Efficiency and Quality Measurement

Example Project: Improve Efficiency of Practitioner Network

We have worked with leading health plans and physician-hospital organizations on improving the efficiency and quality of their practitioner networks. In this capacity, the audit of each practitioner’s medical claims data and charts focused on quality of care and cost-effectiveness of service delivery–two components of care that are inextricably linked because patients are often subject to health risks associated with unnecessary procedures and tests. In each case, a consistent, valid method for measuring practitioner practice patterns variability was employed.

On one assignment, we worked with a large health plan and employed a well-published, claims-based episode of care methodology to identify dermatologists, orthopedists, and cardiologists that had a significantly different practice pattern from their immediate peer group. A subsequent chart audit validated the medical claims results. Several practitioners from each specialty type were eventually deselected from the network.

Experience

  • Developed a patented system that integrates all inpatient, outpatient, ambulatory, and prescription drug claims data into episodes of care by medical condition (Cave et al, Patent Number 5,970,463). The system was designed to accurately and reliability measure practitioners’ efficiency and quality of care.
  • Worked with health plans and physician-hospital organizations to evaluate practitioners’ efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.
  • Familiar with the any willing provider laws, freedom of choice laws, and the Health Care Quality Immunity Act.
  • Worked with health plans and physician-hospital organizations on strategies to improve practitioners’ practice patterns through feedback programs, and to deselect practitioners’ from networks.
  • Performed speaking engagements for trade organizations on practitioner efficiency and quality measurement, and published many articles in peer-reviewed journals and trade journals on the topic.
  • Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology–providing a strong clinical, statistical, and methodological background.