Physician Profiling: How the Numbers Add Up
For the past three years, ED physicians at Parkview Community Hospital in Riverside, CA, have known that for every test they order, every prescription they write, someone is keeping score.
A computer program logs and analyzes data collected from both the hospital and the billing company to form a profile of each doctor’s resource utilization.
Physicians unable to keep their costs per patient relative to acuity in line with the others in the group may soon find themselves looking for another job.
As managed care forces more hospitals to put cost-efficiency on par with patient care, this scenario is becoming a modern fact of life in EDs from coast to coast.
"We started this because we wanted to be good managed care citizens," says Art Wong, MD, FACEP, the chief executive officer of Emergency Physicians Medical Group (EPMG) in San Francisco, which manages the ED at Parkview. "We knew that if we didn’t pay attention to the cost of providing care, we would be out of a job pretty quickly."
The good news is thatwhen done correctlyprofiling programs improve the consistency in the care delivered in the ED, provide an accurate method for physicians and managers to evaluate their practice compared to that of their peers, and aid in establishing treatment protocols.
The Ambulatory Profiling Program was conceived and developed by two physicians at the group, Ian Ahwah, MD, FACEP, and Laurel Hodgson, MD, FACEP, says Wong. It consists of software to analyze physician utilization data to be used in conjunction with a cost-containment "manual" that details treatment guidelines for the top presenting complaints.
ED groups who want to survive must be able to quantify what their physicians do, says Rick Bukata, MD, FACEP, Medical Director of San Gabriel Valley Medical Center in San Gabriel Valley, CA, who developed a software program to both capture lost hospital charges and track clinical data.
"No other business has been so non-business-like as medicine," he claims. "We have no idea what the work product of doctors is in terms of efficiency, those kinds of things."
Start with the right data
The impetus for the development of both software packages was the realization that hospitals do a poor job of tracking data in the ED.
Physician profiling looks at the use of ancillary tests, specifically lab and x-ray tests ordered by physicians, but hospital systems aren’t set up to gather that data accurately for emergency physicians, says Marty Karpiel, MPA, the CEO of Karpiel Associates, an ambulatory care consulting firm in Los Alamitos, CA.
Because of double coverage and changes of shift, the physician of record that is listed on many ED charts is not the physician who actually saw the patient, he states.
"When my company has done manual audits of ED charts, we’ve found that between 29% and 46% of the time, the electronic record has the wrong physician’s name in it," says Karpiel. "Sometimes when you go into the ER, the director’s name is Smith and you’ll find that every patient that comes in that month goes to Smith because it’s the default [name]."
Traditionally, hospitals have not carefully tracked who saw a patient in the ED unless the patient was admitted, Karpiel says. But it is impossible to create accurate profiles for each physician with data that are 29-46% inaccurate.
"Physicians are data-driven beings. If you show them good data, they will read it and respond to it. You show them bad data, and they will find a way to respond to that, too," he notes.
Billing records may not always accurately record the number of ancillary services ordered for each patient, Bukata says.
In most hospitals, nurses are assigned both the task of recording information in a patient’s chart and recording it on the charge sheet, a process that often results in charges being missed, says Bukata.
"The nurses do this poorly [because] their primary focus is patient care and medical records," he says.
After auditing the charts at eight hospitals, his department found that nurses missed an average of $20 per patient chart.
ED groups must have a system in place to ensure that the data used to evaluate a physician will be accurate, say both Karpiel and Bukata.
Two systems
EPMG is using the AMB-Pro (ambulatory profiling) software package as part of a comprehensive cost-containment program that is in the process of being implemented at all 27 of its EDs, says Wong.
AMB-Pro takes the hospital billing files for the ED and the billing records from the physicians’ billing company and combines them to get an accurate picture of the care each physician delivers.
By getting the records from the physician group’s billing company, the program ensures that the correct physician is listed for each patient, even if the data is recorded incorrectly at the hospital, says Karpiel.
Once the data are entered, the program is able to analyze the data and generate reports detailing the physicians’ utilization using standard parameters, Wong says.
The reports rate the physician’s performance numerically using these data fields:
• Average number of items per patientthe total number of items ordered (e.g., drugs, x-rays) divided by the total number of patients seen.
• Use indexaverage number of items per patient for that physician divided by the average number of items per patient for the group.
• Total costtotal charges for items ordered by the physician divided by the cost-to-charge ratio for each item.
• Average cost per patienttotal cost divided by the number of patients seen.
• Cost indexaverage cost per patient for that physician divided by the average cost per patient for the group.
• Case mix indexAcuity for each patient divided by the number of patients seen, with acuity determined by a complex weighted formula based on criteria that include the patient’s age, disposition, number of critical procedures done, and the diagnosis.
• Adjusted cost indexthe cost index divided by the case mix index.
Reports can be generated several different ways, grouped by test, physician, payer, or diagnosis, says Karpiel, who has been licensed by the group to distribute the software to his clients.
"For example, it can tell how many CT scans were ordered on a patient with a chief complaint of a headache during the month of January by Dr. Smith for Medicare patients," he explains.
The physicians are identified by a number, and only the department directors and managers know which doctor has which number. The cost index is also adjusted for the acuity of the patients the physician sees, Wong emphasizes.
Since higher-acuity patients obviously require more ancillary tests, lab work, and medication, the index uses a formula to adjust for acuity to eliminate instances of doctors being "penalized" for seeing sicker patients, he says.
The ED staff at San Gabriel developed a similar program when they took over the task of capturing the department’s charges for the medical center.
Instead of having nurses fill out charge sheets, Bukata developed a software program that would capture the charge data from the hospital chart. The task of keying in the data from the chart was designated to a new staff position, leaving the nurses free to concentrate on patient care, he says.
"Right now, most hospitals probably have four souls involved in data capture for an ER record," says Bukata. "Pharmacy pulls off pharmacy charges, central supply has somebody pull off their charges, some type of nurse puts in the room charges for the use of the facility, and the hospital ICD9 coding and CPT is coding done by someone in medical records. All of this is largely redundant."
By demonstrating that they could have one person collect all of this information and do it accurately, the hospital contracted with the group to take over the service.
The agreement resulted in an unexpected boon for the ED, Bukata says. "We have a database on physician performance that nobody else has."
The program, now known as the Emergency Department Information Tracking System (EDITS), not only collects charge information, it collects a wealth of clinical information at the same time: first and last vital signs, certain key times, length of stay in the department, the name of the physician referring the patient, drugs prescribed, and the tests and supplies requested, Bukata says.
The program not only tracks costly procedures and profiles physician resource utilization, it makes money for the department, proving to be cost-effective in more ways than one.
"We can query this database for management information that’s never been available before, and we’re getting paid for it in the process because we’re getting the hospital’s charge capture at the same time," he states.
Because the department designs the records, ED managers can refine their queries in a number of ways, searching the database by drug, test, diagnosis, or physician.
"The program is kind of designed backward to say, What are the core, key questions we have about physician behavior?’ Prescribing patterns, even though they have nothing to do with hospital charges, are a major factor, so we captured it," Bukata says.
Because the system doesn’t rely on separate hospital records, the way AMB-Pro does, the department can redesign the form for the medical chart to get additional information, he says.
"We capture a lot of stuff that is captured only because we want it for our clinical queries, plus we get all the monthly data and how many patients were admitted and all that other stuff that nurses have traditionally done longhand out of log books."
Data collection is only part of process
Getting information on resource utilization is only the first step in developing an effective cost-containment program, Wong says.
Ahwah and Hodgson combed through the current medical literature to develop pathways that were both state-of-the-art and cost-effective. For each complaint, there is a pathway that is supported by current medical studies listed in an annotated bibliography accompanying the section on that complaint, he says.
"You can change physician behavior, but you have to show them why," he states. "It has to be safe, it has to be good patient care, and the rationale has to be supported in the literature."
In most cases, physicians are ordering too many tests or the most expensive medication because they are trying to "cover every base" or are unaware of the cost of the latest medications.
"Everybody has a different training background," says Wong. "People need a standard medical knowledge base to work from."
When the cost-containment program is implemented at a particular hospital, the physicians get together to discuss the guidelines, developing a consensus about how certain complaints are handled.
"Practice guidelines are supposed to help the doctors order the appropriate tests, not just fewer tests," he emphasizes. "You can over-order tests and you can under-order tests. You don’t hear much about the other side."
Getting results
In many cases, just making physicians aware that they order more tests than their peers is enough to make them alter their behavior and seek new practice patterns, Bukata says.
"Just showing them where they stand is important," he says. "If you tell them they ordered chest x-rays three times as often as [their] peers for a patient who was later discharged, that means something to them."
The EDITS system is currently in use in about 25 hospitals, Bukata estimates, and he has licensed the software to several ED multi-contract groups for use in their departments.
"There are a lot of people who believe data will distinguish ER groups one from the other in terms of how they will be able to manage cases," Bukata says. "We’ve licensed this program to a number of contract ER groups who understand clearly that, for their strategy to grow, they need to profile their doctors, improve their practice, and show their potential clients what their work product is."
In the four years since EPMG began its cost-containment program, it has seen some departments reduce their costs by up to 50%, Wong says. It is essential in a managed care environment to be able to demonstrate how costs are managed, he states.
"Local IPAs [individual practice associations] have all the risks, and if you cost them too much they don’t want to do business with you," Wong says. "If you function inside managed care, you have to be a good managed care citizen, and that means being cost-effective."
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