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The Key to Health Care Innovation: Provider Centric Information

The Key to Health Care Innovation: Provider Centric Information. January, 2005. Lifting the “Veil” on Provider Effectiveness. Tools and data better, more available Comprehensive array of data about physician behavior support more targeted actions

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The Key to Health Care Innovation: Provider Centric Information

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  1. The Key to Health Care Innovation:Provider Centric Information January, 2005

  2. Lifting the “Veil” on Provider Effectiveness • Tools and data better, more available • Comprehensive array of data about physician behavior support more targeted actions • Objective data: Physicians of same specialty do not practice alike and do not produce same outcomes • Challenge: How and where to apply in healthcare decision making process? Should accountability be fostered or pushed?

  3. Stratifying Physicians by Efficiency

  4. What is an Episode of Care? Known Period Definition of an Episode:All the services associated with a particular disease or condition, including facility and pharmacy charges

  5. How Specialties are Stratified by Efficiency of Care Delivered • Providers are compared to their Specialty Peers • Each specialty is stratified into a normal distribution (bell curve) by the Efficiency Index • Efficiency Index is a measure to the extent a provider is more or less costly at treating their specific mix of patients based on episode of treatment group (ETG) Specialty Distribution Providers more Providers less efficient than specialty efficient than specialty average average <1 1 >1 Efficiency Index

  6. Cardiology Profile Average Cost for Commercial Member: $524 Target for further evaluation and potential intervention - Data set = 1 year - No institutional costs - Medical cardiology only (i.e. “like” physicians) - Normalized for fee schedule differences

  7. Nuclear Stress Test Study Stress tests account for 36.9% of all Cardiology non-E&M(office visit) costs The rate of nuclear stress test in NE is higher than expected as compared to normative data 13.3% of all Connecticut members had an office nuclear stress test Target for further evaluation and potential intervention - Data set = 1 year - No institutional costs - Medical cardiology only - Normalized for fee schedule differences

  8. Practical Applications in the Market • New Products • HSA • HRA • Tiered Copays • New Network Designs • Concentric Networks • Non-renewal actions • Termination acceptances • “Providers of Excellence” • Reimbursement Changes • Positive reward (pay for performance) • Negative consequences • Case rates focused on abherencies • Utilization Management Designs • Education/Awareness • Privileging • Gold Carding • Combinations

  9. The Future • Use of tools and resulting information here to stay • Demands and designs of consumers and providers to understand information will only grow • Speed with which this revolutionizes health care is function of time it takes consumers and providers to constructively embrace

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