Physician Profiling

Physician profiling is used by payers to steer their members to in-network physicians who, by their measures, are the most cost-efficient and provide the highest quality of care. Wonder if you’ve made the grade? Look yourself up in a provider directory: if you see a star or two beside your name, you’ve been profiled.

Who’s profiling?

Not every insurer is profiling physicians yet, but there are several other entities that do. And while some rely on feedback from consumers that may be based on popularity - for example, Health Grades and Zagat - several states have their own databanks of information available to consumers based on less anecdotal measures, such as licensing backgrounds and disciplinary information. Administrators in Medicine (docboard.org/aim) goes a step further and catalogues every states’ data in one database, DocFinder.

Payers look at things a little differently. UnitedHealthcare, Aetna, Cigna, Anthem - to name a few - all have their own home-grown grading systems. Some of the more widely known commercial programs include: UnitedHealthcare’s Premium Designation, Aetna’s Aexcel program, Cigna’s Care Network, and Anthem’s Blue Precision. These companies use claims data to determine both “efficiency” and “quality” across several specialties.

How does the grading work?

Efficiency. When assessing efficiency, payers compare a physician’s data to their local market benchmarks for cost of resources used in delivering healthcare. That may include referrals to specialists, prescribing brand-name drugs, use of high-priced emergency room or diagnostic services, or simply what the provider is paid compared to colleagues in the same specialty and region. If a physician happens to manage special needs or chronically ill patients, or is part of a group or organization receiving preferential rates, then she may not be able to achieve this designation.

Quality. This is a hotly debated metric, primarily because of the lack of uniform standards of care for these programs. While there are national standards for treating certain diagnoses such as asthma and diabetes, the application of such standards (i.e., evidence-based medicine) to care management varies from payer to payer. While one payer may use HEDIS metrics to grade physicians, another may use a mix of measures and arrive at a far different outcome for the same provider. Others, such as Anthem, offer a simpler solution and designate quality measures based on completion of a performance assessment program sponsored by either the National Committee for Quality Assurance (NCQA) or Bridges to Excellence (BTE).

What specialties and kinds of care are profiled?

Not all care or every specialty can be measured. Most programs focus on specific types of physicians and services. The most common specialties for profiling are cardiology, allergy, endocrinology, family medicine, internal medicine, pediatrics, OBGYN, nephrology, neurology, orthopedics, pulmonology, rheumatology, and infectious disease. Diagnoses monitored include all of the major heart, lung, and organ diseases; the most prevalent viruses and inflammations; screening for cancers and depression; and immunization compliance rates.

How do I manage my profile?

If you are selected for payer profiling, you will receive feedback from the plans on your scores in these quality and efficiency areas. Reports include details on the patients used for scoring purposes and the data used to arrive at the scores. Pay attention to these reports and act on them! While it may read like Greek at first, once you get used to the format you will be able to validate or refute the findings. Employers and consumers are being incentivized, in the form of lower copays and coinsurance, to use these “narrow network” physicians. So ignoring negative scores may have a real impact on your practice’s bottom line. Now and in the future.

Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.