), he/she is directed to a patient Website. There the patient
is asked to read evidence-based medical content and answer a series
of questions. These questions are designed to test the patient's
understanding of his/her condition, the recommended treatments and
healthy behaviors, and how best to self-manage his/her condition.
These questions also determine the patient's adherence or reason
for non-adherence to recommended treatment, agreement to allow
his/her doctor to confirm/acknowledge/rate his/her adherence or
reason for non-adherence to the recommended treatments and healthy
behaviors, and seek his/her impression of the doctor's care
relative to recommended care (treatments). As the patient answers
these questions, the patient scores points toward a financial
reward or refund of the patient's out-of-pocket medical expenses.
The patient's score is automatically forwarded by the independent
intermediary to the patient's health plan, which makes the
disbursement of a performance-based reward to the patient. In an
alternative embodiment of this model of the invention, the
independent intermediary can disburse the performance-based rewards
to doctors and patients from funds supplied by the health plan. The
current invention provides for the automatic or optional forwarding
of the patient's actual responses by the independent intermediary
through the Website to the patient's doctor to support subsequent
care and as a means for the doctor to confirm/acknowledge the
patient's declaration or demonstration of adherence to a
performance standard. Alternatively, the intermediary can post the
patient's responses on a secured section of the Website for the
doctor to access for follow-up and confirmation purposes.
[0076] The current invention has a number of built-in features that
are designed to achieve service provider (doctor) and patient
acceptance. One of these features addresses concerns doctors have
about being forced to practice "cookbook medicine." The current
invention allows and, in fact, encourages service providers
(medical practitioners/doctors/physicians/clinicians/healthcare or
medical service providers) to deviate from treatment guidelines
when it is appropriate in their judgment. The service provider
Website offers the doctor a menu of reasons to deviate or the
doctor can briefly describe a reason for non-adherence, provided
the doctor agrees to allow the patient to review/concur with the
reason for deviation/non-adherence. When the doctor provides a
reason for deviating from (non-adherence to) a guideline, the
intermediary stores that reason in the Website database to be
presented to the patient later in the process. When the patient
accesses the Website (which is described below), one of the
questions he/she is asked to answer is to rate or express an
opinion about the doctor's reason for deviating from a guideline.
As a result, the health plan is served (wins) by this feature of
the current invention because the doctor knows his/her reason for
deviation (or for that matter, declaration of guideline adherence)
will be rated/confirmed by the patient, which may cause the
patient's opinion of the doctor's care to be reinforced--or
diminished to the point the patient may refer the doctor to others
or seek care elsewhere. Doctors are aware that their patients are
gaining valuable information through the Program and doctors know
that their patients will expect care that is aligned with
evidence-based and/or recommended treatments. Doctors also become
aware that they are being rated by their patients against
evidenced-based and recommended care. Though this rating may or may
not directly impact an individual doctor's compensation on a
per-occurrence-of-care basis, most doctors do not want their
patients to think/learn they may be practicing inferior medicine,
nor do doctors want their aggregate patient rating to cause them to
be ranked poorly against their peers or to suffer negative
consequences because a poor aggregate rating or a low ranking may
be published. This check and balance aspect of the current
invention serves as an important incentive to encourage doctors to
be adherent to guidelines or to provide appropriate reasons for
deviation from a guideline. Doctors are served (win) by this
feature of the current invention because this check and balance
feature alleviates the concerns medical practitioners (doctors)
have about being forced to practice "cookbook medicine" and helps
doctors better communicate and educate their patients. Patients are
served (win) because the Program communicates their doctor's reason
for deviation so patients can understand that a particular
guideline does not necessary fit a specific medical condition. This
feature also helps the developers of guidelines and medical
researchers determine which guidelines are strongest and which ones
need further research and development.
[0077] Another feature of the current invention provides for the
efficient and effective dissemination of advancements in medicine
to service providers (medical practitioners) and serves as a means
(incentive system) to encourage doctors to adopt new and proven
advancements in medicine. This feature accomplishes these
objectives by highlighting new advancements in the decision-tree
guidelines or medical content presented in the medical practitioner
Website. The Website can require the medical practitioner to read
the highlighted guideline or content that contains research studies
or literature that supports the advancement. The medical
practitioner can also be required to answer a questionnaire or
indicate an acknowledgement or take a test about the medical
advancement in order for the medical practitioner to receive
compensation and/or to earn the higher rates of reimbursement
offered through the Program. The successful completion of the
questionnaire or test may earn the medical practitioner credits
toward required continuing medical education (CME). The current
invention may also forward (electronically or otherwise) the
results of the questionnaire to the medical practitioner's
licensure board for accreditation purposes. Since the doctor is
already asked to declare adherence or provide a reason for
non-adherence to the guideline, adoption of medical advancements
can be accelerated.
[0078] Though the service provider and patient psychological
incentives (psychosocial motivators inherent to the doctor-patient
relationship) are interactive in that both parties are aware that
they will be asked to judge/acknowledge each other's
declaration/demonstration of adherence (or non-adherence) to
performance standards against their actual performance (adherence),
the current invention ideally (but not necessarily) separates the
financial reward provided to the medical practitioner from the
reward provided to the patient. Thus, the medical practitioner may
be paid for his/her time and effort independent (or dependent) to
how the medical practitioner's patients respond to their Ix or
adherence (non-adherence) to a patient performance standard.
Patients' performance-based rewards may also be independent (or
dependent) of the medical practitioners' participation/adherence,
prescribing information therapy or adherence to the medical
practitioner performance standards. In other words, the reward
strategies involving participant elections/Website choices of the
current invention have been purposely configured to create a
natural and beneficial check and balance between doctors and the
patients. This set of strategic checks and balances
("doctor-patient mutual accountability") solves the issues of
compliance monitoring and appropriate provider deviation from a
guideline that other incentive-based models cannot solve.
[0079] The current invention provides a method for delivering
healthcare services designed to lower healthcare costs by elevating
the standard of care and encouraging patients to lead healthier
lives through a web-based/telephonic interface, provider-patient
interactive incentive (reward) system. An application of the method
comprises the steps of receiving a claim for compensation for
medical services from a medical practitioner for medical treatment
of a patient covered by the invention's program. The claim includes
at least one applicable diagnosis code corresponding to at least
one applicable medical treatment (such as an office visit) rendered
to patient. If at least one diagnosis code of the submitted claim
corresponds to a medical diagnosis found in a database of
applicable medical diagnoses, then a notice is sent by the
independent intermediary, also known as an Informediary, to the
medical practitioner, directing the medical practitioner to
voluntarily access a Website operated by an Informediary. The
Website presents the medical practitioner with EBM treatment
guidelines or other pertinent medical content relating to the
medical diagnosis of the patient. In addition to rendering the
common/recommended medical treatment, the medical practitioner
prescribes Ix for said patient that provides the patient with
instructions concerning managing the medical condition/diagnosis
and living a healthy lifestyle. The medical practitioner may be
given the opportunity to rate the patient's compliance with the
prescribed information therapy, recommended treatments, and
instructions relating to a healthy lifestyle.
[0080] In another embodiment, the current invention provides a
method for delivering healthcare services through a
web-based/telephonic interface, interactive provider-patient
incentive (reward) system. One method of the current invention
comprises the steps of the Informediary receiving a claim for
compensation for medical services rendered by a medical
practitioner to a patient covered by the Program of the current
invention. The claim filed by the medical practitioner includes at
least one applicable diagnosis code corresponding to at least one
applicable medical treatment rendered to said patient. Upon receipt
by the Informediary, the claim is examined to determine if at least
one diagnosis code corresponds to an applicable medical diagnosis
found in a database of applicable medical diagnoses. If a
corresponding applicable medical diagnosis is present, then a
notice is sent by the Informediary to the medical practitioner. The
notice sent to the medical practitioner includes the instructions
necessary for accessing a medical practitioner Website. Once the
medical practitioner gains access to the Website, the medical
practitioner will have access to EBM treatment guidelines (if one
exists) relating to the medical diagnosis/diagnoses of the patient.
Thereafter, the medical practitioner declares/demonstrates
adherence or provides a reason for non-adherence to the EBM
treatment guideline (if one exists), agrees to allow the patient to
confirm/rate the medical practitioner's declaration/demonstration
of adherence or reason for non-adherence to the EBM treatment
guideline, and then prescribes educational material in the form of
information therapy to the patient relating to the medical
diagnosis/diagnoses through the Website application. The prescribed
information therapy includes instruction for the patient to
self-manage his/her medical condition, guidelines for healthy
behavior, and a means to assess/determine/test the patient's
understanding (health literacy) of the educational material.
Additionally and alternatively, the medical practitioner rates
patient adherence to the prescribed Ix and recommended treatments
and healthy behaviors. Following the prescription of Ix, the
Informediary automatically generates a notice to the patient
directing the patient to access the Website. Once the patient
accesses the Website, the Website provides the patient with the
means to access the educational material relating to his/her
medical diagnosis/diagnoses. The method further provides for the
monitoring of the patient's access of the medical information. The
Website further provides a knowledge exam/assessment/test designed
to measure patient comprehension of the medical diagnosis, how
his/her doctor (medical practitioner) should be treating the
diagnosis, and how the patient can/should self-manage his/her
condition. Provided that the patient takes the exam or declares
his/her understanding, the Website will automatically score the
knowledge exam and it will provide the patient with the option of
(or require) forwarding (posting for access) the knowledge exam or
declaration of understanding results to the medical practitioner.
The patient is also asked to indicate their personal adherence or
reason for non-adherence to recommended care and healthy behaviors,
to report their health status, to agree to allow his/her medical
practitioner to confirm/rate/acknowledge the patient's knowledge
exam/declaration and declaration/demonstration of adherence (or
reason for non-adherence) to recommended care and healthy
behaviors, and to rate their medical practitioner's performance
against the recommended care. Finally, the patient is provided with
the option of authorizing the compliance rating assigned by his/her
medical practitioner to the patient's health plan and/or employer
for the purpose of determining a financial or other types of
reward.
[0081] In a further embodiment of the current invention, the
patient is provided with the option of rating (or is required to
rate) the medical practitioner's adherence or reason for
non-adherence to EBM treatment guidelines or other accepted care
corresponding to the patient's diagnosis. Following review of the
prescribed Ix educational material, the patient is asked to rate
the medical practitioner's care against the Ix educational
material. This rating ideally does not, though it may, directly
affect that medical practitioner's reward or compensation on a
case-by-case basis. However, it does begin to build an overall
clinical performance rating for that medical practitioner. This can
be used to help individual medical practitioners measure their
performance against their peers. Poor ratings can be used in peer
review. This embodiment of the invention allows and encourages
medical practitioners the freedom to use their clinical judgment to
deviate from a guideline while receiving the maximum financial
reward, provided the medical practitioner selects or supplies a
reason for the deviation and agrees to allow the patient to concur
with/acknowledge/rate the medical practitioner's reason for
non-adherence. Preferably, the ratings provided by the medical
practitioner and the patient would be obscured from each other to
help protect the doctor-patient relationship with each party having
the option of releasing his/her rating to the other party.
[0082] Still further, the current invention provides a method for
delivering healthcare services through a web-based/telephonic
interface, interactive provider-patient incentive (reward) system.
The system of the current invention comprises a Website operated by
an Informediary and having a medical practitioner portion/section
and a patient portion/section. The medical practitioner's portion
is programmed to be accessed directly by the medical practitioner
during the patient encounter (the "real-time" method) or to receive
a claim submitted by the medical practitioner after the patient
encounter containing standard codes for the patient's diagnosis(es)
and medical services rendered by the medical practitioner (the
"after-the-fact" method). The Website compares the medical
diagnosis(es) entered by the medical practitioner directly into the
Website during the patient encounter or from a coded claim
submitted by the medical practitioner to a database of medical
diagnoses.
[0083] Preferably, the system of the current invention will provide
suitable incentives to both the patient and the medical provider to
bring about a change in behaviors resulting in an improved standard
of care and an improved level of healthiness that leads to better
clinical outcomes for the patient and lower overall costs for the
healthcare system. Additionally, the improved method for delivering
healthcare aligns the interests of all the key stakeholders in the
healthcare industry. These key stakeholders are generally
identified as medical providers (physicians/doctors/healthcare or
medical service providers/medical
practitioners/clinicians/providers/hospitals), patients (healthcare
consumers/health plan members/beneficiaries), and health plans
(self-insured employers/health insurance companies/governmental
health programs such as Medicare, Medicaid, Veterans
Administration, and Indian Health Service/health plan sponsors).
For the purposes of this discussion, the current invention focuses
on services delivered by a medical practitioner such as a
physician; however, the methods of the current invention apply
equally well to other types of clinicians such as physician
assistants (PAs), nurse practitioners (NPs) and other healthcare
providers recognized by patients as trusted and respected
healthcare authorities.
[0084] To encourage medical practitioner participation in the
method of the current invention, medical practitioners will be
financially rewarded (compensated) for each patient encounter when
the medical practitioner accomplishes the following tasks for each
treated diagnosis: 1) if available, consider EBM and other
recommended treatment guidelines (and other performance standards)
and indicate adherence or reason for non-adherence to the
guideline; 2) prescribe educational material in the form of
information therapy to their patient (not optional for a financial
reward); 3) rate/acknowledge the patient compliance to recommended
care for each diagnosis; 4) agree to allow the patient confirm/rate
the medical practitioner's declaration of adherence or reason for
non-adherence to the guideline or recommended care; 5) respond
appropriately to patient responses on the Website to include
warnings/alerts of patient medical issues; and 6) congratulate the
patient for achieving health objectives.
[0085] As an encouragement to respond to Ix prescriptions and to
live a healthy lifestyle, the methods of the current invention
financially rewards patients for completing the following tasks: 1)
read the medical educational material prescribed to them on the
Website concerning their health condition, recommended (EBM) care
and other pertinent performance standards; 2) answer questions
presented on the Website to demonstrate their understanding of the
educational material; 3) indicate their adherence or reason for
non-adherence to the recommended (EBM) care and healthy behaviors;
4) report (or have health monitoring devices report) their health
status such as weight, blood pressure, blood sugar, and resting
heart rate; 5) authorize access to pharmacy records to verify that
their prescriptions have been filled and they have passed a drug
literacy assessment, and/or request verification that they have
successfully participated in a health assessment or screening
program, and/or authorize access to lab and other test results,
and/or authorize access to a readiness to change program indicating
their participation and accomplishments, and/or request
verification that they have seen or scheduled to see a medical
specialist or have successfully completed or scheduled to complete
other recommended therapies, and/or release information indicating
they have updated a personal health record with pertinent
information and request his/her medical providers to use the
personal health record in his/her treatment to achieve coordination
of care and to prevent duplication of care, and/or provide access
to an advance directive, and/or participate in a pre-authorization
certification of expensive tests and services (such as surgeries
and hospitalizations) through the Website to prevent unnecessary
procedures and insure better clinical outcomes, and/or
demonstrate/declare their healthy behavior or adherence by any
other means to other performance standards prescribed by their
physician or offered by their health plan; 6) agree to allow their
medical practitioner to acknowledge/confirm/rate their adherence to
any and all prescribed or offered performance standards; 7) after
acknowledging their medical practitioner's recorded responses to
the Website question(s) about adherence or reason for non-adherence
to a recommended treatment or performance standard, and taking into
consideration the educational material they have just read on the
method's Website, rate/confirm/refute their medical practitioner's
adherence or reason for non-adherence to the performance standard;
and/or 8) as an option, elect to have (authorize that) their
medical practitioner's rating of the patient's adherence to
recommended care and healthy behaviors (or other performance
standards) be used to determine their financial reward or health
status (this election by the patient further reinforces the
Program's strategic checks and balances ("doctor-patient mutual
accountability") because patients are aware that this election will
cause the Program to compare their personal health adherence
responses against their medical practitioner's rating of their
health compliance, and if the compliance indicators between the
patient and the medical practitioner match, then the Program would
indicate that the patient is be eligible for an additional
financial reward from their health plan.)
[0086] In the preferred embodiment of the current invention, the
intermediary should select the Program's treatment guidelines,
educational material, and other types of medical practitioner and
patient performance standards, as well as the reason for
non-adherence as an independent party to prevent biasing the
Program in favor of any of the stakeholders. With regard to the
medical practitioner's reason for non-adherence, the reasons must
be appropriate/legitimate, and therefore the reasons are
established as the following: [0087] Co-morbidity [0088] Emergent
condition [0089] Pending lab or other test results [0090]
Contraindicated because: (requires the medical practitioner to
explain) [0091] Using an advanced treatment with the patient's
consent [0092] Patient declines for financial reasons [0093]
Patient declines for other reasons: (requires the medical
practitioners to explain) [0094] Guideline in error or out of date:
(requires the medical practitioners to explain)
[0095] The patient's reasons for non-adherence are established as:
[0096] I believe my doctor has mis-diagnosed my condition:
(requires the patient to explain and recommends the patient consult
with his/her physician) [0097] I am afraid of the recommended
treatments--(recommends the patient consult with his/her physician)
[0098] I can't afford the recommended treatments--(recommends the
patient consult with his/her physician) [0099] I believe the
treatments are inappropriate or unnecessary: (requires the patient
to explain and recommends the patient consult with his/her
physician) [0100] I have recovered from my illness [0101] I have
chosen not to follow the recommended treatments because: (requires
the patient to explain and recommends the patient consult with
his/her physician)
[0102] The healthcare delivery methods of the current invention
will be described with reference to FIGS. 1, 2 and 3. To aid in
identification of the various steps of the current invention,
identifying numbers are provided for selected portions of the
process. Electronic communications, such as but not limited to
Internet, e-mail, provide the most efficient means for practicing
the methods of the current invention. However, the methods of the
current invention may be readily adapted to a telephone or
telephonic service, standardize electronic data interchange, text
messaging; traditional mail, faxes and other hard copy
communications or a blend of electronic communication and
traditional hard copy communications.
[0103] FIGS. 1 and 2 provide flow charts of the method for
providing healthcare. FIG. 3 provides an illustrated description of
the preferred embodiment of the current invention. FIG. 1 outlines
an embodiment of the current invention as it relates to the medical
practitioner's portion of EBM and Ix. FIG. 2 outlines the patient's
portion of an embodiment of the current invention. While shown in
step wise format, those skilled in the art will recognize that
various portions of the process can be moved earlier and later in
the charts. The methods of the current invention are designed to
provide flexibility and adaptability depending on the desires of
the local health plan. The format of the current invention may be
adapted by any form of health plan. As used herein, the term
"health plan" refers to the organization underwriting the cost of
the healthcare insurance coverage and managing the healthcare
delivery system, and may include self-insured employers, health
insurance companies (and their customers to include employers and
individuals who purchase health insurance coverage), managed care
plans, healthcare CO-OPs, U.S. governmental programs such as
Medicare, Medicaid, Veterans Administration, military, state and
Federal employees, and Indian Health Service, and all types of
national health services and systems in other countries.
[0104] As shown in FIG. 1, the method of the current invention
begins with educating the patient and the medical practitioner on
the benefits of the current invention (referred to herein as "the
Program"), to include why and how the methods of the Program work.
Medical practitioners are made aware of the Program by a variety of
means to include organized meetings, targeted mailings and
telephone contact, or with the aid of a local medical provider
organizations (medical provider organization licensee) contacted to
sponsor the Program in a market, or patients who inform or ask
their medical practitioner to participate. Medical practitioners
are directed to the Program's Website to enroll online. Prior to
receiving treatment, the patient can identify a medical
practitioner that participates in the Program, but receiving
medical service from an enrolled and participating medical
practitioner is not a requirement in order for the Program to work.
Typically, the Program will be administered by an independent
intermediary that operates the Website and administers the
Program's computer that hosts the Website and manages the Program's
databases and electronic interfaces with the health plan and
suppliers of content and services used to operate the Program. The
intermediary sells Program access and service agreements to health
plan sponsors. Health plan sponsors "bolt-on" the Program to their
actual health plans, which in the case of self-insured employers
may be managed by an independent third party administrator (TPA) or
an administrative services only (ASO) provider. (Though it is not
recommended, in another embodiment of the current invention, the
health plan can also function as the intermediary.) It is the
intermediary that will typically license medical provider
organizations (such as a medical group practice, independent
practice association or IPA, or a physician-hospital organization
or PHO) to administer provider relations and promote the Program in
a market. An example of these relationships is as follows; the
independent intermediary sells a user license and service agreement
to the health plan. The health plan may comprise a self-insured
employer. The health plan's beneficiaries to include a self-insured
employer's covered employees and dependents, collectively,
represent the health plan's members. The health plan supplies,
typically electronically, a list of eligible members to the
intermediary. The intermediary stores the eligible members listing
(file) in the Program's database. This file of eligible members is
updated, typically electronic, by the health plan periodically.
[0105] When a member seeks healthcare, they are described as
patients. A patient seeking medical services presents themselves to
a medical practitioner as a member of the health plan covered by
the Program. Subsequently, the medical practitioner provides
healthcare services to the patient. The medical practitioner can
voluntarily elect to participate in the Program with each service
encounter with a covered patient. Preferably, the medical
practitioner elects to participate by accessing the Program's
Website at the time of service (enrolls in the Program if he/she
has not done so previously) and enters pertinent patient
information and diagnosis(es) information preferably as a
standardized diagnosis(es) code(s). (This preferred time of service
method of practicing the Program is referred to as the
point-of-service-initiated or "POSI" real-time version as opposed
to the claim initiated or "CI" after-the-fact version, which is
described later.) As shown in FIG. 3, the Program's software
application compares the patient and diagnosis(es) information to
the Program's database stored on the intermediary's computer. If
the Program's software finds a patient information match in the
Program's database and there is available EBM or recommended
treatment guidelines (a medical practitioner performance standard)
and patient educational content (material) and/or patient
performance standard related to the diagnosis(es) in the database,
then the Program displays the treatment guideline and educational
content (and any other performance standards) to the medical
practitioner on the Website (Refer to FIG. 3, Step #6). The Website
is interactive. As such, if an EBM or recommended treatment
guideline is available, the medical practitioner considers the
guideline and indicates/declares/demonstrates adherence or reason
for non-adherence to the guideline on the Website. In the process,
the medical practitioner agrees to allow patient to or acknowledges
that the patient will confirm/rate/concur the medical
practitioner's declaration/demonstration of adherence or reason for
non-adherence to the guideline. If educational content and a
patient performance standard are available, the medical
practitioner selects or searches for the preferred content (and/or
other patient performance standard) and orders an Ix prescription
(and/or other patient performance standard) for the patient on the
Website. Optionally, the medical practitioner is asked to rate the
patient's compliance to EBM or appropriate care for each presenting
diagnosis. Again, the medical practitioner may be asked to consider
or initiate other types of performances standards such a
pre-authorization certification for certain heavy cost medical
service, or a pharmacy benefits management service to include
electronic prescriptions and lower cost therapeutic substitutions,
or the updating of the patient's web-based personal health record,
etc. The patient and diagnosis(es) information, the medical
practitioner's response(s) to guideline adherence, the agree to
allow the patient to confirm the medical practitioner's adherence
(or non-adherence), the Ix prescription order, the medical
practitioner's rating of the patient's compliance, and responses to
other performance standards are stored in the Program's database
for subsequent processing to determine the medical practitioner's
rate of compensation by the intermediary.
[0106] The Ix prescription or other performance standard order can
be printed by the medical practitioner at the time of service so it
can be handed to the patient, or these documents can he mailed or
e-mailed to the patient. Alternating, the medical practitioner may
choose to postpone participating in the Program until after an
insurance claim for reimbursement of the medical services is
submitted to the health plan (see description of the CI
after-the-fact version below). Therefore the Program's processes
can be initiated at the time of service by the medical practitioner
accessing the Program's Website or it can be initiated by filing an
insurance claim for normal medical services reimbursement.
[0107] Following treatment of the patient, the medical practitioner
files an insurance claim for medical services reimbursement with
the health plan administrator. Preferably, the medical practitioner
files the claim electronically (FIG. 1, Step #1). The medical claim
contains information commonly found on current claim forms such as
the patient's name, the medical practitioner's name, a primary
medical diagnosis, secondary diagnosis(es) and the service provided
by the medical practitioner. Preferably, the medical diagnosis and
the medical services are identified by a usual and customary
diagnosis and medical services codes, and the diagnosis(es) is
appropriately linked to the corresponding medical service(s). The
health plan simultaneously processes the claim (as usual) and also
forwards a copy of the claim to the intermediary (refer to FIG. 1,
FIG. 2, Step #1, and FIG. 3, Step #10).
[0108] Upon receipt of the claim, the patient and diagnoses
information are compared by the intermediary to any matching
information in the Program's database. Matches then determine if
the claim lists eligible medical services (referred to as
"applicable medical service(s)") contained in the Program's
database. If the claim contains applicable medical services (FIG.
1, Step #1), then the medical practitioner's stored responses to
the Website queries concerning guideline adherence, (or reason for
non-adherence), Ix and other patient performance standards
prescriptions, agreement to allow patient to or acknowledge patient
will confirm/rate medical practitioner's adherence (or reason for
non-adherence), and medical practitioner's confirmation of the
patient compliance for the diagnosis(es) and other performance
standards linked to the applicable medical services are taken into
consideration in determining, the medical practitioner's rate of
reimbursement (compensation) as described herein.
[0109] If the diagnosis code does not match an accepted guideline
in the Intermediary's database (FIG. 1, Step #9), the
intermediary's computer selects information therapy content that
matches the diagnosis code and sends a notice to the service
provider. The service provider responds to the notice by accessing
the Program's Website. The service provider accepts the information
therapy provided by the program or researches and selects
information therapy on the website to be prescribed and dispensed
to the patient through the program. Depending on the compensation
requirements of the health plan and intermediary, the service
provider may be required to acknowledge or confirm a patient
indication of adherence, and then the Program either assigns an
intermediate compensation rate or an Ix prescription letter is sent
by the intermediary to the patient (FIG. 2, Step #14).
[0110] Medical practitioners must submit an insurance claim for
medical service reimbursement within a time limit or they will not
be eligible for the higher rates of reimbursement or any
compensation associated with the Program for that patient
encounter. (As indicated in FIG. 1A, Step #8, missing the time
limit for filing a claim would not necessarily affect future
opportunities to practice the Program.) If information supplied by
the medical practitioner at time of service is not matched to a
claim within a certain period of time, then the Program may send a
notification/warning to the medical practitioner that the claim
filing time limit about to expire.
[0111] Alternatively, if the medical practitioner did not access
the Website or respond to the Website queries at the time of
service (the POSI real-time version), then once the claim for
medical services are forwarded to the Program's (intermediary's)
computer system, the system will not identify matching patient and
diagnosis information (refer to FIG. 1 and FIG. 1A). If this is the
case, then the computer compares the claim information to the
Program's database for applicable diagnoses. If the claim contains
an applicable diagnosis, then the computer determines if the
diagnosis is linked to an applicable medical service. If this is
the case, then the computer automatically sends a notification
(preferably email and/or fax) to the medical practitioner informing
him/her that there is a Program "opportunity" ("AOI opportunity")
available (3). (This after-the-fact method defines the claim
initiated or CI version of the Program and diagrammed in FIG. 1 and
FIG. 1A.)
[0112] The notification sent to the medical practitioner advises
the medical practitioner to access the medical practitioner's
portion of the Program's Website containing EBM guidelines or other
healthcare quality improvement, patient education material, and
other cost control methods (collectively referred to as performance
standards). The Program Website is preferably a secure website
requiring input of the medical practitioner's password to gain
access to the data contained therein. Alternatively, these access
codes may be transmitted by a separate email or otherwise provided
to the medical practitioner. (The method for gaining access to the
Website is not critical to the current invention.)
[0113] For the purposes of this disclosure the term website refers
to the Program's Websites. The Program's Websites may or may not be
located on a central server at the intermediary. Further, the
patient and medical practitioner portions of the Program's Websites
are not necessarily contained on the same computer system, but may
be maintained by health plan's computers or multiple independent
intermediaries. As used herein, the medical practitioner portion of
the Program's Website will preferably be utilized by all parties
authorized to access the medical practitioner's portion of the
Website, including but not limited to nurses, nurse practitioners,
physician assistants and other care providers.
[0114] Upon entry of the appropriate codes or passwords at the
Website (FIG. 1, Steps #2 and #4 and FIG. 3, Step #5 and #6), the
Website identifies the names of patients, the dates and types of
services provided, the medical diagnoses and related medical
services for the accessing medical practitioner or authorized
assistant (delegates can be set-up in the Program's computer,
provided the delegate is approved and supervised by a licensed
medical practitioner). The Website also provides the available EBM
guidelines or other healthcare quality improvement and cost control
methods (performance standards) corresponding to each diagnosis.
Preferably, the medical practitioner reviews and confirms the
appropriateness of the information found on the Website (FIG. 1,
Step #5).
[0115] The Program's Website is interactive. As such, it queries
the medical practitioner concerning adherence or reason for
non-adherence to EBM guidelines or other healthcare quality
improvement and cost control methods (performance standards) for
the diagnoses (FIG. 1, Step #6 and FIG. 3, Step #7), the agreement
to allow the patient to or acknowledgment that the patient will
confirm/rate the medical practitioner's adherence or reason for
non-adherence to the performance standards, the prescription
educational material as Ix to the patient, and patient compliance
with the prescribed treatment and guidelines on living a healthy
lifestyle and methods for controlling/managing the patient's
medical condition (FIG. 1A, Step#12 and FIG. 3, Step #9). The
medical practitioner's response to the queries will determine the
reimbursement rate used to compensate the medical practitioner for
services rendered on each claim associated with a Program
opportunity. If the medical practitioner responds to the queries
concerning patient compliance, prescription of Ix to the patient,
declaration/demonstration of adherence or reason of non-adherence
to EBM guidelines or other healthcare quality improvement and cost
control methods (performance standards), and the agreement to allow
the patient to or acknowledge that the patient will confirm/rate
the medical practitioner's adherence or reason for non-adherence to
the performance standards are appropriate (FIG. 1A, Step #13 and
FIG. 3, Step #12), then the Website will automatically direct
compensation to be made according to a higher payment (practitioner
reimbursement) rate/scale (FIG. 1A, Step #13). Preferably, the
highest rate of medical practitioner compensation (payment) is
selected when the medical practitioner practices the method on a
real-time basis using the POSI version of the Program. (Timeliness
can be important in delivering information therapy and other
services initiated through the Program to the patient. Therefore,
the highest rate of medical practitioner compensation is typically
assigned when the POSI version of the Program is practiced.)
Alternatively, the highest rate of compensation can be assigned in
instances where the medical practitioner has indicated adherence or
reason for non-adherence to a recommended treatment guideline,
agreed to allow the patient to or acknowledged that the patient
will confirm/rate the medical practitioner's adherence or reason
for non-adherence to the performance standards, prescribed Ix for
the patient (FIG. 1A, Steps #10 and #11) and has rated patient
compliance (FIG. 1A, Step #12 and FIG. 3, Step #9). (It should be
noted that additional medical practitioner compensation can be
earned through the Program as other performance standards are added
to achieve the intended objectives.) Typically, a secondary level
or lower rate of compensation (payment) is assigned (selected) when
the medical practitioner practices the after-the-fact CI version of
the Program. Alternatively, the secondary level of compensation can
be assigned (selected) when the medical practitioner has prescribed
Ix for the patient and has rated patient compliance, but no
treatment guideline is available or some other diminished level of
service is provided.
[0116] As noted above, the Website also queries the medical
practitioner concerning the patient's compliance with health
recommendations and EBM guidelines, Ix and any lifestyle activities
necessary to improve the patient's wellness. Preferably, the
Website will provide the medical practitioner with the opportunity
to rate patient compliance with the recommended treatment and
behaviors using the following terms: Compliant, Mostly Compliant,
Somewhat Compliant, Mostly Non-compliant, Non-compliant and
Non-applicable. Alternatively, the patient compliance rating terms
may be: Compliant and No Response. No Response may mean partially
compliant, noncompliant, or non-applicable. To receive the highest
compensation level for the services provided, the medical
practitioner may need to respond to the request for a patient
compliance rating. The ratings provided by the medical practitioner
will be stored by the Program awaiting a response by the patient to
the prescribed Ix. However, the patient will not have the ability
to see the medical practitioner's rating unless the medical
practitioner has selected the option to permit the patient to view
the rating.
[0117] Typically, the medical practitioner must access the
interactive Website within 48 to 96 hours of receipt of the
after-the-fact, CI notification in order to qualify for the higher
payment rate scale. In the preferred embodiment, the medical
practitioner is required to respond to the notice within 48 to 96
hours or two to four business days. If the medical practitioner
does not respond within the indicated period of time (FIG. 1A,
Step#8), then the Website will direct compensation to be made
according to a lower (or lowest) rate scale or to cause the Program
opportunity for the medical practitioner to expire resulting in no
compensation to the medical practitioner association with the
Program for that opportunity (FIG. 1A, Step #8c).
[0118] As previously indicated, the Program's Website is
interactive. To provide the maximum flexibility and greatest
possibility of improved clinical outcome for the patient, the
method of the current invention does not rigidly limit the medical
practitioner only to the EBM guidelines in order to receive the
highest degree of compensation. Rather, the Program's Website
provides the medical practitioner with the option of indicating the
treatment falls outside of the guidelines while explaining the
reason for prescribing treatment outside of the guidelines.
Provided that the medical practitioner completes the section
describing an appropriate reason for non-adherence to the
recommended treatment (FIG. 1, Step#8a), the Program's Website will
still select the highest compensation level for the medical
practitioner. Thus, the present invention avoids the practice of
"cookbook medicine" by encouraging the medical practitioner to use
appropriate clinical judgment and medical skills when deciding to
on whether or not to follow the EBM guidelines. In order for this
"anti-cookbook" feature to work, the medical practitioner must
agree to allow the patient to confirm/rate/concur with the medical
practitioner's declaration/demonstration of adherence or reason for
non-adherence to the recommended (EBM) care.
[0119] As previously indicated, in the preferred method the medical
practitioner must prescribe educational material as Ix for the
patient and (alternatively) rate patient compliance with
directions/guidelines on living a healthy lifestyle and other
methods for controlling/managing the medical condition before
becoming eligible to receive payment at the highest or second
highest (intermediate) compensation rates.
[0120] Again, the medical practitioner is not required to indicate
compliance with the EBM guidelines; however, failure to respond
within 48 to 96 hours or indicating non-adherence without providing
an appropriate reason for treatment outside of the EBM guidelines
can have a negative financial impact on the medical practitioner.
Specifically, these actions will trigger the intermediary's
computer system to select the lowest possible payment scale for the
medical practitioner's services (FIG. 1A, Step #8c) or terminate
that "opportunity" for the medical practitioner to earn any
additional compensation at all. If the medical practitioner fails
to prescribe educational material as Ix for the patient, then the
Website will direct the selection of the lowest payment scale for
compensation of the medical practitioner or not compensation the
medical practitioner for that "opportunity" at all. Furthermore, if
the medical practitioner fails to participate in the Program for
any given "opportunity" or to satisfactorily complete the steps
that are required of a successful participation for any given
"opportunity" as established by the health plan sponsor (in
consultation with the intermediary) and adjudicated by the
intermediary within the specified time limit, then the medical
practitioner's opportunity will expire and he/she will not be
compensated.
[0121] As a result of the medical practitioner's failure to
successfully participate in the Program for any given
"opportunity," the patient's "opportunity" to participate may or
may not be affected in accordance with Program requirements
established by the health plan sponsor in consultation with the
intermediary. Typically, the patient's "opportunity" to participate
is not affected. In this case, the diagnosis listed on the medical
service claim for payment submitted by the medical practitioner
provides the means by which the intermediary's computer system can
automatically generate an Ix prescription letter, email or other
type of notification to the patient that informs the patient of
chance to participate in the Program for said "opportunity." This
notification to the patient may inform the patient that the medical
practitioner failed to participate in the Program for said
"opportunity" or, if it is the case, a series of `opportunities."
As a result, the current invention can promote consumerism by
providing patients with important medical service quality
information to help them be more discerning in their healthcare
choices or to encourage them to urge their medical practitioners to
participate in the Program. This method also heightens the current
invention's "checks and balances" ("doctor-patient mutual
accountability") designed to motivate better health behaviors and
healthcare.
[0122] Thus, the method of the current system provides a financial
incentive to the medical practitioner to follow the EBM guidelines
or to provide an appropriate reason for deviating from these
guidelines, provided the medical practitioner agrees to allow the
patient to confirm/rate/concur with the medical practitioner's
declaration/demonstration of adherence or reason for non-adherence
to the guidelines. Additionally, the method of the current
invention provides a financial incentive to the medical
practitioner to prescribe Ix to the patient and to rate patient
compliance with the prescribed treatment/lifestyle necessary to
manage the medical condition. Furthermore, the method of the
current invention provides a financial incentive to the medical
practitioner to practice the Program on a real-time basis as
opposed to after-the-fact. However, the method uses financial
incentives to create other perhaps stronger incentives for the
medical practitioner to practice the method. These incentives
include the medical practitioner's desire to: 1) improve
communications with patients; 2) improve the patients' understand
of their medical condition and how to self-manage their health; 3)
provide a means to help/motivate patients be more compliant to
recommended care and adopt and maintain better health habits; 4)
increase productivity; 5) gain a degree of medical malpractice risk
management; 6) have access to the latest and best methods for
treating diseases and injuries; 7) incorporate other beneficial
performance standards; and last but not least 8) prevent patients
and others from thinking he/she practices inferior healthcare or,
worse yet, learn that lie/she is not truthful about what kind of
medicine he/she practices. This final (8.sup.th) incentive (i.e.,
motivator) describes one of the checks and balances that is unique
to the current invention. In effect, the medical practitioner is
aware that the patient earns a financial reward for becoming
qualified to rate the practitioner's adherence to and performance
against high and beneficial standards. The medical practitioner is
also aware that patients' ratings will be aggregated and compared
to the medical practitioner's peers. This is a powerful incentive
that encourages medical practitioners to participate in the Program
and to practice medicine that is recommended by the medical
profession or to provide appropriate reasons for non-adherence. In
general, treatment according to the EBM guidelines and appropriate
treatment outside of the guidelines coupled with patient compliance
with treatment protocols and a healthy lifestyle will produce
better clinical outcomes. Further, the prescription of educational
material as Ix to the patient empowers the patient to be more
compliant with their medical practitioner's treatment orders and
instructions, leading to improved clinical outcomes. Additionally,
the patient's access to educational material and the process of
assessing the patient's understanding of that material provides the
patient with the empowerment and additional motivation to improve
the medical practitioner's medical condition, which leads to
improved medication adherence and other therapies, which leads to a
decrease in expensive services such as hospitalizations. Thus, the
current invention provides a method for improving clinical
outcomes, promoting healthiness, which leads to reduction in
healthcare costs. Clearly, the current invention integrates the
activities of the patient and medical practitioner by encouraging
the incorporation of EBM, Ix and other beneficial performance
standards by combining financial incentives with powerful
psychosocial motivators.
[0123] In order to achieve medical practitioner participation and
adherence while preventing fraud and abuse, the Program's Website
software applications provide the means to monitor and audit the
medical practitioner. In one aspect, the Website provides the means
for tracking the medical practitioner's access to the Website. This
tracking mechanism provides an indication of the medical
practitioner's use of the EBM guidelines. For example, the
Program's Website tracks the access time for each webpage reviewed,
if the time of usage for each page does not meet a predetermined
minimum, then the medical practitioner may be questioned concerning
the legitimate usage of the EBM guidelines. However, the
predetermined minimum time period for accessing a webpage is not a
rigid requirement Rather, the minimum access time period may vary
from practitioner to practitioner and from diagnosis to diagnosis
based on various parameters such as but not limited to the medical
practitioner's area of expertise and experience and whether a
particular webpage has been previously reviewed and/or printed by
the medical practitioner. If a new medical treatment is established
as recommended by the medical community and is new in a EBM
treatment guideline, then the invention's Website application may
prevent the medical practitioner from exiting that webpage or from
receiving a higher rate of reimbursement or additional compensation
until the medical practitioner "drills-down" into the application
to learn about this new medical development, advancement, and/or
treatment. The Program can also administer exams to verify medical
practitioner compliance and to prevent fraud and abuse. However,
the strongest means to prevent fraud and abuse rests with the
Program's "doctor-patient mutual accountability" feature. Patients
are educated by an independent expert source about how their
medical practitioner should care for their medical condition, and
then patients are immediately queried about how their medical
practitioner is performing against what they have learned, and how
consistent the medical practitioner's declaration of adherence is
to, again, what they have learned. This represents a fair and
appropriate way to rate medical practitioner performance
(especially compared to web-based satisfaction surveys) that
balances the interests of the medical practitioner with the
interests of the patient and the health plan sponsor.
[0124] In another aspect, the Website provides the means for
monitoring the frequency of treatments outside of the EBM
guidelines (FIG. 1A, Steps #8 and #8a). Thus, the current invention
provides health plans using the methods of the current invention
with the ability to audit medical practitioners who may not be
using the best treatments for their patients by using treatments
outside of generally accepted procedures. As indicated above, the
methods of the current invention are flexible and can be adjusted
for individual practitioners on the basis of their practice area
and experience and also adjusted to incorporate additional types of
performance standards linked to specific incentives (as long as one
or more incentive is interactive involving the checks and balances
between the medical practitioner and the patient facilitated by the
current invention) to achieve the objectives of better health and
better and more affordable healthcare. The current invention's
capability to adjust and expand performance standards and
incentives to achieve specific objectives is referred to as
"precision-guided incentives and performance standards."
[0125] The foregoing steps of the method of the current invention
provide an incentive to the medical practitioner to comply with the
treatments specified in the EBM guideline database and to rate
patient compliance with prescribed treatment/lifestyle necessary to
manage the medical condition. The current invention is design to
accommodate EBM guidelines from any unbiased, independently
derived, highly reputable source that has used generally accepted
testing protocols to establish recognized level of proof.
Therefore, the Program does not endorse any one source of
guidelines, content or medical intervention. However, the Program
is constantly seeking the best possible guidelines, content and
medical interventions to integrate with the current invention.
[0126] Providing an incentive to the medical practitioner addresses
only one part of the total cost of healthcare. In order to further
improve the patient's clinical outcome, promote healthiness, and
enhance healthcare cost control, the patient must also play a role.
Accordingly, the methods of the current invention provide an
incentive to the patient to take a pro-active approach to recover
from and prevent adverse medical conditions.
[0127] With reference to FIG. 2, the method of the current
invention provides the medical practitioner with the option of
prescribing Ix and other performance standards to the patient (FIG.
1A, Step #11). In the preferred embodiment, the method encourages
the medical practitioner to prescribe Ix and other performance
standards to the patient by rewarding the medical practitioner with
additional compensation. Preferably, the medical practitioner will
prescribe the Ix and other performance standards at the same time
the medical practitioner is responding to the Website's inquiry
regarding medical practitioner's compliance with EBM guidelines for
the prescribed medical treatment. The prescribed Ix will normally
be provided via an Internet website or a telephone/telephonic
service. For the remainder of this discussion, the source for the
prescribed Ix and other performance standards will be referred to
as the Program's Website; however, other sources of information are
within the scope of the present invention.
[0128] If the medical practitioner prescribes Ix for the patient,
then a notice in the form of an e-mail, fax, text message, letter
or other similar communication will be sent automatically to the
patient by the Program or handed to the patient at the time of
service by the medical practitioner (or the practitioner's staff).
This patient notification (FIG. 2, step #14) may contain the
medical information or more preferably the notice will contain the
information about the benefits of the Program, including the
financial incentives available to the patient, and instructions on
how to gain access to the Program's Website. The notification will
also inform the patient that his/her participation in the Program
is completely voluntary.
[0129] As mentioned previously, if the medical practitioner fails
to participate or fails to successfully complete an "opportunity,"
then the diagnosis listed on the medical service claim for payment
submitted by the medical practitioner provides the means by which
the intermediary's computer system can automatically generate the
notification to the patient (FIG. 1A, Step #8c) that informs the
patient of his/her chance to participate in the Program for said
"opportunity."
[0130] Upon receipt of the correspondence/notification, the patient
will be directed to the patient portion (section) of the Program's
Website. Once online, the Website will inform the patient (FIG. 2,
Step #15) that he/she can earn a financial incentive and gain
valuable health information by successfully completing the
following tasks: 1) read the educational material presented to them
on the Website about his/her health condition, recommended (EBM)
care, other pertinent and beneficial performance standards (FIG. 2,
Step #15); 2) answer questions presented on the Website to
demonstrate his/her understanding of this material (health literacy
assessment) (FIG. 2, Steps #17, #17a, and #17b); 3) declare his/her
adherence or reason for non-adherence to the recommended (EBM) and
appropriate care or other beneficial performance standards (FIG. 2,
Steps #18, #18a, and #18b); 4) report (or have health monitoring
devices report) his/her health status such as weight, blood
pressure, blood sugar, and resting heart rate (FIG. 2, Step #17c);
5) authorize to access pharmacy records to verify that
prescriptions have been filled, and/or request verification that
the patient has successfully participated in a health assessment
and/or screening program, and/or release information that he/she is
participating in a readiness to change program, and/or authorize
access to lab and other test results, and/or request verification
that the patient has seen or is scheduled to see a medical
specialist or has successfully completed or scheduled to complete
other recommended therapies, and/or release information concerning
his/her participation in therapeutic social networking, and/or
authorize or affect the population of a personal health record with
pertinent information and request his/her medical providers to use
the personal health record in his/her treatment to achieve
coordination of care and to prevent duplication of care, and/or
participate in a pre-authorization certification of expensive tests
and services (such as surgeries and hospitalizations) through the
Website to prevent unnecessary procedures and insure better
clinical outcomes, and/or release an advance directive, and/or
demonstrate his/her healthy behavior by any other means; 6) after
acknowledging their medical practitioner's responses to the Website
question(s) about adherence or reason for non-adherence to a
recommended (EBM) treatment or other performance standards (and
taking into consideration the information he/she have just read on
the method's Website), confirm/rate/concur with his/her medical
practitioner's declaration/demonstration of adherence or reason for
non-adherence to the performance standard (FIG. 2, Step #19); and
7) agree to allow his/her medical practitioner to have access to
his/her health literacy assessment and declaration/demonstration of
adherence or reason for non-adherence to the prescribed treatments
and Ix (or other performance standards) (FIG. 2A, Steps #19a, #20a,
and #20b). (This agreement by the patient reinforces the Program's
strategic checks and balances ("doctor-patient mutual
accountability") by making the patient aware that someone he/she
respects and trusts when it comes to his/her health, namely his/her
medical practitioner, has access to (and may rate the patient on)
their health literacy assessment and declaration/demonstration of
adherence or reason for non-adherence to Ix and other performance
standards creates powerful motivation for the patient to improve
and maintain good health behaviors. The Program is also able to
compare the patient's declaration/demonstration of compliance
responses against his/her medical practitioner's rating of his/her
health compliance. If the compliance indicators between the patient
and the medical practitioner match, then the Program would indicate
that the patient is be eligible for an additional financial reward
from his/her health plan.)
[0131] With reference to FIG. 2, the patient is expected to review
the health educational material made available by the Program's
Website (FIG. 2, Step #15). The review of the prescribed
educational material as Ix is supplemented with a questionnaire to
be completed by the patient to assess the patient's understanding
of and adherence to the material. In the preferred embodiment, the
Program's Website also provides the means to monitor the patient's
access of the Website and completion of the questionnaire (FIG. 2,
Step #16). This monitoring aspect provides the network with the
means to audit patient compliance with the Ix and other treatment
prescribed by his/her medical practitioner. Further, the monitoring
system provides the ability to award "points" to the patient for
reading the Ix, and for answering the questionnaires that indicate
the patient's knowledge and adherence to recommended treatments. As
a means to insure compliance and prevent fraud and abuse, the
network can designate a minimum period of access time necessary
prior to awarding a point for reviewing that section of the Ix. By
requiring a minimum time period, the method of the current
invention ensures that the patient performs more than a cursory
review of the information provided.
[0132] Following completion of the questionnaires that tests the
patient's knowledge and adherence to recommended (EBM) care,
establishes the patient's agreement to allow his/her medical
practitioner to have access to and rate his/her responses and
adherence, and rates his/her medical practitioner performance
against recommended (EBM) care; the Website scores the patient's
answers and awards points to the patient's account according to the
patient's responses. Following scoring, the patient has the option
of further reviewing the Ix and repeating the questions or
answering additional questions. Thus, the current invention
provides the patient with the ability to gain further knowledge of
his/her condition while enhancing the number of points awarded to
his/her account. Clearly, the comprehensive nature and flexibility
of the Program's Website provides the patient with the tools
necessary to improve his/her health literacy, empowerment,
motivation, and the clinical outcome of his/her treatment and to
improve his/her overall general health. Optionally, the health plan
may elect to award patients with additional points and financial
rewards for reviewing other medical information and accomplishing
other performance standards intended to improve health and control
cost, that are made available through the Program.
[0133] Upon completion of the Ix and indication of adherence and
understanding of recommended and appropriate care, agreement to
allow his/her medical practitioner to have access to and/or
rate/acknowledge/confirm his/her responses to the Website
questionnaires, and the rating of his/her medical practitioner's
performance; the patient is provided with a means for notifying the
health plan of the receipt and review of the Ix material.
Additionally, the patient will be provided with the option of
sharing the medical practitioner's rating of patient compliance
with the health plan. Typically, the patient will be provided with
separate option boxes or other "clickable" devices on the Website
to indicate the patient's desire to share the medical
practitioner's compliance rating and to transmit a notice of
completion of the Ix material to the health plan and/or employer.
In the preferred embodiment of the current invention, the Program
Website transmits the patient's actual responses to the
questionnaire to the medical practitioner or posts the responses on
the Website for access by the medical practitioner. Though these
choices are optional to the patient, if the patient elects not to
share information, then the health plan will most likely not
provide the financial reward(s) to the patient.
[0134] In view of the incentives offered by the method of the
current invention, the patient will likely request transmission of
such notices to the health plan and/or employer. Upon receipt of
such notices, the health plan has the option of providing a
financial reward to the patient based on the patient's completion
of the Ix, declaration/demonstration of adherence or reason for
non-adherence to the recommended care, rating of his/her medical
practitioner, and the patient's compliance and performance rating
of the medical practitioner. In keeping with the flexible nature of
the current invention, the financial reward may be granted upon the
completion of each prescribed Ix, indication of adherence,
agreement to allow the medical practitioner to have access to (and
rate) the patient responses to the website's questionnaires, and
the patient's medical practitioner rating portion. Before the
intermediary assigns a reward to the patient, the patient declares
or demonstrates adherence to the performance standard. The party
paying the reward may establish point thresholds for payouts. In
the case of point thresholds, the patient's points are accumulated
and upon reaching a predetermined level, the financial reward can
be paid to the patient.
[0135] It should be noted that as with the medical practitioner,
the patient's participation in the Program for a given
"opportunity" is voluntary and may or may not affect the medical
practitioner's compensation for participating in the Program for
said "opportunity." In a preferred embodiment of the current
invention, the medical practitioner's compensation is not affected
by the patient's non-participation.
[0136] Typically, a patient will not to earn a financial reward
through the Program if the Patient: fails to complete Ix
"opportunity" within the established time limit; or fails to pass a
health literacy test or demonstrate knowledge of the Ix educational
material (though literacy tests in the Program are open book,
meaning that patients are asked to read the educational material
again when they miss a health literacy question); or fails to
report health status; or denies Medical Practitioner access to his
or her Website questionnaire responses; or fails score enough
points answering Website questionnaires (FIG. 2A, Step #22).
[0137] As noted above, the method of the current invention
preferably includes the medical practitioner's confirmation of the
patient's health literacy and the patient's indication of adherence
to recommended treatments. The process of the patient sharing
information with his/her medical practitioner and health plan
and/or intermediary creates another check and balance that is
designed to help improve health behaviors and control costs. In
effect, the patient is aware that his/her answers to questions on
the Website (or over the telephone) about his/her compliance to
performance standards will be available to his/her medical
practitioner, health plan, and intermediary for review and
authentication. The patient's desire to demonstrate his/her
knowledge and compliance to his/her medical practitioner is a
strong motivator. The psychological consequence of being found
untruthful by someone that the patient trusts and respects, namely
the medical practitioner, is a powerful motivator for the vast
majority of people.
[0138] Obviously, the ideal embodiment of the current invention
involves participation of both the medical provider and the patient
with each and every "opportunity." However, one important aspect of
the current invention that is unique has to do with its
functionality and effectiveness when only one of the two parties
participates. Since neither the medical practitioner nor the
patient knows if the other party will or will not participate in
the confirmation of the other's performance, then the psychology
that inspires best behaviors inherent to the doctor-patient
relationship is present for either party even when the other party
does not participate. In the case of the medical practitioner,
he/she does not want his/her patients to think or learn that he/she
practices inferior medicine after his/her patients complete the
Program's information therapy process. However, the medical
practitioner will have no way of knowing whether any given patient
will participate in any given "opportunity." So to be safe, the
medical practitioner is inspired to incorporate EBM (best
practices) with every encounter involving a patient covered by the
Program just in case. In fact, the Website reminds the medical
practitioner of this fact each time he/she is asked to respond to
the acknowledgment that the patient will (may) rate the medical
practitioner's performance against an independently derived EBM
standard. Conversely, the patient does not want his/her trusted and
respected medical practitioner to think he/she is health illiterate
and/or non-compliant to recommended treatments and healthy
behaviors. Again, he/she will have no way of knowing if his/her
medical practitioner will or will not review his/her information
therapy and declaration or demonstration of adherence responses to
the Website questionnaires. Therefore, each time a patient
participates in the Program and accepts the Website agreement to
allow his/her medical practitioner to have access to his/her
Website responses, the Program's psychological motivators are
helping to inspire the patient to be healthy and compliant. This is
why the medical practitioner's acknowledgment of the patient
rating/confirmation and the patient's agreement to allow the
medical practitioner to access/rate/confirm "switches" incorporated
into the website are such an important feature of the current
invention.
[0139] Finally, the current invention also preferably provides for
patient inquiries of the medical practitioner through the Website,
by e-mail or other similar means, during Ix sessions. Thus, the
current invention integrates the patient's Ix with the medical
practitioner's medical treatment and provides financial rewards to
the patient based on completing the educational aspects of Ix as
well as financial rewards for adopting a healthy lifestyle and
adherence to treatment protocols as recommended by the medical
practitioner, for agreeing to allow the medical practitioner to
confirm/rate/acknowledge the patient's health literacy and
indication of adherence to healthy behaviors and recommended
treatments, and for rating their medical practitioner's performance
against recommended and appropriate care.
[0140] In accordance with the Health Insurance Portability and
Accountability Act (HIPAA), the notice to the health plan and any
notices to any other third parties will not divulge any protected
patient health information unless arrangements have been made to
meet HIPAA requirements.
[0141] In the method, the service provider (medical
practitioner/doctor/physician/clinician) and patient may be
required to perform an action or physical act to demonstrate as
oppose to declare adherence to a performance standard. An action or
physical act may or may not be captured on the Website. Since the
action or physical act may be captured by the Website, then the
service provider and patient would be asked to acknowledge the
action or physical act of each other. This implies that the action
or physical act can be independently, verified by the acknowledging
party and authenticated by the intermediary. An example of a
performance standard involving a verifiable action is the service
provider electronically prescribing drug therapy to the patient
through the Website. Since this action is captured by the Website,
the method would ask the service provider to agree to have the
patient acknowledge his/her action (adherence to a performance
standard), and would preferably involve the patient acknowledging
his/her service provider's adherence to the performance standard.
Therefore, the terms "declare and confirm" and "declaration and
confirmation" are synonymous to "demonstrate and acknowledge" and
"demonstration and acknowledgment" when a verifiable action or
physical act is involved.
[0142] The present invention is designed to allow the health plan
and the intermediary to select (or determine) a variety or varying
amount of performance-based incentives depending upon the level or
degree of adherence or performance by the service provider and the
patient against a performance standard or multiple performance
standards. An example of this feature involves establishing one
amount of compensation for the service provider when he/she
prescribes information therapy to the patient and an additional (or
separate) amount of compensation when he/she uses a drug therapy
management system to electronically prescribe pharmacy to the
patient. In this case, the intermediary would authenticate the
service provider's performance and determine the level of
performance-based incentive to be paid to the service provider.
Alternatively, the method may require the patient to confirm and
acknowledge the service provider's performance in addition to the
intermediary's authentication to determine the level of adherence
(performance) and compensation.
[0143] Another embodiment of the present invention comprises
pre-authorization certification programs that integrate the patient
into the authorization process. This is referred to as
"patient-integrated pre-authorization certification" and as
"doctor-patient mutual accountability pre-certification." In
effect, patient-integrated pre-authorization certification involves
compensating the service provider for prescribing an educational
material as information therapy through the Website to the patient
when expensive or risky medical services (such as surgeries or
hospitalization) are planned. The patient is financially rewarded
for reading about his/her conditions, the planned treatment and
treatment alternatives. The patient would then be required to
demonstrate his/her knowledge by taking a test so he/she can be
qualified to authorize the planned treatment or consult further
with his/her service provider about the treatment and ask about
alternative treatments or seek a second opinion or refuse the
treatment.
[0144] Another embodiment of the present invention comprises an
enhancement to hospital care management systems by integrating
patients into the hospital care process. This is referred to as
"patient-integrated hospital care management program." In effect,
patients earn financial rewards for performing certain tasks
associated with their hospitalizations. One such task is to
designate a personal advocate such as a family member or friend.
This method of the invention compensates hospitals and attending
physicians for prescribing a hospital care plan and discharge
instructions through the Website or during admission and at
discharge to the patient and his/her advocate. Pre-admission,
during the admission and after discharge, the patient and/or
advocate would be queried through the Website to demonstrate their
knowledge of the hospital care plan and discharge instructions. The
Website then asks the patient and advocate to rate the hospital's
and attending physician's performance against the hospital care
plan. The patient would be asked to declare his/her compliance to
hospital care plan and discharge instructions. As a means for the
intermediary to authenticate performance, the hospital and
attending physician could also be required to access the Website to
enter the name of patient's advocate and to indicate the patient's
adherence to the hospital care plan.
[0145] Clearly, the method of the current invention provides a
means to incent and motivate the patient to take an active role in
managing their medical condition. As a result, the clinical outcome
of the patient's medical treatment will be enhanced. Thus, the
methods of the current invention enhance the quality of medical
care by encouraging the patient and medical practitioner through
financial rewards and mutual accountability checks and balances to
adhere to the scientifically proven best treatment guidelines or
preferred methods, healthy behaviors and other performance
standards, and by enabling the patient through information therapy
to manage the treatment of the medical condition to achieve a
higher level of health. By enhancing the quality of medical care
and increasing the patient's ability to manage their medical
condition, the current invention promotes better health and
healthcare, which reduces the overall cost of healthcare; while
providing an increase in compensation to the medical practitioner,
a financial reward to the patient, and cost savings that produces a
return on investment to the health plan sponsor. Thus the current
invention aligns the interests of these three key stakeholders in a
win-win-win arrangement.
[0146] Collectively, the descriptions and illustrations presented
herein and the terms such as "checks and balances," "declare and
confirm," "demonstrate and acknowledge," "doctor-patient mutual
accountability," "triangulation," "win-win-win," "mutual
accountability partnership," "precision-guided incentives and
performance standards," and "alignment of interest" or "AOI" define
the invention's unique "interactive" characteristics between
medical providers, patients, and health plan sponsors. Hence, the
invention can be accurately described as a "web-based interactive
provider-patient incentive system."
[0147] FIG. 3 is a diagrammatic illustration of the method of the
present invention. The embodiment of FIG. 3 comprises an
Information Therapy (Ix) Program. The following discussion provides
a step-by-step description intended to illustrate the of combining
the method and system of the current invention with the mechanics
of the Ix Program process and is not intended to imply that this is
the only application of the invention. The following discussion is
made in reference to FIGS. 3-16. FIG. 3 illustrates the steps of
the process described below. FIG. 4-16 provide exemplary webpage
interfaces useful with the present invention.
[0148] The example of the current invention discussed below
comprises a web-based healthcare delivery incentive method (system
or program) that, in this example, is referred to as the Ix
Program. The Ix Program described herein involves four parties:
health plan sponsor (health insurance companies, self-insured
employers, and the Medicare and Medicaid programs) that purchase
the Program and underwrite (fund) the cost of health care of
persons (beneficiaries/plan members) covered by health insurance
(health plan); medical providers (service providers,
physicians/doctors, medical practitioners, healthcare providers,
and clinicians) who participate in the Program; beneficiaries
(patients/consumers) of a health plan that offers the Program; and
an intermediary (Informediary) that operates the Program and
administers the three agreement between the health plan sponsor,
the plan member and the medical provider.
[0149] The current invention comprises the following elements: a
performance standard or set of performance standards; an Internet
website with software applications (Ix Program Website or Website);
a computer system operated by the intermediary that hosts the
Website and contains certain Ix Program databases; financial
rewards; and a system of checks and balances. The performance
standards may comprise a set of healthcare treatment standards that
have been shown to be effective at improving healthcare rendered by
providers, improving the health of beneficiaries, and controlling
healthcare costs such as evidence-based medicine (EBM) treatments
and information therapy (Ix) prescriptions. The Website contains
the Ix Program's proprietary applications that effectuate the
system of checks and balances and performance standards or
information about performance standards operated by the
intermediary. The financial rewards and other types of
non-financial incentives are disbursed by the health plan sponsor's
administrator (TPA, ASO provider, or health insurance company) to
providers and beneficiaries for successfully practicing the Ix
Program as determined by the intermediary. The system of checks and
balances is established between the medical provider and
beneficiary to motivate Ix Program participation and performance
standard compliance, and to prevent fraud and abuse.
[0150] With reference to FIG. 3, at Step #1 the health plan
sponsors adopt the Ix Program by purchasing the Ix Program from the
intermediary (FIG. 3) as a "bolt-on" benefit to the sponsors'
health plans. Typically, payment for a "bolt-on" benefit is made on
the basis of the number of plan members
(consumers/patients/beneficiaries) who are covered by the Ix
Program, often referred to as a per-member-per-month (PMPM) access
fee.
[0151] At Step #2 the beneficiaries enroll, receive orientation,
are informed of their opportunity to earn financial or other types
of rewards, and are encouraged to request information therapy from
their service providers. Beneficiaries may be introduced to and
enrolled in the Ix Program through their employment or health
insurer. The intermediary and the health plan typically orient
beneficiaries (patients) to the Ix Program through written
materials, instructional videos, and Website tutorials. One
instruction advises beneficiaries to seek care from a participating
provider (physician) or to encourage their physician to participate
in the Ix Program. Beneficiaries should expect to receive care from
his/her provider that meets the performance standard such as EBM
treatments and information therapy prescriptions. The Ix Program
orientation explains that financial rewards are available to the
beneficiary when he/she accesses the Website and appropriately
responds on-line (or over the telephone through a telephonic
interface to the Ix Program) to information therapy prescribed by
his/her physician and/or meets other performance standards.
[0152] At Step #3 the service providers
(physicians/clinicians/medical practitioners) receive orientation
and are encouraged to prescribe Ix. An exemplary webpage
illustrating the web interface used in Step #3 is shown in FIG. 4.
Physicians may be oriented to the Ix Program by the intermediary
and health plan in a variety of ways including organized meetings,
in-office presentations, mailings, through professional
organizations, and faxed notices from the intermediary. Another
common means of introduction may involve patients requesting or
suggesting that their physicians participate in the Ix Program. The
service provider is informed that by practicing the Ix Program,
he/she: 1) should have more knowledgeable and compliant patients,
2) will be rendering a higher standard of care, 3) may gain a
degree of malpractice risk management, 4) should experience an
increase in productivity, 5) should expect a better clinical
outcome, and 6) will be appropriately compensated for his/her time
and effort. The provider is also informed that the patient will be
seeking and expecting information therapy, EBM treatments, and/or
other performance standards, and that the patient will be asked to
rate the physician's level adherence to the performance standard.
Finally, medical providers are informed that participation in the
Ix Program: is purely voluntary, even on an encounter-by-encounter
basis; involves no costs to set-up or on-going purchases except for
Internet access; is designed to be fast and easy to use; and is
anti-cook, encouraging medical providers to use their clinical
judgment in treating patients. Physicians enroll in the Program
online through the Website.
[0153] At Step #4 a beneficiary visits a physician and, if he/she
wishes, can ask for information therapy and/or other performance
standards. When the beneficiary seeks a medical provider
participating in the Ix Program or requests services that satisfy
the Program's performance standard(s) from his/her physician, it
represents the first in a series of checks and balances
(nonfinancial or psychological incentives/motivators) between the
doctor and patient that encourages positive behavior modification.
During an office visit (or other types of medical encounter), the
physician renders treatments to the patient and files a normal
insurance claim to the patient's health plan for compensation. The
physician would typically collect any co-payments or annual
deductibles from the patient according to the patient's health plan
benefits.
[0154] Continuing with Step #5, the physician accesses the Ix
Program through the Website. The physician can practice the Ix
Program in many ways. Two exemplary methods of practicing the
current invention are discussed herein. An exemplary webpage
illustrating the web interface used in Step #5 is shown in FIGS. 5
and 6.
[0155] The physician can initiate the process at the time of
service (in the presence of the patient or shortly thereafter) by
accessing the Website and using the Point of Service Initiated or
POSI real-time version of the Ix Program (FIGS. 4, 5, and 6). On
the Website, the physician enters the beneficiary's name or
identification number and diagnosis(es) (See FIGS. 5, 6 and 7) and
responds to questions and/or performs services at Step #7, as
described below. The physician's POSI responses are stored in the
intermediary's computer system database for later processing. If
the physician forgets or fails to use POSI, then the process can be
performed "after-the-fact" using the Claims Initiated or CI version
of the Ix Program. FIGS. 8a and 8b are exemplary webpages
illustrating the web interface used in Step #5 to evaluate the
performance standard provided by the Program in response to the
received diagnosis code.
[0156] The Website's proprietary software applications determine
whether the POSI or the CI version is to be used for each
occurrence of care. This is accomplished when the intermediary
receives (preferably electronically) a copy from the health plan
administrator of the physician's insurance claim for the services
rendered during the patient encounter (as mentioned in Step #4,
above, and described in Step #10, below). The Website's software
applications look to match the claim information to POSI responses
by the physician stored in the intermediary's database. If there is
a match, then the intermediary orders compensation for the
physician as described in Step #12, below. If there is no match,
then the intermediary sends an e-mail notification to the physician
to practice the Ix Program "after-the-face." This "after-the-fact"
process that uses a physician's insurance claim to initiate an
e-mail notification to the physician is, in effect, the Claims
Initiated or CI version of the Ix Program. The CI version is not
depicted in the diagram. However, with the exception of how the
processes are initiated, the POSI and CI versions are similar.
[0157] At Step #6 the Website supplies EBM treatment guidelines or
other types of performance standards, provided guidelines and other
types of performance standards exist for the patient's diagnosis).
The Website automatically displays EBM treatment guidelines or
other types of performance standards to the physician related to
the patient's diagnosis(es) and/or health plan benefits. In the
case of the Ix Program, if a guideline does not exist, then the
Website displays medical educational content related to patient's
diagnosis(es) (FIGS. 8A and 8B). Immediately following Step #6 the
service provider acknowledges patient will confirm/rate/concur
with/acknowledge service provider's performance after the patient
completes an Ix prescription.
[0158] Other types of performance standards include but are not
limited to: web-based patient-integrated pre-authorization
certification of expensive medical services; web-based
patient-integrated hospital care management services; web-based
drug therapy and pharmacy benefit management programs including
e-prescription, therapeutic drug substitution, automated drug
interaction warnings, and patient drug education with knowledge
assessment; the adoption and use of personal health records;
web-based health risk assessment programs; web-based readiness to
change programs; web-enabled health screening programs; web-enabled
disease management programs; web-based medical education programs;
web-enabled wellness and fitness programs such as smoking
cessation, weight management and health club usage; web-enabled
health monitoring devices; promotion of web-based patient health
self-management and therapeutic social networking programs; an
integrated advance directive; a medical provider quality and cost
transparency program; and or other programs and systems shown or
designed to improve the standard of care, promote healthiness and
control costs or make health care more affordable.
[0159] In Step #7, the physician responds to Website questions
designed to initiate an Ix prescription to the patient in the case
of the Ix Program model of the invention, if a guideline is
displayed on the Website (FIGS. 8A and 8B), the physician is asked
to answer two or three questions: [0160] a. "Are you following this
guideline for this patient? Yes or No" In conjunction with this
question, the physician may also be asked to respond to one of the
following statements: "I understand that my patient will be asked
to confirm or rate my declaration of adherence to this guideline
after my patient has been educated about recommended treatments.
"Acknowledge," or "I understand that my patient will be asked to
concur with my reason for not adhering to this guideline after my
patient has been educated about recommended treatments.
Acknowledge," (Note: This understanding or agreement can also be
included in the service provider Website agreement, which is
accepted by the service provider at time of enrollment and/or each
time the service provider logs onto the Website.) A physician's
answer to this adherence question and his/her acknowledgment of the
patient's confirmation together can have a profoundly positive
effect on how healthcare is delivered as a result of the current
invention. This particular application of the "declare and confirm"
method, coupled with patient education, is one of the most powerful
checks and balances instigated by the current invention. It is
obviously intended to encourage physicians to be adherent to EBM
guidelines (or other performance standards) or provide their
patients a legitimate reason for non-adherence. It is also
intending for patients to be knowledgeable and discriminating about
the healthcare they receive. In effect, the health plan is
compensating both the physician and patient to participate in this
check and balance with the expectation that better healthcare will
rendered, and that this will lead to better health and lower costs.
It is important to note that one of the most important aspects of
the method (invention), which makes it especially attractive to
physicians, is its "anti-cookbook medicine" feature. This feature
allows physicians to answer this guideline adherence question
either "yes" or "no," and still earn full compensation for
practicing the method. The reason the health plan sponsor would
agree to pay physicians when they answer this question "no" is
because the method requires physicians to select a reason for
non-adherence to a guideline from a pop-up menu (refer to FIGS. 9A
and 9B). The physician's reason for non-adherence is stored in the
Website's database to be presented to the patient later in the
process. The health plan sponsor knows that the physician is aware
that his/her reason for non-adherence will be judged by an informed
patient. This check and balance solves the issue physicians have
had with "cookbook medicine" associated with other
pay-for-performance methods that force them to follow a protocol or
guideline to be compensated. In fact, this feature encourages
physicians to answer "no" when it is appropriate, as long as the
patient is educated as to why a guideline does not fit his/her
particular health condition. [0161] b. "Which patient education
articles do you wish to prescribe to this patient?" The Website
attempts to make prescribing educational material fast and easy for
the service provider to complete (See FIG. 9c). As shown in FIG.
9c, multiple articles are listed in relevancy order to the
diagnosis. The service provider simply selects one or more of the
articles as information therapy for the patient. The Website also
provides a means for the service provider to preview the articles,
see which articles he/she prefers for this diagnosis, and see which
articles he/she and other service providers have prescribed to the
patient in the past. The Program also presents the service provider
with a listing of his or her favorite articles or previously
prescribed articles. The presentation of information shown in FIG.
9c is based on stored information keyed to the diagnosis code
received, the service provider and the patient's history. It should
also be noted that this act of prescribing information therapy is
extra effort exerted by the physician, which supports the case for
additional pay. It should be further noted that many health plan
sponsors are not enthusiastic about pay-for-performance programs
that compensate physicians more for merely following a recommended
treatment guideline because health plan sponsors feel this is what
the physician is being paid to do in the first place. This is not
the case in the Ix Program's method. [0162] c. "Please rate your
patient's compliance for this diagnosis: Compliant; Compliance is a
non-factor; or No response" or "Compliant, Mostly Compliant;
Somewhat Compliant; Mostly Non-compliant; Non-compliant" This is an
optional question that a health plan sponsor can elect to have
added to the Ix Program before or after the patient participates in
the Ix Program. The health plan sponsor may assign a portion of the
patient's financial reward based on how the physician answers this
question. The service provider's response to this question is not
made available to the patient to prevent undermining doctor-patient
relations.
[0163] Once the physician answers these questions, the POSI
real-time version of the Ix Program model allows the physician to
print an information therapy prescription to hand to the patient
before the patient leaves the office. Alternatively, the physician
can practice the real-time version at the end of the day for all
enrolled beneficiaries, and the intermediary will mail or e-mail
the prescriptions to each patient. (In the CI after-the-fact
version, all Ix prescription letters are sent by mail or e-mail or
text message.) The process continues for the physician when he or
she is asked to review and consider patient responses to the
Website's questionnaires. These responses are available to the
physician through the Website. Responses that indicate the patient
is experiencing additional medical issues or distress is sent to
the physician as a priority e-mail notice. Since physician
participation in the Ix Program is voluntary on a
per-occurrence-of-care basis, the act of participation by a
physician is an indication that the physician is committed to
delivering a higher standard of care, is committed to better
patient communication, is interested in patient compliance to
recommended treatments, and is willing to have his/her performance
judged by his/her patient. Conversely, a physician's
non-participation may imply a whole other set of values that may
result in patient and health plan sponsor dissatisfaction.
[0164] The Physicians' level of participation and patient ratings
are intended to aggregated over time. Typically, these results will
be used first to recognize the service providers with the highest
rate of participation and the highest patient ratings. These
results can also be made available to physician peer review
organizations to provide a degree of due process for the poor
performing service providers. Eventually these results are to be
made available to health plan sponsor and the general public, thus
allowing market forces to provide additional motivation
(incentive). But perhaps the most powerful incentive to the
physician is his/her desire to prevent his/her patients from
thinking he/she practices inferior medicine.
[0165] In other models of the invention, different types of
performance standards can and will be accommodated. However, the
process of the service provider (physician/clinician/medical
practitioner) being asked to demonstrate or declare adherence or
reason for non-adherence to a given performance standard with the
understanding that his/her patient will confirm/rate/concur with
the service's providers indication of adherence, followed by the
patient being asked to learn and demonstration knowledge about the
performance standard and, once qualified, being asked to rate the
service provider's indication of adherence to the performance
standard remains the same for all types of performance standards.
The optional process step of physicians rating their patients'
adherence to recommended care and the process step of physicians
having access to their patients' Website responses (including
medical issue warnings) also remain the same for all types of
performance standards. The invention is most effectively delivered
through the Internet, though it can be delivered by telephone or
telephonic interface or other means, provided that the parties and
the other elements of the invention remain the same as described
herein.
[0166] At Steps #8a and 8b of the current invention, the patient
receives and responds to the Ix prescription letter/email/text
message/notification from the intermediary. In the Ix Program model
of the invention, the patient can receive his/her information
therapy (Ix) prescription letter from his/her physician as he/she
leaves the physician's office or by mail or e-mail. If the
physician fails to participate or fails to successfully complete an
"Ix opportunity," then the diagnosis listed on the medical service
claim for payment submitted by the physician provides the means by
which the intermediary's computer system can automatically generate
the notification to the patient that informs the patient of his/her
chance to participate in the Ix Program for said "Ix
opportunity."
[0167] The prescription letter directs the patient to access the
Website (Step #8b) (See also FIG. 10) where his/her actual
prescription will be ready and waiting as a result of the
physician's earlier responses to the Website or, when the physician
fails to participate in the "Ix opportunity", as a result of the
medical service claim for payment submitted by the physician. For
each diagnosis entered by the physician associated with this
occurrence of care, the beneficiary/patient is asked to do the
following on the Website to earn his/her financial reward: [0168]
1. Read the health information about his/her diagnosis, including
EBM treatments, recommended care, health maintenance, and/or other
performance standards (refer to FIG. 11); [0169] 2. Answer a
questionnaire to indicate or assess his/her knowledge or
understanding of the health information (refer to FIG. 12A). If an
incorrect answer is received the patient may be presented with the
exemplary webpage shown in FIG. 12B which provides the patient with
notice that it has answered incorrectly and directs them to the
correct answer; [0170] 3. Answer a questionnaire about his/her
current health status; [0171] 4. Answer a questionnaire about
his/her compliance to the recommended care (See FIG. 13); [0172] 5.
Answer a questionnaire about releasing his/her responses to the
questionnaires about his/her knowledge or understanding of the
health information, his/her health status, and his/her indication
of compliance to the recommended care to his/her physician (See
FIG. 14); [0173] 6. Answer a questionnaire to rate his/her
physician's performance against EBM treatments, recommended care or
other performance standards as: [0174] Consistent; [0175] Mostly
Consistent; [0176] Somewhat Consistent; [0177] Mostly Inconsistent;
[0178] Inconsistent [0179] or review any reasons recorded by the
physician for non-adherence to the treatment guideline or other
performance standards and answer a questionnaire to express a
qualified opinion in regards to the physician's reason for
non-adherence (See FIG. 15); and [0180] 7. Alternatively, elect to
authorize the release of the physician's rating of his/her
compliance to recommended care (if the physician is asked this
question).
[0181] Depending upon how or if the patient answers these
questions, he/she scores points toward a financial reward for this
occurrence of care (Ix opportunity). Once his/her point total
reaches a required threshold, the Website presents a voucher (See
FIG. 16) that notifies the patient that he/she has earned the
financial reward offered by his/her purchaser/payer. (Note that the
physician rating questionnaires can be made even more objective by
asking the patient to qualify his/her rating response. For
instance, if the patient's diagnosis is hypertension and the
patient rated the physicians performance as "Consistent," then the
Program can drill down by asking the patient if the physician
informed him/her about controlling salt intake or being sure to
stay on his/her medication or that he/she should check his/her
blood pressure regularly. Again, this provides a more objective
means of rating physicians than the prevalent use of subjective
satisfaction surveys.)
[0182] The patient's participation and authorization to release
his/her responses to the questionnaires to his/her physician is an
indication that the patient wants his/her physician to know he/she
understands how to self-manage his/her medical condition and is
committed to being compliant to recommended care and healthy
behaviors or is providing a reason he/she is willing to share with
his/her physician as to why he/she is not being compliant. In the
process, the patient learns valuable information that he/she may
have not known or did not understand or forgot to ask the physician
that can be used to better self-manage his/her health. In addition,
the patient gains the peace of mind that he/she is receiving EBM
treatments or other standard of performance from his/her physician.
Finally, the patient receives a financial reward for his/her effort
and healthy behavior.
[0183] As with service providers
(physicians/doctors/clinicians/medical practitioners/healthcare
providers), other types of performance standards can and will be
accommodated by the current invention. However, the process of the
patient (beneficiary/health plan member) being asked to demonstrate
or declare his/her health literacy and adherence (or provide a
reason for non-adherence) to a given performance standard, agreeing
to allow the physician to review/confirm/rate/acknowledge his/her
health literacy and indication of adherence to the performance
standard(s), and the confirming/rating/concurring
with/acknowledging the physicians declaration or demonstration of
the adherence or reason for non-adherence to performance standards
remains the same for all types of performance standards. The
optional process step of physicians rating their patients'
adherence to recommended care and the process step of physicians
having access to their patients' Website responses (including
medical issue warnings) also remain the same for all types of
performance standards.
[0184] Referring still to FIG. 3, in Step #8c the patient agrees to
allow the service provider to review/confirm the patient's
responses to the queries posed the patient in Steps 8a and 8b.
[0185] In Step #9, the physician and patient confirm each other's
performance using the Internet application. As mentioned in
reference to Steps #7 and #8, the method asks the physician and
patient to review and confirm each other's declarations or
demonstration of adherence or reason for non-adherence to an EBM
benchmark and/or other performance standards. Both parties are
aware they must agree or acknowledge that the other party can and
may confirm/rate/acknowledge/concur with their declaration or
demonstration of adherence or reason for non-adherence to the EBM
benchmark and/or other performance standards in order to earn the
financial rewards offer through the Ix Program. Physicians do not
want their patients to think or learn they practice inferior
medicine. Conversely, patients (especially patients with chronic
conditions that have close relationships with their physicians) do
not want their physicians to think they are health illiterate or
non-compliant with recommended treatments and health behaviors. As
a result, physicians and patients are motivated to please one
another by gaining health literacy, adopting healthy behaviors,
following recommended treatments and delivering high quality
healthcare. Furthermore, since both parties are aware that their
responses are being recorded and stored by an independent third
party (the intermediary), and that this information could be
reported to the health plan and, in the case of physicians, the
general public, then both parties are even more motivated to gain
health literacy, adopt healthy behaviors, follow recommended
treatments and deliver high quality healthcare. In effect, the
method's processes that combine the attributes of financial
(behavioral economics) and non-financial (health psychology)
motivators (incentives) creates powerful "checks and balances"
("mutual accountability") that encourages a higher standard of care
and healthier behavior that leads to lower costs.
[0186] At Step #10, the physician files a health insurance claim
with the health plan. As mentioned with reference to Steps #4 and
#5, the normal filing of an insurance claim by the physician for
medical services covered by the Ix Program can occur before,
concurrently, or after the method is practiced by the physician.
(An insurance claim contains all the information needed by the Ix
Program's web-based software applications to complete the process.)
The claim must be filed within a certain time limit established by
the health plan sponsor and the intermediary. If a physician does
not access the Website and practiced the POSI real-time version of
the method by the time the physician's claim reaches the
intermediary, then the CI after-the-fact version of the method will
send an e-mail notification to the physician. This is referred to
as a "CI opportunity." The physician will have a time limit to
respond to a "CI opportunities." If a "CI opportunity" expires, the
health plan sponsor and the intermediary may elect to send the
patient an Ix prescription based on the diagnosis(es) listed on the
insurance claim submitted by the physician. This allows patients to
gain valuable health information and earn a financial reward, even
when their physicians fail to participate in the Program. This
process is referred to as "system-generated information therapy."
To encourage physician participation while insuring patients are
not deny the opportunity to participate in the Ix Program when
their physician fail/forget to participate, the health plan sponsor
and the intermediary can offer patients larger financial rewards
for "physician generated Ix" than for "system-generated Ix."
[0187] Step #11 comprises the health plan/payer sending claim
information to the intermediary. A plan administrator can be a
third party administrator (TPA) or a health insurer's
administrative services only (ASO) contracted be a self-insured
employer (the health plan sponsor) or the health insurer (the
health plan sponsor) in the case of fully-insured employers and
individuals or government agencies. The plan administrator forwards
all insurance claims to the intermediary. Preferably, claims are
sent automatically and electronically on a daily basis, using
industry standard electronic data interchange (EDI) interfaces and
formats. Once downloaded into the intermediary's computer, the Ix
Program's software applications sort the data to find claims
containing covered medical services (applicable medical services)
rendered to beneficiaries covered by the Ix Program.
[0188] Step #12 comprises the intermediary matching claims to
"opportunities," then authenticates and adjudicates physician and
patient Website responses, and directs financial compensation and
other reward notifications to the health plan/payer. As described
with reference Step #5, above, the intermediary uses the Website's
software applications to match insurance claims to physician POSI
responses stored in the intermediary's database. If there is a
match, the intermediary sends an (electronic)
authorization/directive to the plan administrator to compensate the
physician (and sends the information therapy prescription to the
patient as described in Step #7, above). Since the POSI real-time
version is the preferred method, the intermediary can select a
premium or highest rate of compensation for the physician. If the
intermediary cannot match an applicable insurance claim to a POSI,
then the Claim Initiated or CI version of the method sends an email
notification to the physician. If the physician responds to the "CI
Opportunity" and successfully practices the method within the
allotted time, then the intermediary sends an (electronic)
authorization/directive to the plan administrator to compensate the
physician (and sends the information therapy prescription to the
patient as described in Step #7, above). Since the POSI real-time
version is the preferred method, the intermediary can select a
lower rate of compensation for the physician practicing the CI
after-the-fact version of the method. The Website applications
track patient information therapy and other performance standards
responses. When a patient successfully completes an Ix prescription
or other performance standard through the Website (or over the
telephone or by other means), then the Ix Program's software
applications adjudicate the patient's reward and the intermediary
sends an authorization/directive to the plan administrator to pay
the assigned reward to the patient. If the physician or the patient
do not independently and individually (or perhaps dependently and
collectively) respond to their respective "Ix opportunities" within
established timeframes, then the Ix Program software applications
close-out each opportunity accordingly, and the physician and
patient do not earn financial compensation or rewards. All of these
events are recorded and stored for future consideration by the
intermediary and the health plan.
[0189] Step #13 comprises the health plan sponsor, through the plan
administrator, compensating the physician. When the plan
administrator receives the payment authorization/directive from the
intermediary, the plan administrator reimburses the physician one
of multiple levels of compensation according to the contracted
terms between the health plan or intermediary and the physician.
Alternatively, the health plan sponsor may assign the physician and
payment function to the intermediary. In this case, the
intermediary makes payments to physicians from funds supplied by
the health plan sponsor. In the current invention and under the
terms of the agreement between the health plan or intermediary and
the service provider, varying amounts of compensation can be paid
for a variety of performances standards.
[0190] At Step #14 the health plan sponsor, through the plan
administrator, pays the beneficiary a financial reward. When the
plan administrator receives the payment authorization/directive
from the intermediary, the plan administrator pays the patient one
of multiple levels of compensation according to the benefit
established by the health plan sponsor in consultation with the
intermediary and the performance standard achieved by the patient.
Alternatively, the health plan sponsor may assign the payment
function to the intermediary. In this case, the intermediary makes
payments to patient from funds supplied by the health plan
sponsor.
[0191] Step #15 comprises the health plan sponsor realizing a cost
savings. Though this is not an actual step in the process, the
intended by-products of the method is a higher standard of care
(featuring EBM treatments and information therapy) and healthier
behaviors that studies have shown leads to lower costs. In the
current invention, the health plan sponsor agrees to compensate
medical providers and patients to "declare and confirm" their
adherence to performance standards, and to compensate the
intermediary for operating the system and authenticating physicians
and patients' declarations and confirmations. More specifically,
the health plan sponsor agrees, in order to achieve cost
containment as a result of better health and healthcare, to: [0192]
1. compensate the medical provider (physician and hospital) for
accessing the Website to: [0193] a. declare or demonstrate
adherence or providing a reason for non-adherence to evidence-based
treatments and other provider performance standards; [0194] b.
agree or acknowledge the provider's patients will
confirm/rate/concur with/acknowledge his/her declaring or
demonstrating adherence or providing a reason for non-adherence to
evidence-based treatments and other performance standards after
patients demonstrate they understand the treatments on the Website;
[0195] c. prescribe information therapy and other performance
standards to the patient; [0196] d. optionally, rate his/her
patients' level of adherence to recommended care; and [0197] e.
responding to his/her patients' responses to the Website's
questionnaires and inputs to include warnings of medical issues
[0198] 2. financially reward patients (beneficiaries) for accessing
the Website to: [0199] a. read prescribed educational material as
information therapy; [0200] b. declare or demonstrate (by tests)
his/her understanding of the educational material (health
literacy), especially as it pertains to self-managing his/her
health and the recommended treatments; [0201] c. declare or
demonstrate adherence or providing a reason for non-adherence to
the recommended treatments, healthy behaviors and other related
performance standards; [0202] d. report his/her health status;
[0203] e. agree to allow his/her medical providers to
review/rate/acknowledge his/her health literacy, health status, and
indication of adherence responses; [0204] f. confirm/rate/concur
with/acknowledge his/her medical providers' declaration or
demonstration of adherence or reason for non-adherence to
evidence-based treatments and other performance standards; [0205]
3. compensate the intermediary for: [0206] a. operating the
invention's incentive system to include the Program's Website
and/or other technologies; [0207] b. developing and maintaining the
associated software applications and databases; [0208] c. providing
and/or interfacing the performance standards supplied by vendors;
[0209] d. the performance standards; [0210] e. adjudicating and
authenticating medical providers and patients' declarations,
confirmations, demonstrations, and acknowledgments of adherence to
performance standards; [0211] f. adjudicating and authenticating
medical providers and patients' agreements and acknowledgments to
allow the other party's declarations, confirmations,
demonstrations, and acknowledgments of adherence to performance
standards; [0212] g. directing and/or affecting service provider
and patient compensation and financial rewards; [0213] h. tracking,
reporting, and analyzing results; and [0214] i. recommending
refinements to the Program to include "precision guided incentives
and performance standards (adjustments to and expansion of the
incentives and performance standards).
[0215] By combining the parties and elements of the method in the
manner described herein, the invention "triangulates" the interests
of healthcare's key stakeholders--the health plan, the medical
provider and the consumer/patient--in a win-win-win arrangement. By
attaining this unique "triangulation" among these key stakeholders,
the invention achieves the goals of better health and better and
more affordable healthcare. Thus the invention can be described as
a "web-based healthcare incentive system" that creates an
"alignment of interests" and a "state of equilibrium" and a "mutual
accountability partnership" among the key stakeholders to achieve
the goals of better health and better and more affordable health
care. As a result, the invention is better described as an
"alignment of interest" or "AOL" program as opposed to the more
familiar pay-for-performance program descriptor.
[0216] Other embodiments of the current invention will be apparent
to those skilled in the art from a consideration of this
specification or practice of the invention disclosed herein.
However, the foregoing specification is considered merely exemplary
of the current invention with the true scope and spirit of the
invention being indicated by the following claims.
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