HSC 572 Study Guide - Summer 2018, Comprehensive Midterm Notes - Quality Management, Pdca, Nursing
HSC 572
MIDTERM EXAM
STUDY GUIDE
Fall 2018
HSC 572 Physician and Provider Profiling
What is physician profiling?
-process used in an attempt to constrain spending and reduce inpatient length of stay
-the practice pattern of physician or group is expressed as a measure of the use of resources
and or length of stay during a defined period for the population served
-creates a way to compare physicians and allow payers to compare networks, groups, and
individual physician physicians with metrics that track quality, utilization, cost, and prescribing
practices against group, network, and national benchmarks
-showing physicians how their performance compares to other physicians to improve clinical,
quality and cost related outcomes
Why physician profiling?
-shown to be a major contributor to unexplained clinical variations in healthcare
-collection of provider-specific and practice level data used to analyze physician practice
patterns, utilization of services, and outcomes of care
-in response to public demand for greater physician accountability, initial attempts to change
physician behavior resulted in these report cards.
-the goal is to improve physician performance through accountability and feedback
-decrease practice variation through adherence to evidence-based standards of care
Scope and Use of Profiling in Healthcare
Value based purchasing:
-included in the ACA is a requirement for increased measurement and public reporting of
doctors and hospitals performance
-many employees receive health insurance through their employers, employers have a stake in
purchasing high quality care
-evidence is growing that healthcare buyers are beginning to use value-based purchasing to
make healthcare decisions
-efforts to determine quality measures for hospitals and healthcare plans are now being
expanded to include physicians through the centers for Medicare and Medicaid services (CMS),
Physician quality reporting system (PQRS) program
Scope and Use of Profiling in Healthcare
-the PQRS iitiated i ’07 as a oluta poga is ke ude CMS’s alue-based purchasing
strategy
-common strategies that large employers use to compare quality among physicians and
hospitals include asking health plans to identify low-cost physicians and hospitals and
encouraging their employees to seek care from these providers
-these strategies have a significant effect on physician practice patterns and decision making
find more resources at oneclass.com
find more resources at oneclass.com
Profiling as Part of Continuous Quality Improvement
-physician profiles are a valuable educational tool and is one of the many tools used in CQI
-numerous studies have documented that when presented with info on their performance
relative to that of their colleagues, doctors will change behavior to meet a specified outcome
-as part of CQI strategies, healthcare organizations use many mechanisms to maintain the most
competent physician staff
-new standards in healthcare continue to evolve in response to new research and treatment
options
-organizations can use physician profiles to compare various processes and determine the most
efficient, cost-effective way to practice medicine
-an organization using physician profiles must adopt a commitment to CQI
-A quality improvement committee should
–identify the areas most appropriate for profiling and the areas in which it wants to
Improve performance;
–identify the techniques it will use to gather and disseminate data;
–develop an objective and appropriate way to interpret the results;
–communicate the results in a way that will be most valuable for physicians; and
–schedule meetings on a monthly or quarterly basis so that physicians have the
opportunity to provide input on how the profiling system is working.
Scope and Use of Profiling in Healthcare
Profiling as part of continuous quality improvement
-Credentialing: refers to the process of hiring a well-qualified medical staff that is able to deliver
the highest quality care. Physicians are offered positions based on criteria such as peer reviews,
board certification, and hours spent in continuing medical education.
-Physician report cards: compare physicians on outcomes related to measures such as quality,
patient satisfaction, and cost-utilization patterns
-Benchmarking: uses quantitative measures of best practices to evaluate physician performance
Keys to success:
•Healthae ogaizatios a use phsiia pofiles as a aluale educational tool.
•Pofiles poide phsiias ith the ifoatio to deteie hih oditios the ae
treating appropriately and how they compare against set benchmarks or with their peers.
•Wok losel ith phsiias
•Deteie a tie fae fo all physicians to review the information before the profile
becomes an official tool of the organization
•Ogaize ultiple eduatioal sessios
•Poide phsiias ith ieties
•Use a pofile sste that is ot theateig
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Process used in an attempt to constrain spending and reduce inpatient length of stay. The practice pattern of physician or group is expressed as a measure of the use of resources and or length of stay during a defined period for the population served. Creates a way to compare physicians and allow payers to compare networks, groups, and individual physician physicians with metrics that track quality, utilization, cost, and prescribing practices against group, network, and national benchmarks. Showing physicians how their performance compares to other physicians to improve clinical, quality and cost related outcomes. Shown to be a major contributor to unexplained clinical variations in healthcare. Collection of provider-specific and practice level data used to analyze physician practice patterns, utilization of services, and outcomes of care. In response to public demand for greater physician accountability, initial attempts to change physician behavior resulted in these report cards. The goal is to improve physician performance through accountability and feedback.
