Profiling moves from defense to offense
January 1, 1998
Profiling moves from defense to offense
Track physicians’ data to improve quality,
"Your best defense is a good offense" is a lesson leaders at The Heart Institute of St. Petersburg (FL) learned the hard way when they had a brush with physician decredentialing recently. Their experience represents the good and bad 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. Bourschel, MS, administrator of The Heart Institute. "On the surface, we were told it was part of a panel cutdown. Internally we heard differently that there was economic credentialing involved."
The Heart Institute decided to develop a system for monitoring its physician profiling, and that ultimately resulted in reinstatement with the insurer. Its experience represents both the opportunities and the challenges facing hospitals and heart centers in this era of managed care. Measurement by managed care organizations (MCOs) of utilization components such as hospital bed days per thousand members and emergency department (ED) visits by patients is a reality that’s not going away.
A study by the Chicago-based 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 MCOs and other entities, while 36% of physicians were subject to economic profiles. Given that reality, it makes sense for facilities to use profiling data proactively as a tool to improve quality and position itself for success in a managed care environment.
"One of the most important things is to know the rules of the [managed care] organizations you participate with," says Evelyn Eskin, MBA, president of HealthPower Associates in Philadelphia. "You need to get in the belly of the beast, or you’ll be surprised. You have to know the rules if you’re going to prevent information from being used against you."
Cardiologists, as well as all physicians, are trained to think in an outcomes-oriented way but in a piecemeal fashion, Eskin explains. "They’re used to going into a room with a patient, solving the problem, finishing what they’re doing, then closing the case. It’s a completely isolated kind of experience vs. thinking in terms of patient populations." That’s what physicians need to do to thrive in a managed care environment.
Let profiling work for you
When your MCOs issue their profiling reports, you can see how your facility’s physicians are being judged. The reports serve as guidelines to help you ensure compliance. Beyond that, you can institute your own profiling system. Measurements vary among payers, however, and it’s important to know what factors your major plans use and the weights they assign to each element.
Knowing where you and your facility fall within the established ranges, and having the willingness and ability to improve, is important to making profiling data work for you. It’s also important to know ranges MCOs use to award bonuses or deduct points, Eskin adds. Often, they will tell you where you fall within a certain range but will not tell you their cutoff points for each category. For example, a payer may deduct three percentage points or add five percentage points to a cardiologist’s base capitation rate based on where the physician falls in median measurements for member survey rates.
Once you’re sufficiently convinced that developing your own physician profiling is important, where do you start? Here are some elements your facility can begin measuring right away. These factors can be generated through most software systems:
• Diagnosis and CPT codes by frequency.
• Bed days per thousand.
• Average age distribution of your patient base.
• Patient base sorted by zip code.
• Large employers those whose employees make up a significant percentage of your patient base and their payers.
• Average length of time current patients have come to your facility.
• Number of hospitalizations per patient per year.
• Number of active patients.
You also may want to consider comparing the performance of your physicians.
Facility steps up profiling and peer review
The Heart Institute has been tracking bed days per thousand for its patient population for five years, but it stepped up the extent of its profiling earlier this year, Bourschel says. The facility compared its bed days per thousand data for its capitated patients to the rest of its patient base and found that utilization for all patients went down. Extended profiling "has forced us to examine the cost per unit of services and the benefit of those services," he says. The result is better outcomes.
The Heart Institute now profiles each cardiologist within the facility and the facility as a whole. Data including length of stay, cost of services done by physician, and a comparative analysis of these services by DRG code are analyzed. Heart Institute physicians are compared to other attending physicians as well as national averages. "I was able to gather information over a period of years to substantiate the profiles of our physicians related to cardiovascular care," Bourschel says. "It showed our physicians were in the 20th percentile of all physicians in terms of charges."
Another type of profile tracks data for every CPT code utilized. The Heart Institute 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 facility also profiles utilization of services compared to consultation work. If one physician who mainly consults, for example, orders very few diagnostic tests, and one with less consult work does substantially more ordering of diagnostic tests, the profile looks at the severity of the second physician’s patient base to see if there is a problem, Bourschel says.
The Heart Institute uses its data in managed care contract negotiations. "We present areas where we can differentiate ourselves," Bourschel explains. Rather than generating one overall report, the facility pulls bits and pieces from the data to show how it has saved money, improved patient care, and instituted preventive programs. For example, the report may demonstrate that the Heart Institute performs the majority of pacemaker implants in its catheterization lab, which can offer significant cost savings over performing the procedure in a hospital. Or it may present data based on care delivered at its lipids clinic or through its congestive heart failure disease management program.
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