Data processing: measuring – calibrating – or testing – Measurement system in a specific environment – Earth science
Reexamination Certificate
1998-01-05
2001-02-27
Kemper, Melanie A. (Department: 2764)
Data processing: measuring, calibrating, or testing
Measurement system in a specific environment
Earth science
Reexamination Certificate
active
06195612
ABSTRACT:
CROSS-REFERENCE TO RELATED APPLICATIONS
Not Applicable.
STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT
Not Applicable.
REFERENCE TO A “MICROFICHE APPENDIX”
Not Applicable.
BACKGROUND OF THE INVENTION
1. Technical Field
The present invention relates in general to a pharmacy benefit management system and method of using it. The invention more particularly relates to a system which facilitates the monitoring of prescriptions authorized by a medical group according to a novel method.
2. Background Art
The health provider system known as managed care was created to provide health care at a reasonable cost. Under managed care, subscribers of a health care plan received health care at reduced rate by controlling the health care costs of the entire pool of subscribers. One such health care plan was the health maintenance organization (“HMO”) which controlled health care costs, in part, by contractual arrangement with individual physicians. In exchange for agreeing to provide health care services for the subscribers of the HMO, the physicians would be reimbursed by the HMO for the health care services provided.
In an effort to obtain more leverage in negotiating agreements with the HMOs, groups of physicians became associated with one another as medical groups. Such medical groups were formed as corporations, partnerships, and other associations to enable each physician in the medical group to obtain more patients, higher reimbursements, etc. from the HMOs than a single physician could obtain without the medical group.
A component of managed care was the capitation of a pharmacy benefit. The capitation referred to a fixed amount of money paid by the health care plan to the medical group to manage the costs of prescription drugs for subscribers of the health care plan (the patients of the medical group physicians). The amount paid by the health care plan was determined on a per subscriber, per month, basis. In the event the costs of drugs prescribed by the medical group are less than the capitation of the pharmacy benefit, the medical group realizes the difference between the capitation and the actual drug costs as a pharmacy benefit profit. However, if the costs of the prescribed drugs exceeds the capitation, the medical group was indebted to the health care plan for the difference between the actual drug costs and the capitation, and the medical group realized a pharmacy benefit loss.
It has been difficult to monitor the drugs actually prescribed by the physicians of the medical group to enable the medical group to identify the prescribing activity of the physicians to help predict the expected costs for the actual drug costs. Furthermore, the actual drug costs could not be determined with a high degree of certitude, since the costs for the drugs prescribed could vary, depending upon the pharmacy where the drugs were obtained by the patient. Consequently, the actual drug costs relative to the pharmacy benefit capitation could not be determined with any real accuracy for the small medical group.
Therefore, it would be highly desirable to have a new and improved pharmacy benefit management system which can enable a medical group to analyze actual drug costs relative to a pharmacy benefit capitation for managing prescription drug activity. Such a pharmacy benefit management system should be relatively inexpensive, and convenient to use.
Also, it has been difficult to monitor pharmacy claims received from the pharmacies supplying the prescription drugs to the patients. As a result, the medical group could not determine if the patients were obtaining the drugs actually prescribed by the medical group physicians. Without the pharmacy claim information, the medical group was unable to determine the drugs, and the actual costs of the drugs, actually obtained by the patients.
Therefore, it would also be highly desirable to have a pharmacy benefit management system which would provide information regarding the drugs obtained, and their actual costs, to the medical group based on the prescription activity of the medical group physicians.
SUMMARY OF THE INVENTION
Therefore, the principal object of the present invention is to provide a new and improved pharmacy benefit management system, and a method of using it, wherein a medical group is enabled to analyze actual drug costs and utilization rates by individual physicians and by the entire medical group relative to a pharmacy benefit capitation for managing prescription drug activity, in a relatively inexpensive manner and in a manner convenient to use.
Another object of the present invention is to provide such a pharmacy benefit management system which provides a medical group with information regarding the drugs obtained, and their actual costs, based on the prescription activity of the medical group physicians.
Briefly, the above and further objects of the present invention are realized by providing a new and improved pharmacy benefit management system which enables a medical group to monitor prescription utilization information for the medical group to enable the medical group to manage pharmacy costs relative to a pharmacy benefit capitation.
The pharmacy benefit management system includes a pharmacy computer for generating pharmacy claim information based on pharmacy activity of a medical group. A health plan computer is responsive to the pharmacy claim information for generating pharmacy activity information for the medical group. A medical group computer receives the pharmacy activity information from the health plan computer and stores the pharmacy activity information. The pharmacy activity information is processed to generate utilization information to enable the medical group to monitor the pharmacy activity.
REFERENCES:
patent: 5544044 (1996-08-01), Leatherman
patent: 5845255 (1998-12-01), Mayaud
patent: 5918208 (1999-06-01), Javitt
Jones, John D. “Easier to Swallow: Strategies for Managing Pharmaceutical Costs” Risk Management v43 n2 p 42(5), Feb. 1996.
Mandelker, Jeannie “Get the Most Out of Your PBM” Business and Health v 12 n 11 p37(6), Nov. 1994.
“For Sale: Prescribing Information” Managed Care Marketing, v2 n4, p29, no author listed, Oct. 1996.
Banahan et al., “Using Pharmacy Computer Systems for Better Patient Care”, Drug Topics, v138, n1 p80(9), Jan. 10, 1994.
Higgs Fletcher & Mack LLP
Kemper Melanie A.
Kleinke Bernard L.
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