Method of optimizing healthcare services consumption

A method of optimizing healthcare services consumption of patients in a healthcare plan provided by an employer and administered by a healthcare quality management firm in a health economic zone that corresponds to the residences of the patients and the locations of providers used by the patients, the method including the steps of:

• ranking providers in the health economic zone based on an analysis of the quality and cost efficiency of practice patterns associated with the providers;
• dividing the ranking of providers into a first level of providers, a second level of providers, and a third level of providers;
• responding to a healthcare request from a patient by determining the level into which the provider associated with the request falls;
• urging the patient to use a first level provider if the associated provider is a second or a third level provider;
• urging the patient to use a second level provider if the associated provider is a third level provider;
• conducting a first set of intervention actions corresponding to a first degree of involvement of the healthcare quality management firm in the provision of services by the provider used by the patient if the used provider is a second level provider;
• and
• conducting a second set of intervention actions corresponding to a second degree of involvement of the healthcare quality management firm in the provision of services by the used provider if the used provider is a third level provider, the second degree of involvement being greater than the first degree of involvement.

A method of optimizing healthcare services consumption by patients of a population in a healthcare plan provided by an employer, the method including the steps of:

• calculating a cost efficiency index of each healthcare provider in a health economic zone based upon past claims information;
• assigning a non-certified designation to each provider having cost efficiency index that fails to satisfy a first predetermined condition;
• determining a service rate for each provider based upon the past claims information;
• assigning a non-certified designation to each provider having a service rate that fails to satisfy a second predetermined condition;
• evaluating practice patterns of each provider based upon the past claims information;
• assigning a non-certified designation to each provider having practice patterns that fail to satisfy a third predetermined condition;
• assigning a qualified designation to each provider having a cost efficiency index, a service rate, and practice patterns that satisfy the first, second, and third predetermined conditions, respectively;
• and
• responding to a request from an patient for healthcare services by urging the patient to obtain the services from a provider having a qualified designation.