reports

Provider profiling: implementation issues within Florida MediPass

Gainesville, FL, USA: University of Florida.

University of Florida, Gainesville, FL, USA

Provider profiling use epidemiological methods to compare physician practice  patterns across various dimensions of care. These dimensions of care may include length  of stay, procedures ordered or cost per diagnosis – related group (DRG). The premise  behind provider profiling is that physicians with appropriate information will change the  way they practice in order to conform to acceptable guidelines thereby improving the  quality of care. Increasingly, managed care organizations and other delivery entities are  using provider profiling as a means to understand and control costs.

This report provides the Agency for Health Care Administration (AHCA) with  important conclusions made from reviewing literature regarding provider profiling  programs. Findings from interviews with key informants, state Medicaid agency  officials, and physicians are also provided to highlight the important conclusions and  implications of implementing provider profiles.

Specifically, areas of concern for the current AdvancedMed profiling system used  by AHCA would be the time lags associated with data used to compile provider profiles,  the current configuration of reports and its usefulness for providers, and the level of input  Medicaid physicians have on the design and implementation of the provider profiling  program. As AHCA considers the implementation of provider profiles within its  Medicaid program, the following guidelines are critical to assuring some level of success:

• The initial emphasis should be on quality improvement

• Performance measures should be clinically important

• Accountability for performance should be limited to patients and services for which physician is directly responsible

• Adequate risk and case mix adjustment must be incorporated in the program design with accompanying explanation of how data was adjusted

• Physicians should be involved early in the design and implementation of provider profiling strategies in order to generate ‘buy-in’

• Performance reports should be clear and easy to understand and coupled with provider feedback and educational opportunities

• Provider profiling programs should make every attempt to use accurate data