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"PAR serves to provide each physician with an accurate picture of his or her practice," says Donald Balfour III, MD, president and medical director of Sharp Rees-Stealy. "Coupled with incentives, it gives physicians the capability of improving skills and productivity. It is not used as a tool for discipline but rather as a tool to assist physicians and management in working together to build and maintain an organization that will survive the fiscal challenges of a changing marketplace."
"We have an open house on a regular basis where health plans can come in and look around," says Balfour. "When they come in and see this report, they just love it."
Pleasing health plans was the reason behind creating the computerized physician profile in the first place. In 1993, the medical group was operating under value-based incentive programs with a number of HMOs. This means the revenue it was receiving from these HMOs was based, in part, on quality measures. In short, some HMOs required the group to prove it was providing quality care.
The group had to find a way to get its departments — information management, quality management, administrative services, patient liaison, risk management, scheduling, and utilization management — to report the information to a central quality management department, which produced the computerized physician profile.
The group had placed its physicians at risk in hopes of aligning physician incentives with that of the medical group’s. Sharp Rees-Stealy adopted a system where departments of physicians are capitated.
But the group felt there was a need to promote quality and hold physicians accountable for the care they deliver. PAR was designed to evaluate physician performance based on principles of total quality management.
"The report demonstrates that we care about quality," Balfour says. "Not only do we measure quality, but we make improvements based on our findings."
Patient satisfaction results since the group implemented its physician profiling system in 1994 show the rate of "satisfied" and "very satisfied" patients has increased from 90% to 93%.
The group benefited from the fact that it already had a sophisticated information system in place to handle its claims and patient encounter data. Data collection is handled internally. The only additional cost (other than employee work time) is $70,000 per year for an outside firm to handle patient satisfaction surveying. Sharp Rees-Stealy also hired an outside consultant to write the computer application that allows it to download the needed information and convert it to readable format.
Liz Paxton, MA, senior quality analyst for Sharp Rees-Stealy, says the most important data the group measures for primary care physicians fall into the following categories:
• Chart reviews. Each physician is required to review colleagues’ charts and, based on a set of criteria, determine whether the charts are satisfactory. The percentage of satisfactory chart reviews is reported.
• CME hours. Physicians are responsible for reporting CME credits to administrative services.
• Patient satisfaction. At least one patient per physician is surveyed each month by the contractor, and the results are reported to the quality management department.
• Access complaints. Each time a patient complains about difficulty in making appointments, the scheduling department reports the incident to quality management, and it is entered into the profile.
• Written compliments. Praises of a physician are passed along by the patient liaison coordinator.
• Liability claims. Claims against a physician, such as a malpractice suit, are reported by the risk management department.
• Internal transfers. Each time a patient leaves a primary care physician for another, it is noted. The data are tracked by the organization’s computerized information system.
• Panel activity. The report notes the total number of patients in a physician’s panel and gives an adjusted patient panel total to reflect illness severity.
• Encounters. The information system also tracks the number of patients each primary care physician sees based on charge tickets submitted by physicians.
• Active panel visits. The report illustrates, in percentages, how many of the encounters from within a physician’s patient population were made with the physician, another primary care physician, midlevel practitioner, Sharp Rees-Stealy specialist, or urgent care. The data are gathered from the group’s information system.
• Resource utilization. This information, reported by the utilization management department from stay sheets from institutional facilities, shows the cost of referrals the physician made and average length of stay in acute and skilled-nursing facilities.
• Peer review. The result of annual site reviews, peer surveys give scores in the following categories:
— promotes teamwork;
— appropriateness of care;
— likelihood of patient referral.
Specialists are profiled in a similar manner. Because they rely on referrals for their patient base, their panel is measured on a per-1,000-visit basis, Paxton says.
Sharp Rees-Stealy administrators regularly review the reports, and each physician receives his or her own profile every quarter. Aside from providing snapshots of individual physician performance, the system gives administrators a basis for comparison among the group’s various sites.
"Averages for an entire site or department can be viewed on a single screen," says Balfour. "Trended studies of specific indicators for a particular department, division, or site can also be accessed and compared with historical data."
The report also helps the group keep up with credentialing and keep a watchful eye on malpractice and liability trends. For instance, if a physician profile indicates an inordinate amount of liability claims, administrators are prompted to take the matter up with the risk management department.
Balfour admits that the size of his group places it at an advantage to build a computerized physician profiling system and to collect data, but he says profiling is an essential part of any practice involved in capitation.
Capitated physician practices today are under increased pressures from HMOs to provide quality data as well as to reduce the cost of care. Consumers are increasingly afraid that quality of care will be compromised as a result of managed care’s cost-containment aims.
Many capitated practices have skimpy information systems. Nevertheless, Balfour advises physician groups to make the necessary investments and move toward physician profiling. "Not every group can measure 34 criteria. But they can start measuring with data they already have," he says.