Process Improvement For Physicians and Health Plans
[Aligning Incentives Among Stakeholders]
By Brent A. Metfessel
Sometimes when you innovate, you make mistakes. It is best to admit them quickly, and get on with improving your other innovations – Steve Jobs
Physicians and health plans use practice pattern information for a number of initiatives including network optimization; incentive pool, bonus, or withhold distribution; and physician education. Other stakeholders are also interested in physician cost-effectiveness and quality profiles, including health care consumers, employer groups (both self-insured and health plan customers), accrediting bodies (such as the Joint Commission), as well as physicians and others involved in day-to-day patient care.
Health plans, consumers, and employer groups desire to use information from practice pattern profile reports for decision making concerning physicians. There exist several areas where such decisions affect physician practices.
Some MCOs use practice profiles to determine which physicians should be brought into the network, maintained as a network member or given a new level in a tiered network. Some health plans allow from one to three years between when they initiate dissemination of physician profiles and when they use them for network decision-making to educate physicians in the methodology and for practice improvement. A gap between providing initial physician profiles and using them for decision-making may also be provided if there are significant changes or updates to the health plan methodology used for practice pattern profiling, to allow time for education, questions, and feedback.
Practice pattern profiles are not usually used alone in making network status decisions. Other considerations, such as patient satisfaction results, credentialing, and information on possible sanctions must also be considered.
More recently, some health plans have begun using the Web to display physician practice pattern measurement results directly to health care consumers and employer groups that are customers of the MCO. Some MCOs have used a color-coded or symbolic system (such as a stars or check marks) to communicate physician performance results to employer groups and consumers to help them determine which physicians are best for their needs. Several dimensions may be included in a Web-based report, including quality performance, cost-efficiency of practice, patient satisfaction, and other indicators. Web-based physician reporting is a relatively new paradigm and several more years may be needed to fully ascertain its effect on MCO relationships with physicians, employer groups, and consumers.
Another issue in practice pattern profiling is the relative weighting of quality and cost measurement in physician profiles. MCOs are increasingly adopting the “quality first” paradigm; that is, first measuring quality of care then only measuring cost-efficiency for those who “pass” quality. The intent of this paradigm is to avoid measuring cost at the expense of quality, and promoting those who practice both high quality and cost-efficient care. In some systems, those who pass quality only will still get a positive quality grade, and those who pass both quality and cost-efficiency will get positive grades in both areas. Patient satisfaction survey results may result in a third grade. Accordingly, an active research area that is just beginning to be explored is the correlation of quality and cost of care. The initial thinking, based on preliminary data analysis, is that high quality of care may increase cost somewhat in the short run (e.g., by prescribing more recommended long-term controller medications for persistent asthmatics, statins for coronary artery disease patients, and increased monitoring for diabetics as recommended in guidelines).
In the long run, however, costs would be expected to decrease through fewer “sentinel events”, such as emergency room visits and hospitalizations for potentially preventable exacerbations, as well as decreased costs from long-term complications, such as diabetic retinal and kidney disease. To more clearly answer these questions requires large data repositories that cover multiple years of follow-up for each patient in question. Given that many patients do not stay with the same employer or health plan for more than two or three years, initiatives to develop centralized databases across different employers and health plans to track these patients over the long term will be useful for this and other research questions.
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