The report describes physician efficiency of care by comparing a physician’s use of resources measured in cost against the adjusted expected cost of care to create an efficiency ratio.  This ratio is further compared to that of the physician’s peers refined by the user selection of line of business and physician specialty.   Average patient risk, efficiency and cost is displayed in the header which provides additional information for the comparison process.

 

 

 

Target Audience for this Report

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

 

Business Processes Impacted by this Report

Physician performance measurement of cost-efficiency provides an opportunity to improve based on benchmarking their cost-efficiency and quality performance against that of their peers using objective indicators.  The Medical Management Department can create presentations using this report - and others in the QMX platform - that focus physicians in their improvement strategies.

 

Goal setting by the health plan medical management and physician advisory group is essential to assist physicians in the network in creating strategies for improvement.

 

Network evaluation and strategic planning are informed by efficiency data.  When combined with other metrics physician groups/individuals can be measured and compared to determine where to place a physician in the network - e.g. preferred vs a lower tier.

 

Physicians control a substantial portion of health care utilization and require data to understand the cost impact of their care.  While they do not control the plan fee structure they can impact referral patterns and utilization.  At the same time the health plan can use this data in combination with other metrics to evaluate their pre-authorization processes and controls that impact utilization.

 

Details and Definitions

“Specialty” is the NPI taxonomy of the provider (servicing provider on claims). 

 

“Group” is the group name associated with the provider in the NPI database.

 

“Total Actual Cost” is the total cost for the reporting period.

 

“ACG Expected Cost” is the predicted cost for that providers based off of the diagnoses associated with the provider’s patients.

 

Providers below expected cost will be assigned a score of 1.0 or less and are sorted from best to worst in the list.

 

Report data is based on the most recent 12 months of claim details.

 

Selecting a row in the PCP Group by Efficiency of Care table will filter the PCP by Efficiency of Care table to only providers assigned to the selected group.

 

Header

  • Specialty
  • Patient Count >=
  • Avg Patient Risk
  • Avg Specialty Efficiency Ratio

 

Best Performing PCP Group by Efficiency of Care

  • Group
  • Providers
  • Patients
  • Actual Costs
  • ACG Expected
  • Act/Exp Ratio

 

Best Performing PCP by Efficiency of Care

  • PCP Name
  • NPI
  • Patients
  • Actual Costs
  • Expected Costs
  • Act/Exp Ratio
  • Efficiency Ratio

 

Lowest Performing PCP Group by Efficiency of Care

  • Group
  • Providers
  • Patients
  • Actual Costs
  • ACG Expected
  • Act/Exp Ratio

 

Lowest Performing PCP by Efficiency of Care

  • PCP Name
  • NPI
  • Patients
  • Actual Costs
  • Expected Costs
  • Act/Exp Ratio
  • Efficiency Ratio

 

Provider Group (Graph) – Shows the percentage of patients in each patient risk category (Healthy, Low, Moderate, High, Very High)

 

Specialty (Graph) – Shows the percentage of patients in each patient risk category (Healthy, Low, Moderate, High, Very High)