Mc-Chpt 32Using Data In Medical Mgmt; Provider Profiling

Front 1

THE USE OF DATA AND INFORMATION IN MEDICAL MGMT
User Needs:

Back 1

 Quick access to data
 Ease of use
 Flexibility
 Compatibility with other programs
 Consistency
 Simple Format (graphs; outliers and averages visible)
 Clean Data
 Case mix / severity mix adjustment should be built in
 adequateness of Sample Size or Time Period
 statistical significance p displayed
 decide which reports are routine? Which ad hoc?

Front 2

Patient data Confidentiality

Back 2

 HIPAA regulates security of patients’ info; penalties for unauthorized use

Front 3

Sources of Data used in Medical Mgmt and Provider Profiling

Back 3

(This section is called “Data Elements and the Application of Reports” in Kong 32.)

 Quote the whole General – “An MCO’s Internal Data Sources” list.
 Performance Reports
Whole Plan Average Report
Advantages
 relates to plan’s financial performance
Disadv:
 Ignores specific causes

Individual Physician Profile Report
Disadv:
 Physicians feel that extenuating circumstances are ignored
 so, Pay attention to the statistical significance;
 Adjust for phys’s case mix

Premium Source Group Report
 Tracks utilization by enrolled group.
Advantage:
 uncovers problems with a particular er group.

Hospital Report
 Daily Logs (best for UR)
 Monthly Summaries

Outpatient Utilization Report
Reporting in Open Access Plans
 hard to monitor utilization, b/c no specified patient base.

Front 4

PROVIDER PROFILING
Uses:

Back 4

 feedback reports (to help them modify their behavior)
 choosing the best providers / getting rid of bad ones
 improving quality

Front 5

Characteristics of Good Provider Profiling Reports

Back 5

 be cheap to produce
 identify high volume and high cost areas
 involve internal and external customers
 involve the providers
 compare data to an external norm
 Accurately identify the provider / specialty type
 use Scientific Criteria (have concensus)
 include the statistical significance (p-value)
 Adjust for Case Mix and Severity Mix, and demographics
Sources of Case Mix and Severity Mix Data
 Ambulatory visits; inpatient; entire episode; nursing home episodes; intensive care episodes

Done.