Provider Data Analysis

Question 1

Sources of data for provider profiling (6)

Answer 1

1. ) Lab test results
2. ) Biometric info
3. ) Feeds from electronic health records
4. ) Patient satisfaction measures
5. ) Operational information on vendor programs
6. ) Claims system data is major source. Must be standardized and stored in a data warehouse.

Question 2

Provider profiling Data & Analysis (4)

Answer 2

1. ) Identification
2. ) Collection
3. ) Collation
4. ) Analysis of data to develop a characterization of the provider’s performance

Question 3

Data to include in a data warehouse for provider profiling purposes (6)

Answer 3

1. Unique patient identifier
2. Diagnostic information
3. Procedural information
4. Level of service information
5. Paid and allowed dollar amounts from services ordered by provider
6. Unique provider identifier

Question 4

Principles for designing provider profiling reports (9) -F2015

Answer 4

1. ) Identify high-volume and costly clinical areas to profile
2. ) Involve appropriate internal and external customers (including providers) in developing & implementing the profile
3. ) Compare results with published performance
4. ) Report performance using a uniform clinical data set
5. ) When possible, employ external data source for independent validation of the provider’s data
6. ) Consider onsite verification of data from provider’s info system
7. ) Present comparative performance using clinically-relevant risk stratification
8. ) Require statistical significance for comparisons & establish thresholds for min sample size
9. ) Adjust performance measurements for severity

Question 5

Desired characteristics of provider profiles (8)

Answer 5

1. ) Accurately identify the provider
2. ) Accurately identify the provider’s specialty
3. ) Help to improve the process and outcome of care
4. ) Have a firm basis in scientific literature and professional consensus
5. ) Meet certain statistical thresholds of validity and reliability
6. ) Compare the provider to a norm - can be total health plan average results, peers, or budgeted amounts
7. ) Cost the minimum amount possible to produce
8. ) Respect patient confidentiality and obtain patient consent when necessary

Question 6

Validity (of data)

Answer 6

Extent to which the data actually means what you think it means

Question 7

Reliability (of data)

Answer 7

Extent to which the data is consistent and means the same thing from provider to provider

Question 8

Provider profiling uses (5)

Answer 8

1. Payer-provider collaboration initiatives - explain how they compare to their peers and discuss options to improve performance.
2. Payers can use to determine which providers to exempt from prior authorization.
3. Use to equip P4P programs with metrics for bonus calculation
4. Used to set up preferred provider tiers in a PPO
5. Data can be used as basis for PCMH and ACO

Question 9

Customers and users of provider profiles (4)

Answer 9

1. Health plans - provider relations, medical directors
2. Consumers - effective dissemination or profiles still under developed
3. Employers - interested in cost control
4. Providers - interested in change if methods to measure performance grounded in scientific evidence or prof consensus.