Category Archives: Provider Profiling

Access to my data – The Provider Portal

Provider Profiling, Quality Reporting

The advent of changing reimbursement frameworks moving from fee for service and volume based incentives to budget-based and shared savings methodologies has intensified the need for physicians to access meaningful, timely physician profile reporting.

There are many variations in what gets presented in physician profile reporting as well as how and when it is delivered. In July 2012, the American Medical Association launched their Physician Reporting Guidelines in an effort to provide a physician perspective in profile reporting. The guidelines called for the need to be easy to understand, easy to access and provide an opportunity for review of detailed data. While the AMA reporting guidelines also called for standardized reporting, that remains a significant work in progress.

Technology and data availability continue to improve and have given rise to sharing information through provider or physician portals. There is a great deal of work on the front end to gather data, select measures and validate all this data before release.  Today, we scratch the surface of physician portals and share some examples and considerations in the design of the portal.

The critical elements in the design and implementation of a physician portal require early inclusion of physicians in the planning and design process. In accordance with the AMA Reporting Guidelines, it should also address ease of use, availability of actionable information and drill to their member detail.

Dashboards are a popular method for sharing information through a portal. They provide for an accessible, visual and portable look for physicians. This type of display can begin at a higher level such as the medical group and then allow for drill to individual providers and then to their members. Depending on the tool and data sources, the provider portal can include claims and EMR data reporting. Retrospective data is very valuable in providing insights into opportunities for change.  The examples below are claims based and allow for review of the retrospective performance as well as provide transparency and insight into prospective issues, using risk assessment results and other mainstream methodologies.

Provider Profile

Provider Quality Measures

Lastly, providing the option to submit feedback is a critical element for provider portals. Throughthe portal, the physician can be given access to submit requests to update or revise the data, and related results, based on additional information. The workflow of this process should be a significant consideration in the planning process to define standard reasons.

There is a great deal of planning involved in determining the specific metrics and the data visualization option but with early physician engagement and thorough data governance rules, the physician portal is a valuable tool in broadening the engagement of physicians.

Narrow Networks and MedInsight

Healthcare Reform, Provider Profiling, Quality Reporting

In the late 1980s and early 1990s, managed care plans frequently featured offerings with provider networks of limited size, based on the idea that using the most cost-effective and efficient providers would result in lower healthcare expenses.  As a result these plans (which usually had lower premiums than larger network counterparts), would be hoped to funnel a greater number of patients to the smaller network, resulting in an additional “volume” of traffic to the providers. Advocates of this approach also argued that a smaller network would produce a more favorable risk profile, since members willing to choose from a smaller list of providers were less likely to have an existing condition already in treatment.

A variation on this theme is the “tiered network,” in which the highest benefits are paid when members visit the most efficient providers.  However, a “narrow network” is not necessarily a “tiered network” since the concepts involved represent two different methods for reducing costs while improving access and quality (although “narrow networks” and “tiered network” concepts are often utilized in tandem).

The “narrow network” approach, which was often combined with other payment methodologies such as capitation or staff-model network design, did produce significant cost savings, but several market factors (including members’ demand to see specific providers, and provider contracts that made inclusion in the most favorable tier a requirement for participation) caused typical network size to steadily increase in the years since.

Another factor which affected the success of this approach was the diverse methods payers used to define the network’s composition; in addition to fee negotiation, providers were often analyzed using a variety of measures, to determine those with the best quality outcomes.  However, since these analysis methods varied between payors and were usually not completely disclosed, providers often challenged the results, arguing that important factors, such as the health status of a particular group of patients, had been overlooked.

Now, with the Patient Protection and Affordable Care Act (the “ACA”) and its associated Exchange dynamics, as alternative reimbursement methodologies and risk adjustment are fundamentally changing the way health plan business is conducted, the “narrow network” concept is being revisited.  Several plans have introduced “narrow network” offerings in hopes that such plans will be attractive in the Exchange environment.

MedInsight has always offered a variety of innovative ways for payors to measure provider quality.  The platform includes Provider Network Management capabilities, which enable organizations to analyze, compare, and manage the performance of providers and provider networks. These analytic techniques include the ability to understand both the overall and relative cost performance of provider contracts, analyze how well specific disease and healthcare conditions are managed by providers, compare efficiency within provider peer groups, and identify best practice patterns, all of which can assist in developing and administering “narrow networks.”  In addition, MedInsight supports a variety of analytic tools, both proprietary and from third parties, which assist in the quality measurement process.  The table below provides an example, derived using MedInsight sample data:

Table 1.

Sample Provider Measurement Report

Network Comparison

Since many new contracting methodologies (including ACOs) rely on quality measures, and since Federal and State risk adjustment will incorporate payor-provided claims and EMR data submitted for audit, these abilities will continue to be of increasing value to MedInsight customers.  Finally, these tools can also be used to help provider organizations participating in “narrow networks” to create a better relationship with members.

Risk Adjustment and Provider Profiling – My Patients Are Sicker

Healthcare Analytics, Provider Efficiency, Provider Profiling, Severity Adjustment

In physician profiling initiatives, risk adjustment is often employed as part of the profiling process. The use of a risk adjuster can adjust for some of the effects of patient characteristics that may vary across providers. Using a risk adjuster can be a helpful advantage when reviewing and presenting data to physicians in a meaningful, credible manner. In most risk adjustment tools, the models offered present two perspectives. There is a concurrent model and a prospective model. Each offer different advantages and their use will vary based on the business question or need to be addressed. This post will look take a brief look at the use of concurrent model results in calculating a provider efficiency score.

The concurrent model describes the health status of a physician’s panel of patients based on the patients’ claim and enrollment experience during an assessment period. The assessment period is often the most recent 12 months. The concurrent model is particularly helpful in provider profiling when evaluating patterns or outcomes of practice.

In the following table, the populations enrolled with three hypothetical physician panels were compared to calculate efficiency scores; this process addresses a common provider concern that “my patients are sicker.” Efficiency scores are typically calculated as a ratio of physicians’ actual allowed claim costs and the expected allowed claim costs based on the concurrent risk scores of the population for which a physician is responsible.

Provider Profile Comparison

Without risk adjustment, one may draw incorrect conclusions, because the physician practice or panel that appears to have the worst outcomes may simply have the sickest patients.  In the example above, while Provider B has the lowest concurrent risk score and lowest actual PMPM cost, their efficiency score is the highest at 1.09 or 9% higher than the average for the total population.

Depending on your decision support tools and risk adjustment tools, risk scores are also available by service breakouts, such as inpatient, outpatient, and pharmacy. In this example, a further drill to the service categories to monitor the distribution of the costs across the service categories would provide additional insight. For example, a comparison of providers’ efficiency in managing inpatient costs by comparing a population’s actual inpatient costs to the costs predicted by the concurrent inpatient risk score.

Stay tuned for upcoming physician profiling blogs.