Patent Application
20060224443
A portion of the disclosure of this patent document contains material which is subject to copyright protection. The copyright owner of that material has no objection to the facsimile reproduction of the patent document or the patent disclosure, as it appears in the Patent and Trademark Office patent files or records, but otherwise reserves all copyright rights.
The present invention relates to health care cost reduction systems. In particular, the present invention is directed to providing a) incentives to patients to utilize health care options that will reduce costs for both the patient and the sponsor of their health insurance plan or their health insurer itself and b) a practical mechanism for enabling them to act on those incentives.
Advances in modern-day health care have introduced many different options for the health care consumer, or patient, in nearly every aspect of health care. Typically, there is no longer just one town doctor that advises the patient on every aspect of medical care. Now there are a variety of doctors, supported by innumerable specialists—each of these with a different view on the best health care options for the patient. These different views are due in part to the multitude of medications and other types of treatment that are available. Instead of one medication for one medical problem, there are now scores of medications to treat the same problem. The same can be said for treatments other than medications. Each treatment or medication has its own benefits and drawbacks. Some of these options are therapeutically equivalent in most if not all regards, though. For example, many medications that were once only available by prescription have been released for sale without a prescription, as over-the-counter medications. Anyone can walk into a drugstore and buy them, without having a doctor prescribe them first. Many of these over-the-counter medications are identical to what was once provided by prescription only. Sometimes only the name of the medication has changed. Many of these over-the-counter medications are much more affordable to the average person than were their prescription-only counterparts or different medications that are available only by prescription. As a result, it is often much more economical to buy the over-the-counter version of the medication than the prescription version or an alternative prescription medication. Nevertheless, sales of many of these prescription drugs continue to grow. Two reasons for this continued growth in sales of the prescription version drugs are direct-to-physician marketing by pharmaceutical company sales representatives (sometimes referred to as “physician-detailing”) and direct-to-consumer marketing. Another reason for continued growth in sales of the prescription version drugs is the nature of health insurance in the United States. Just as patients have a multitude of doctors, specialists, medications and other treatments to choose from, they also have a multitude of insurance options. Most medical insurance plans include some type of prescription drug coverage. Under such plans, the patient typically pays a fixed amount (“co-pay”) for a prescription drug, and the insurance company pays the rest of the cost. Sometimes the insurance plan includes several different levels of fixed costs, such that the patient pays more for a name-brand prescription drug than for a generic prescription drug, for example. Many times the fixed cost that the patient pays for a prescription medication is lower than the retail price of the over-the-counter version or an over-the-counter alternative—which is often not covered by the insurance plan at all. As a result, although the prescription version of the medication is often vastly more expensive, sometimes approaching an order of magnitude difference, there is often an incentive for the patient to buy the more expensive prescription version or a more expensive prescription alternative, rather than an over-the-counter alternative because the prescription medication is cheaper from the patient's viewpoint. As a result, insurance companies spend millions of dollars paying for medication, when an alternative that was equally safe and effective could have been purchased for a fraction of the price. Pharmaceutical firms spend considerable sums on direct-to-consumer advertising to increase the likelihood that patients request and use the higher cost prescription options.
The present invention is directed to a method, apparatus and computer readable medium for reducing health care costs by creating a) an incentive for patients to choose the most economical treatment option that is both safe and effective and b) a practical mechanism for enabling them to act on that incentive. According to an embodiment, a computerized analysis of a population's (e.g. health plan members, employees of a company, patients with a certain health condition) prescription drug insurance claims is performed to identify a patient that currently uses a health care option that is not the most economical, safe and effective option. A coupon is prepared for the patient, which would provide a discount for a certain health care option that provides economical benefits over the health care option currently utilized by the patient. The coupon can include identification information that can be used to track the patient's use of the coupon. In addition, the patient's prescription drug insurance claims can be monitored to see if the patient stopped using the less economical health care option. If the patient uses the coupon to purchase the more economical health care option, and stops using the less economical option formerly utilized, then additional coupons can be prepared for and sent to that patient, allowing continued use of the more economical health care option. The invention is best understood with reference to the specification, drawings, and claims.
a is a block diagram of an overall system in accordance with an embodiment of the present invention.
b is a block diagram of an overall system in accordance with an embodiment of the present invention.
c is block diagram of an overall system in accordance with an embodiment of the present invention.
a is a representation of a coupon in accordance with an embodiment of the present invention.
b is a representation of a coupon in accordance with an embodiment of the present invention.
a is a front view of a coupon delivery system in accordance with an embodiment of the present invention.
b is a back view of a coupon delivery system in accordance with an embodiment of the present invention.
a is a block diagram in accordance with an embodiment of the present invention.
b is a block diagram in accordance with an embodiment of the present invention.
c is a block diagram in accordance with an embodiment of the present invention.
d is a block diagram in accordance with an embodiment of the present invention.
e is a block diagram in accordance with an embodiment of the present invention.
The present invention may be implemented in a computer system 100, as shown in
The database 110 may also store reference data that is employed in connection with the application of the rules to the source data stored therein. The database 110 may also store the analysis results, which result from the application of the rules to the source data stored therein. The reference data may include formatted and/or unformatted industry standard insurance or medical codes, or a representation thereof, which are useful in implementing the rules. The reference data may also include information describing health care providers, such as hospitals and doctors, as well as their specialties.
The computer system 100 also includes a data store 130, which may be optionally employed for large sets of source data and corresponding analysis results. The data store 130 may be coupled to the database 110 via a network. The data store 130 may be implemented as a data warehouse or data mart. If access to the database 110 or (if utilized) the data store 130 is to be provided via the Internet, then a web server 140 may be employed that includes one or more program applications that provide reports or coupons generated by embodiments of the present invention. The reports or coupons may be provided as web pages (e.g., HTML or XML based web pages), which are made accessible to a web browser residing on a workstation 150 (or other computer) that is coupled to the web server 140 via the internet 160. The reports or coupons are provided in response to user queries via the web browser. These requests may be authenticated by the web server to ensure that the person is authorized to review the information requested. Optionally, a firewall 145 may be provided between the web server 140 and the database 110 or data store 130 (if utilized).
As an alternative to the use of the web server 140, reports or coupons generated by the present invention may be provided by one or more program applications residing on the computer server 105 or workstation 150. These reports or coupons may further be printed and distributed to users manually or by some other means. Further the data file, for the coupons that have been created, can be stored in a database. When the coupon is used, it can be tracked by a redemption agent, or other entity, in a variety of ways. For example, the identification information or tracking code on the coupon can be recorded electronically to a database by the redemption agent. Alternatively, an electronic coupon could contain a tracking signal (for example a signal similar to a return receipt that can be attached to an email, which automatically notifies the sender when an email is opened) which could notify the redemption agent or other entity, for example the coupon provider, that the coupon has been redeemed electronically. These are merely examples of embodiments of this invention, and are not meant to limit the invention in any way. When usage data is received, an insurance claim can be created. This claim can be entered into the insurance claim system. This data may also be entered into the database 110, either directly, or through a report from the insurance company. In this way, the usage data can also be considered by the rules, which are implemented by a rules engine as discussed above, when they are again applied. The rules for creating coupons, which are applied by the rules engine, can therefore also consider whether a coupon has been issued or used, as well as other things, for example the health history of the user, or continued use of the more expensive health care option.
In accordance with an embodiment of the present invention, health care information is received for a plurality of patients. This patient information can be received from many different sources, as will be apparent to one having skill in the art. In accordance with an embodiment of the present invention, these sources could include records from an insurance company or program sponsor, or from individual patients through biometric data sent over a telephone line, or clinical data reported by physicians, for example. The health care information for a patient can be analyzed to determine proposed changes that may have a tendency to reduce future health care costs for individual patients and/or health plan sponsors or insurers.
These changes may include, for example, an adjustment in treatment that would reduce the overall cost of treatment. A coupon can then be issued to the patient to create an incentive for the patient to adjust his or her treatment in order to reduce the overall cost of treatment. An example of this type of treatment adjustment could be where a patient uses a prescription medication that is also available in a non-prescription form for a reduced cost. Because of insurance coverage, the patient may not have to pay the entire cost of the prescription medication, making the cost to the patient of the prescription medication less than the cost to the patient of the non-prescription, or over-the-counter, form of the medication. This can occur because often insurance coverage does not cover non-prescription, or over-the-counter medications, at least in part due to the fact that there has been no reliable and efficient way for a claim to be submitted for these products to an insurer on behalf of these patients. As a solution to this problem, a coupon can be provided to the patient which would allow the patient to receive the non-prescription form of the medication at a reduced cost relative to the cost to the patient of receiving the prescription medication, creating an incentive to the patient to use the over-the-counter medication instead of the prescription medication. Even if the insurance company pays the entire cost of this coupon, it can cost the insurance company less than if the insurance company paid only a portion of the cost of the prescription medication. According to another embodiment of the invention, the coupon could provide a discount for a preferred brand drug, i.e. a brand name prescription medication that the insurance company prefers that the patient use for some reason instead of the prescription medication the patient is currently using.
According to an embodiment of this invention, predetermined rules can be created to determine whether a coupon should be provided. These rules could include such considerations as: “does the patient use an expensive target prescription drug?” (for example, prescription proton pump inhibitors or prescription non-sedating antihistamines), “does the patient's medical history support the use of any alternative drugs?”, “does the patient's medical history indicate any reason why the patient should not be using this medication?”, “does the patient's medical history indicate any reason why the patient should not switch to a non-prescription (over-the-counter) version of the medication or a non-prescription (over-the-counter) alternative medication?”, “has the patient been issued coupons before, and, if so, has the patient used such coupons before?” All of these considerations are presented as examples of ways to determine whether to provide a coupon for a particular patient or class of patients.
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The retailer 220 can then supply the information from the coupon to a redemption agent 230. According to one embodiment, the retailer 220 can supply the coupon itself (thus also supplying the information from the coupon) to the redemption agent 230. According to another embodiment, the retailer 220 can supply just the information from the coupon, and not the coupon itself to the redemption agent 230. In return, the redemption agent 230 can reimburse the retailer 220 for the value of the coupon. As will be known to one of skill in the art, the reimbursement can be for the actual value of the coupon, or can exceed the actual value of the coupon, in order to encourage retailer 220 to continue to accept coupons.
According to an embodiment of this invention, the retailer 220, could alternately provide the information from the coupon directly to the coupon provider 200, bypassing the redemption agent 230. The coupon provider 200 could then reimburse the retailer 220 directly. However, the reimbursement need not be limited to the value of the coupon.
Similarly, according to an embodiment, the patient 210 could redeem the coupon directly with the coupon provider 200, providing the coupon in exchange for the health care product or service at a discount. As a result, the retailer 220 and the redemption agent 230 need not be involved in the use of the coupon.
In instances where a redemption agent 230 is employed, the redemption agent 230 can then provide the information from the coupon to the coupon provider 200. This information can be provided in the form of the coupon itself or as compiled information such as a chart or computer database. The information could be compiled in a way that is compatible with an insurance claim system, such that an insurance company can determine whether to pay the claim as it would for any other insurance claim. The coupon provider 200 can then evaluate the information from the coupon or chart or computer database. In this way, the coupon provider 200 can determine the patient 210 whose coupon was used. This could be done, for example, by tracking which coupon was redeemed, and reviewing records to determine to whom that coupon was distributed. According to an embodiment of this invention, the coupon provider can maintain a record of all coupons in circulation. (i.e. coupons that have been produced and/or distributed, but not yet redeemed). When the coupon provider receives information showing that a particular coupon was redeemed, or that a coupon issued to a particular person was redeemed, an insurance claim can be prepared, in order to inform the insurance company of this redemption. In this way the insurance company can determine whether to pay the claim, as it would for a prescription medication, for example.
After determining what patient's 210 coupon was used, the coupon provider 200 can produce another coupon for the patient 210 in order to encourage the patient 210 to continue to reduce overall health care costs. Moreover, in accordance with an embodiment of the invention, the coupon provider or a third party can make a deposit into a health savings account for the patient in response to the patient's use of the coupon. In this way, an alternative or additional incentive could be provided for the patient to use the coupon. According to an embodiment of this invention, the coupon provider 200 can also evaluate whether the patient 210 has actually stopped using the product or service that the coupon was intended to replace, thus reducing overall health care costs. If the patient 210 used the coupon to obtain a discount on the alternative product or service, and still purchased the original product or service again, then the coupon provider 200 may choose not to produce a new coupon for the patient 210. Similarly other considerations may be evaluated by the coupon provider 200 in deciding whether to produce another coupon for the patient 210. Such considerations could include changes in the patient's health care, changes in services or products available, changes in product or service prices, changes in patient's insurance coverage, changes in availability of health care options, or changes in the patient's health, as well as others.
Further, the information from the coupons can be delivered to a health care provider 240, or to a manufacturer 260. According to an embodiment of the invention, care can be taken to ensure the privacy of the patients in this process. This can include abiding by any applicable governmental regulations of patient privacy, as well as any other measures necessary or desirable in order to ensure patient privacy. By way of example, the identification information from coupons can be delivered to the health care provider 240 or to the manufacturer 260 in summary form only, so it is not discernable what particular patients are taking part in this plan. In either case, the coupon provider 200 can be reimbursed for the value of the coupons. This reimbursement may include not only the actual value of the coupons, but may also include reimbursement for other things, which may include, for example, gathering the information from the coupons, preparing the coupons, delivering the coupons, or evaluating the health history of the patient.
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As discussed above, the coupon and reimbursement could then transfer between the patient 210, retailer 220, redemption agent 230, and manufacturer 270 with the manufacturer 270 filling the role of the coupon provider 200. As discussed above, the retailer 220 and the redemption agent 230 need not be included in the use of the coupon.
A coupon 300 according to an embodiment of this invention can be seen in
For example, the title block 330 could say “Save 50 cents on your next purchase of a pharmaceutical.” In this case, the patient 210 and the retailer 220 can both understand that the coupon can be good for a fifty-cent discount on the purchase of a pharmaceutical. The coupon 300 can further include an identification information block 340. The identification information block 340 can be a bar code, a radial, two-dimensional type code symbol, or text. These examples are presented as samples of possible identification information blocks 340, and are not meant in any way to limit the present invention to a certain type of identification information block 340. The identification information block 340 can convey information such as the value and use of the coupon 300, the expiration date of the coupon 300, the identity of the patient 210 to whom the coupon was sent or who can use the coupon, as well as various other pieces of information. Again, this information is presented as description of embodiments of the invention, and should not be used to limit the invention itself to these particular disclosures. The coupon 300 can also include a text block 350, which can contain text addressed to the patient 210 or the retailer 220. The text in the text block 350 can explain, in more detail, the value of the coupon 300 and how it can be used. The coupon 300 can also include an expiration date 360. Additionally, the coupon 300 can contain a box 370, in which the retailer 220 can write the value of the coupon as redeemed. According to an embodiment of the invention, the box 370 is particularly relevant when the coupon 300 is valued as a certain percentage of the retail price of a product or service. The retailer 220 can then write in the amount that the coupon 300 was actually redeemed for. Further, the maximum value for which the coupon 300 can be redeemed can be displayed on the coupon as a max value 320. Further, as is clear to one of ordinary skill in the art, the coupon 300 could be produced in such a way that fraudulent copying will be discouraged. For example, the background of the coupon 300 could include microprinting that will blur or become more apparent when copied by a standard copying method. Similarly, according to an embodiment of the invention, the coupon 300 could be printed in color, on unusual paper, or with a color backing. As will be understood by one of ordinary skill in the art, each of these methods, along with many others, which can also be employed in accordance with the present invention, could help to reduce fraudulent copying of the coupon 300.
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Additionally, the mailer 400 can be sent by itself to the patient 210, or with other informational mailings. For example, a feedback form may be included with the mailer 400. Similarly, an informational mailer may be included with the mailer 400 in order to describe the coupon program to the patient 210. A mailer summarizing the patient's health history can also be included with the mailer 400. The mailers can be selected such that all of the mailers can be mailed for the cost of one fist-class stamp.
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