Clinigence Health Help Desk

This report shows performance of the primary care provider groups of members/patients represented in the population of records in the database, at a detailed level, as compared to their peers (groups in the same specialty) overall.

Target Audience for this Report

Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, Utilization Management, and Sales and Client Relations.

Business Processes Impacted by this Report

Filtering by PCP provides information that supports a targeted approach to provider outreach, education and network management.

Physician specific data in a format that allows comparison of like specialties and member populations are increasingly used as the basis for quality improvement efforts, contracting decisions, and financial incentives.

Public and private health plan purchases are demanding more information about physicians and this can aid in presenting that information to clients or potential clients as well as supporting bids with Medicaid and Medicare Advantage plans.

Individual physicians as well as physician groups are interested in data which they believe represents their performance in a comparative manner.  Using this report with physicians allows them an opportunity to validate and learn about the metrics in order to modify aspects of their practice.

Detail and Definitions

Header

• Provider Group Name
• Score - The overall calculated score is the average percentile ranking of each of the five categories: Cost, Utilization, Quality, Prevention, and Pharmacy.
• Avg Patient Risk
• Panel Size
• Overall Ranking - Example: 10 / 50 – The provider group selected is ranked 10^th out of the 50 other provider groups.
• Percentile (ranking)

Performance Score (Graph) – shows the relative performance increase or decrease (by percentage) of the selected provider group’s performance, by category (Cost, Utilization, Quality, Prevention, Rx) vs all other provider groups.  Bars/numbers above the axis indicate the provider/group is “Better” than their Specialty (by the indicated percentage) in that category.   Bars/numbers below the axis indicate the provider/group is “Worse” than their Specialty (by the indicated percentage) in that category.

• Provider Group performance based on other Provider Groups.
• Performance Categories

Provider Group Ranking (Graph)

• Provider Group Score – shows Provider Group score in relation to the other Provider Groups
• Ranking

Provider Group vs. All Other Provider Groups Performance Metrics

The individual metrics in the Provider Group vs. All Other Provider Groups Performance Metrics, are grouped by category.   Each metric shows the Provider Group performance vs all other Provider Groups.

• Cost: 
  • PMPM – a rollup of PMPM; based on direct and indirect costs
  • Paid/Claim – the amount paid per claim; based on direct and indirect costs.
  • Paid/Admit – Average paid amount per Admit; based on direct and indirect costs
  • % Level 4/5 – Percentage of Level 4 and 5 E&M claims against all office visits for both the Provider Group; based on direct costs
• Utilization:
  • ALOS – the ALOS of the Provider Group’s panel members with admissions., vs.
  • Admissions/1000 – Admissions/panel size * 1000.
  • ER Visits/1000 – ER Visits/panel size * 1000.
  • Lab Radiology/1000 – Lab and Radiology Procedures/panel size * 1000.
• Quality:
  • Readmissions/1000 – Readmissions/panel size * 1000.
  • EKG (%) – Percentage of EKG procedures.
  • Avoidable ER (%) – Percentage of ER visits flagged as avoidable.
  • Complications (%) – Number of complications/panel size * 1000.
• Rx:
  • PMPM – Pharmacy PMPM Costs; based on direct and indirect costs.
  • Scripts/Member – The average number of scripts per member.
  • Brand/Generic – The percentage of brand vs. generic of all.
  • Formulary/Non-Formulary – The percentage of formulary vs. non.  Dependent on receiving the formulary/non-formulary flag on the pharmacy claims.
• Prevention:
  • Breast Cancer (%) – Breast Cancer Screening
  • HbA1c (%) – Hemoglobin A1c Testing
  • Eye Exam (%) – Eye Exam
  • Adult Infl Vac (%) – Adult Influenza Vaccination
  • CAP (%) - (Children’s Access to Care) Percentage completed (of eligible members < 20 years).
  • W15 (%) – (Well visit first 15 months of life) Percentage completed (of eligible members).
  • W34 (%) – (Well visit, 3^rd, 4^th, 5^th, 6^th years) Percentage completed (of eligible members).
  • AWC (%) – (Adolescent Well Child Care) Percentage completed (of eligible members 12 to 21 years.