Computer system and method for generating healthcare risk indices using medical claims information

A system for generating a risk index for an individual using said individual's medical information, said system comprising:

• means for generating a medical condition score using said individual's medical information for each medical condition possessed by said individual;
• means for modifying each medical condition score according to a regression coefficient thereby resulting in one or more modified medical condition scores;
• and
• means for generating said risk index by summing said one or more medical condition scores, wherein said risk index is indicative of at least one of said individual's medical costs, chronic medical conditions, and variation in medical costs.

A computer readable medium for generating at least one risk index for at least one of an individual and a group of individuals using medical information, said computer readable medium comprising:

• computer readable instructions for generating a medical condition score using said medical information for each medical condition possessed by said but least one of individual and group of individuals;
• computer readable instructions for modifying each medical condition score according to at least one regression coefficient thereby resulting in one or more modified medical condition scores;
• and
• computer readable instructions for generating said at least one risk index responsive to said one or more modified medical condition scores, wherein said risk index is indicative of at least one of medical costs, chronic medical conditions, and variation in medical costs for said at least one individual and group of individuals.

A method for utilizing a combination of risk indices for an individual using said individual's medical information, said method comprising the steps of:

• (1) determining a medical claims risk index indicative of at least one of said individual's medical costs, chronic medical conditions, and variation in medical costs;
• (2) determining a pharmacy claims risk index indicative of at least one of said individual's medical costs, acute medical conditions, and variation in medical costs, by using said pharmacy claims modified by a compliance medication score indicative of said individual's compliance with prescribed pharmaceuticals;
• and
• (3) analyzing and using said medical claims and pharmacy claims risk indices to determine at least one of:
• clinical case identification, disease management, prediction of concurrent and prospective medical-related utilization, prediction of concurrent and prospective pharmacy-related utilization, prediction of concurrent and prospective total healthcare utilization, and comparison of groups which may have differing rates of chronic illness.