System and method for management of health care services

Abstract

The present invention is a system and method for management of consumer services such as health care services which combines new financial structure for health insurance and health benefit plan, payment methods, health plan design, benefit development algorithms, unique procurement methods for health care benefits with and without application to an individual consumer's personal state of health, and is integrated with financial services and asset management products, and benefits for an individual consumer's future medical and / or retirement savings, for healthcare needs. The method and system employs a combination of the defined benefit and defined contribution approaches which combination is referred to herein as “defined-care.” Defined-care model or the healthcare asset management model has two primary components, one which is referred to herein as a “health management and retirement account”, and the other of which is an infrastructure “connected portal” that interfaces through a technology platform with the health management and retirement accounts and the account holders. The foundation of this infrastructure according to the present invention is a technology platform across which a variety of processes are implemented. In the technology platform for the infrastructure of the present invention, the conventional processes and the new processes are integrated, thereby allowing a change to one process to be adopted by or otherwise accommodated by the other processes.

Description

CROSS REFERENCE TO RELATED APPLICATIONS [0001]This application is a divisional of application Ser. No. 10 / 103,267, filed Mar. 20, 2002, which claims priority from provisional application Ser. No. 60 / 277,994, filed Mar. 21, 2001, which applications are incorporated herein by reference.BACKGROUND OF THE INVENTION [0002]1. Field of the Invention[0003]The invention relates generally to a new and improved automated system and method for facilitating management of individual benefits or assets, such as those of an employee or consumer of services, that is capable of interfacing with a variety of entities or “stakeholders” who will or who potentially will benefit, financially or in some other manner, for example, by the acquisition of goodwill. More particularly, the invention relates to a system which creates an infrastructure that is used to connect together consumers, employers, health care providers and health plans and their affiliates so as to combine the process of benefits manageme...

AI Technical Summary

Benefits of technology

"The present invention is a system and method for managing consumer services, particularly health care services, using a combination of defined benefit and defined contribution approaches. The system provides a transparent and easy-to-use interface for consumers to access and choose from available benefits, preventing them from inadvertently not selecting core health care benefits. The system includes a health management and retirement account that provides clear and comprehensive information to consumers about their health care pre-defined benefits and options for using those benefits. The system also allows consumers to invest in their employer's health care plan and earn cash or other incentives for using the plan appropriately. The stakeholders in the system include employers, health care providers, health care plans, financial services, and underwriters. The invention provides a solution for managing health care benefits in a cost-effective and efficient way."

Problems solved by technology

Prior systems and methods of providing health care services and administering employee health care benefits have proven unsatisfactory in recent years for at least several reasons.

The fee-for-service model has fallen into disfavor with employers, the insured and the insurers, because the available systems and methods for management and oversight of the various implementations of the model are less than efficient, increasing costly and vulnerable to mismanagement and even fraud.

There is dissatisfaction with defined benefit plans from the point of view of the employee / patient, the employer and the providers, at a minimum.

The providers suffered financially in the transition from the fee-for-service system to the defined benefit model.

Moreover, complicated administrative procedures mandated by the defined benefit plans before a provider can provide certain services lead to inefficiencies, provider overhead expenses, and situations in which non-physicians effectively are making decisions about what is best for a patient.

The employee / patient is wary of defined benefit plans because the capitation model gives them concern that they may be denied a procedure that is otherwise indicated because of financial rather than medical reasons.

The providers are faced with practical and very real cost / benefit analysis decisions, which arguably impact the provider's ability to provide the level of care that would be in the best interest of each patient.

When employees / patients feel particularly aggrieved, the patients increasingly are bringing lawsuits against employers and health care plans.

Employers likewise are unhappy with defined benefit plans because the cost of the premiums and of administering the plans is ever escalating and the bottom-line outcome of the employers' investment is not totally satisfying to the employees.

Defined contribution health care has not been attractive to employees to date, however, because the terms of the health care plans are difficult to comprehend and are increasingly opaque in terms of benefits, services, providers and reimbursement protocols.

In practice, though, the benefits plans are too complicated and inscrutable that employees risk choosing a plan that will not give them the minimal coverage they ought to have, and the plans similarly are too obtuse as to give an individual insight as to how best to take advantage of the contribution.

In addition, these defined-contribution plans pose very high-deductibles for the employees / patients.

This will result overtime in a greater divide between healthier and ill employees, causing “adverse selection” and even greater health benefit cost increases in the future.

Such changes generally are costly and disruptive to the various entities involved and, if not implemented properly, can lead to non-compliance legal liability.

Images