The use of a risk adjuster can adjust for some of the effects of patient characteristics that may vary across providers. Using a risk adjuster can be a helpful advantage when reviewing and presenting data to physicians in a meaningful, credible manner.
In most risk adjustment tools, the models offered present two perspectives. There is a concurrent model and a prospective model. Each offer different advantages and their use will vary based on the business question or need to be addressed. This post will look take a brief look at the use of concurrent model results in calculating a provider efficiency score. The assessment period is often the most recent 12 months.
The concurrent model is particularly helpful in provider profiling when evaluating patterns or outcomes of practice. Without risk adjustment, one may draw incorrect conclusions, because the physician practice or panel that appears to have the worst outcomes may simply have the sickest patients.
In the example above, while Provider B has the lowest concurrent risk score and lowest actual PMPM cost, their efficiency score is the highest at 1. Depending on your decision support tools and risk adjustment tools, risk scores are also available by service breakouts, such as inpatient, outpatient, and pharmacy. In this example, a further drill to the service categories to monitor the distribution of the costs across the service categories would provide additional insight.
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It also explains why reliability measurement is an important component of evaluating a profiling system. RAND technical reports may include research findings on a specific topic that is limited in scope or intended for a narrow audience; present discussions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research professionals, and supporting documentation; or deliver preliminary findings.
All RAND reports undergo rigorous peer review to ensure that they meet high standards for research quality and objectivity. Permission is given to duplicate this electronic document for personal use only, as long as it is unaltered and complete. Copies may not be duplicated for commercial purposes. Payers look at things a little differently.
UnitedHealthcare, Aetna, Cigna, Anthem - to name a few - all have their own home-grown grading systems. That may include referrals to specialists , prescribing brand-name drugs, use of high-priced emergency room or diagnostic services, or simply what the provider is paid compared to colleagues in the same specialty and region.
If a physician happens to manage special needs or chronically ill patients, or is part of a group or organization receiving preferential rates, then she may not be able to achieve this designation.
This is a hotly debated metric, primarily because of the lack of uniform standards of care for these programs. While there are national standards for treating certain diagnoses such as asthma and diabetes, the application of such standards i. While one payer may use HEDIS metrics to grade physicians, another may use a mix of measures and arrive at a far different outcome for the same provider.
Not all care or every specialty can be measured. Most programs focus on specific types of physicians and services.
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