|
Provider profiles or report cards are being
touted as one of the tools to improve the quality of healthcare. However, many physicians believe profiles do not adequately characterize the care they render, do not make sense, and do not indicate what specific changes are needed. This claim is valid unless profiles adequately adjust for
significant case mix and severity differences associated with the
patient panels physicians are managing. To provide a balanced scorecard, quality as well as
controllable aspects of cost and utilization should be included.
Furthermore, the method for calculating the various measures within
the profile should be clear, have face validity, and be based on
generally accepted evidence based national guidelines. Finally, unless the profiles include specific actionable
recommendations for specific patients, they may fail to produce
needed outreach and care improvement to those members needing
services.
RPNavigator, using CRGs from 3M HIS, provides a
powerful tool for profiling primary care physicians (PCPs). CRGs create a method for age/gender, case mix and severity
adjusting of a provider’s panel. This risk adjustment creates expected utilization and costs
at the PCP specialty level. Therefore, the physician who cares for sicker patients may have higher expected
utilization and cost compared to a same specialty provider who does
not.
RPNavigator also tracks the provision of
preventive services. RPNavigator
includes recommendations of Health Plan Employer Data and
Information Set (HEDIS), American Diabetes Association (ADA),
Centers for Disease Control and Prevention, and the US Preventive
Services Taskforce (USPSTF). Measures include HgbA1c and retinal exam in diabetics,
pediatric immunizations, breast cancer, cervical cancer and colon
cancer screening. The quality metrics, along with potentially preventable types of
admissions, as defined by the Agency for Healthcare Research and
Quality (AHRQ), and the risk-adjusted utilization and cost metrics,
create a multi-dimensional profile.
All elements of the profile are either based on
case mix and severity adjusted utilization and cost elements and
compared with peer performance within the plan, or are derived from national organizations which have published generally accepted guidelines. Transparency is
based on the documentation of all aspects of the profiling process.
Perhaps the most important product of
RPNavigator’s profiling is the accompanying list of members who
appear to require further interventions to improve the quality of
services they are receiving. In addition, the profile is not a closed and final document, since the
limitations of claims based data means that some measures may not
capture pertinent information from the medical record. Services may have occurred prior to the claims data analysis
period or may only be present in records obtained from other
physicians or facilities. This
information should be sent to the plan to obtain a more accurate
picture of the care rendered. Finally,
where there are questions about the accuracy of utilization and cost
statistics, a list of members can be obtained from the plan to
indicate the basis for the reported statistics.
Profiling can achieve the goals of fairness,
transparency and usefulness as a tool to improve patient care, if
properly structured. It is also a communication tool for physicians and health plans to
better coordinate their mutual efforts to enhance the effectiveness,
efficiency and quality of care.
|
