The healthcare system in the United States is currently undergoing changes aimed at providing affordable care, but the complexity of many health decisions prevent patients from making informed health and insurance decisions and achieving the full potential of healthcare reform. Case in point, the cost and coverage of prescription drug plans is complex. First, these plans vary from company to company, and from region to region. Second, these decisions have to be made in the presence of uncertainty of patient health outcomes. Third, every patient is different and exhibits different preferences. The variance and uncertainty leaves many Americans without the ability to make an informed decision about which plan(s) suit them and defeats the promise of healthcare reform. Federal healthcare reforms (e.g. digital medical records) have facilitated the widespread availability of statistical data (e.g. Centers for Medicare and Medicaid Services’ (CMS) Public Use Files (PUFs), comprised of data from more than 23 million patients).
Focus of this Work
The objective of this project is to exploit this data by designing a Decision Support Tool (DST); specifically a tool to assist the patient’s decision to purchase prescription drug plans (PDPs) by comparing and ranking Medicare Part D PDPs based on a patient’s individual situation and preferences, and historic costs. These tools give patients options based on complexity of plans, uncertainty of health outcomes, and individual patient preferences.
A Mean Reciprocal Rank (MRR) method is used to establish the importance of insurance-related attributes. These weights provide the basis for a cost-utility analysis to determine which insurance plan is appropriate for each individual to consider. Comparisons on prescription spending will also be made to past patients who have a similar health-profile as identified by the current patient.
The results will change for every user, depending on their health profile. For example, the DST will identify the most suitable option for this user as 1) AARP MedicareRX Enhanced, 2) Blue MedicareRX Premier, and 3) Health Net Value Orange Option 2; based on their insurance attribute ranking of premium payment, deductible, GAP coverage, and cost sharing. The DST also displays the monthly premium, deductible, and number of prescription drugs covered by the insurance plan.
Preliminary testing with subject-matter-experts as well a range of patients has shown that the tool is extremely useful. Based on the success of these tools, it is likely that this will become a standard way of doing business and that these tools will be found in doctor’s office waiting rooms, and on insurance provider’s websites will help enhance the customer’s knowledge base; breaking the barrier to the insurance industry.