The document outlines a provider profiling approach for health plans, detailing methods to create comprehensive performance profiles of healthcare providers based on metrics like care gaps and quality outcomes. It emphasizes the importance of transparent scoring processes, accurate data usage, and continuous improvement to engage providers and enhance healthcare delivery. Challenges such as patient assignment and communication are also highlighted, alongside references to various guiding principles and studies in the field.

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Provider Profiling
Approach document for Health Plans
By Roshan Venugopal
Abstract
Provider profiling creates a 3600 profile of a Provider, which details valuable
performance information about their practice like care-gaps, cost of care and
average quality outcomes (based on member claim history). It also benchmarks
providers against their peers to provide an overall rank and rating group (1-3 stars).
This document attempts to describe approach towards provider profiling.
Introduction
With the focus on ever increasing healthcare costs, various stakeholders like
Employer groups, Members and Payers are focusing on getting most value with best
quality outcomes. This has led to increased focus on ranking providers into best
performing, average and least performing categories within their networks and
incentive pay based on quality improvement. Provider groups are requesting
ranking and scoring as they look to improve their relative performance and improve
member health. But there is also resistance from the provider community on some
of these ranking methods as a lot of healthcare dollars are earmarked based on
these ranking.
For a successful provider-profiling program/campaign, the quality of reported data,
measures used and the scoring algorithm must be beyond reproach.
 Clear Purpose: The purpose of profiling should be well defined and clearly
communicated to all stakeholders, particularly providers. Care must be taken
to ensure this process is not seen as punitive.
 Program Definition: Accurately define the measures identified in the scoring
process and make the scoring process transparent to providers. Request
feedback from Physician groups and Patient advocates on setting up
measures.

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It’s advisable to use measures already endorsed by standard committees like
NQF's Quality Positioning System, which list’s all measures endorsed by
various national groups.
Also communicate on the rewards and penalties of the scoring process.
Action to be taken on low quality or at risk providers must be explained and
must be transparent from day-one.
 Provider Outreach is most critical to ensure the program’s success. The
Provider relations communication team must approach this with utmost
planning and ensure local representatives of Physicians organizations,
Hospital Executives and Practice directors are informed about the motive
and scope of the profiling.
See AMA’s flyer regarding Physician Profiling and how Physicians need to
prepare.
 Actionable measures: Ensure each of the measures used in the scoring
process is actionable, clear and under control of the physician. This will
enable them to work on improving measures in which they are lacking.
 Ensure scoring process has a tie-in to the existing Appeals and Grievances
workflow process. This will enable the Physicians to provide fast feedback
about issues in profiles and keep them involved in the process.
 Robustness of source data: The source data (Claims, member feedback, Chart
reviews, Surveys etc) used for the scoring process must be scrubbed and
verified before using for scoring. The Physician must be able to dig into the
measures and understand the data sources used for each scoring. The data
cleansing process if explained to the physician would also help alleviate their
worries regarding wrong data.
 Statistical correctness: Scoring and Ranking algorithms must ensure
statistical correctness and must undergo rigorous testing before publishing
results. The initial results can be kept specific to providers actively
participating in the program.
Physicians must be ranked in their peer specialty group. Care must be taken
to limit scoring and ranking (sample size) for Physicians with members less
than 5 or claim history less than 6 months for statistical accuracy. Age of
members also must be considered in scoring and ranking.
 Member outreach: Identify members with care-gap issues and plan
communications and health related incentives to improve health. Ensure

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Physicians are informed about the about the outreach process and actively
involve them in the process
 Continuous improvement: All parts of the program including the measures,
algorithms, communication and reports must be geared towards accepting
feedback and continuous improvement. This is required to achieve improved
results and to ensure active participation from the physicians.
Once the Profiling program has successfully initiated, communication with provider
community has to be further increased with workshops, webinars and site visits to
the health plan offices followed documentation on understanding reports and
dashboard and how physicians can improve their rank and reduce their members
care gap and cost of treatments.
Challenges to take care in Provider profiling campaigns are
 Patient Assignment:
 Physician Attribution and responsibility for the episode of care
 Exclusion of patients
 Member communication
 Provider Contracts
 Geo-location and associated cost variances
 Specialists vs PCPs
References
 American Academy of Family Physician’s Guiding Principles for Physician
Profiling
 Value Behavioral Health of Pennsylvania's Provider profiling and action
taken report for 2012
 Highly quoted Technical paper from Rand Corp on (lack of) reliability of
Physician profiling. By John L. Adams, Ateev Mehrotra, Elizabeth A. McGlynn
 CMS white paper on Risk Adjustment of Medicare Capitation Payments Using
the CMS-HCC Model

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 CMS white paper on Profiling Efficiency and Quality of Physician
Organizations in Medicare by Gregory C. Pope, M.S. and John Kautter, Ph.D.
 Pay for Performance in Health Care: Methods and Approaches by Cromwell,
J., Trisolini, M.G., Pope, G.C., Mitchell, J.B., Greenwald, L.M.
 Provider Profiling: Implementation Issues within Florida MediPass by
Virginia A. Schaffer, MA Allyson Hall, PhD