Profiling moves from a defensive to an offensive stance for savvy practices
The old high school football coach’s philosophy of "your best defense is a good offense" holds true when it comes to physi-cian profiling. It’s a lesson leaders at The Heart Institute of St. Petersburg (FL) learned the hard way through a brush with decredentialing that represents the good and bad extremes of tracking physician utilization and productivity.
"We went through a decredentialing process with a major insurer about seven months ago that drove us to take on a more active role [in profiling]," says T.J. Borschel, MS, administrator of The Heart Institute of St. Petersburg. "On the surface, we were told it was part of a panel cut-down. Internally, we heard differently that there was economic credentialing involved."
The Heart Institute’s decision to develop its own physician profiling system, which ultimately resulted in reinstatement with the insurer, represents both the opportunities and the challenges facing practices with any sort of managed care business. Measurement of utilization components such as hospital bed days per 1,000 members, emergency department visits, and catastrophic care by managed care organizations is a reality that’s simply not going to go away.
A study by the American Medical Association’s Center for Health Policy Research found that in 1994 (the latest year data were available), 54% of physicians were subject to clinical profiles from managed care organizations and other entities, while 36% of physicians were subject to economic profiles. And given that reality, it makes sense for practices to use profiling data proactively as a tool to improve quality and position the group for success in a managed care environment.
"One of the most important things is to know the rules of the [managed care] organizations you [physicians] participate with," says Evelyn Eskin, MBA, president of Philadelphia-based HealthPower Associates. "You need to get in the belly of the beast, or you’ll be surprised when you lose points. You have to know the rules if you’re going to prevent information from being used against you."
Physicians are classically trained to think in an outcomes-oriented way, Eskin explains. "They’re used to going into a room with a patient, solving the problem, finishing what they’re doing, and then going on to the next patient. It’s much different from thinking in terms of patient populations," which physicians you work with need to do to thrive in a managed care environment, he says.
Making profiling data work for physicians
Many managed care organizations issue profiling reports to practices participating in their networks. These profiles can show the physicians your hospital contracts with how their practice is being judged and serve as a guideline to help them ensure their compliance and institute their own profiling system, Eskin says. Measurements can vary among payers; therefore, it is important to know what factors the major plans doctors you contract with use, as well as the weights assigned to each element. "Knowing where you [physicians] and your practice fall within the established ranges and having the willingness and ability to improve is important to making profiling data work for you," Eskin says.
It’s also important to know ranges managed care organizations use to award bonuses or deduct points, she adds. Often, MCOs will tell them where they fall within a certain range but will not tell them their cutoff points for each category. For example, a payer may deduct three percentage points or add five percentage points to a practice’s base capitation rate based on where a practice falls in median measurements for member survey results.
Once they’re sufficiently convinced that developing their own physician profiling is important, where do they start? Here are some elements your hospital administration can suggest physicians begin measuring right away, which Eskin says can be generated through most computer practice software systems:
• diagnosis and CPT codes by frequency;
• hospital days per 1,000 active patients;
• average age distribution of your patient base;
• patient base sorted by zip code;
• large employers whose employees make up a significant percentage of their patient base and which payer(s) these employers contract with;
• average length of time their current patients have been with their practice;
• number of office visits per patient per year;
• number of active patients in the practice. For primary care practices, a current patient is anyone who has visited the practice during the last two years, but specialists may consider it appropriate to track patients for a longer period of time.
You should also relate to practitioners that they may want to consider comparing the performance of physicians within the group, Eskin says. But can these principles translate from a classroom setting into the real world? Yes, Borschel says. The Heart Institute of St. Petersburg has been tracking its patient population’s bed days per 1,000 by physician for five years, although it stepped up the extent of its profiling earlier this year, he says.
The practice compared hospital and office utilization data for its capitated patients with data on the rest of its patient base, and found that utilization for all patients went down. "Taking capitation has demanded that we examine the cost per unit of services and the benefit of those services, while continuing to monitor clinical outcomes," he says.
Three profiling methods
The close call with decredentialing drove the practice to take its profiling to another level, Borschel says. The group now profiles each physician within the practice and the practice as a whole, through three methods:
• Hospital-based profiles, which you, the hospitals it contracts with, provide. These data include length of stay, cost of services done by physician, and a comparative analysis of these services by DRG code of The Heart Institute’s physician, compared with other attending physicians based on average numbers computed by the hospital. "I gathered information over some years to substantiate the profiles of our physicians related to cardiovascular care," Borschel says. "I was able to gather information over a period of years to substantiate the profiles of our physicians related to cardiovascular care. It showed our physicians were in the 20th percentile of all physicians in terms of charges [by attending physicians at the hospitals profiled]."
• Diagnosis-based profiles, which track data for every CPT code the practice utilizes. The practice is beginning to do a more active peer review on patient charts and has established a quality assurance peer review committee of physician and administrative leaders. The practice also profiles utilization of services compared with consultation work. "If one physician who does a majority of consult work orders very few diagnostic tests, and one with less consult work has an increase in the utilization of diagnostic tests, we look at the severity of the second physician’s patient base and see if there is justification," Borschel says.
• Interventional profiling. Over the past three years, the practice has monitored the volume and scope of interventional procedures performed by each physician. It decided to adopt the American College of Cardiology (ACC) volume guideline and move away from the mode of "everyone does everything" to subspecializing within the group, Borschel explains. "Where three years ago, we had six physicians doing interventions, we now have two. This, we feel, improves the quality of patient care and the proficiency of the physician through increased volume. In addition, our group profile will not show one cardiologist performing procedures that do not meet the ACC volume criteria," he says. These actions resulted in other efficiencies in the form of improved scheduling, physician satisfaction, and decreased cost of malpractice premiums.
For example, the practice may demonstrate that it performs pacemaker implants in its office in a catheterization lab, which can offer significant cost savings over having to perform the procedure in the operating room, with additional costs for anesthesiologist services. In addition, it will present data based on care delivered through its preventive programs and through its congestive heart failure disease management program, which provides in-office infusion therapy.
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