Physician data: mysteries that can be solved

Resources from the AMA allow doctors to figure out how insurers are determining their profiles.

Posted April 2, 2012.

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Just about every health insurer puts together data profiles on their contracted physicians. The stated goal is to influence doctor behavior and decision-making to ensure better and more cost-effective care for their members. But often, the profiles are ineffective. In large part, that’s because they vary from plan to plan, with the reports’ commonality typically being that they are difficult to read and interpret.

Unfortunately for physicians, these often impenetrable and inaccurate reports can affect their livelihood and reputation. The profiles are used as the basis of pay-for-performance. They are used to place physicians in tiered or narrow networks in which the “best” physicians are the best-rewarded. And they are used as the basis to direct patients to the “top” physicians, as posted on the plans’ own websites.

The American Medical Association has developed resources to bridge this information gap. For physicians, the AMA’s Private Sector Advocacy unit has released “Take Charge of Your Data,” a guide that shows doctors how to mine and use the data reports provided by health plans and other third parties. For all stakeholders in this situation, the AMA has created its “Guidelines for Reporting Physician Data,” which should allow health plans to design data reports that are more accessible to physicians and easier to understand.

The basis for both free resources is the AMA’s Standardized Physician Data Reporting Form, which could be used by all plans to create data profiles. The “Take Charge” guide uses the standardized form to walk doctors through how health plan profiles are put together and how they should be read. The guide shows how physicians can identify general report features, such as the date range for administrative claims data, and how to read and interpret sections on overall performance, quality and cost-of-care reporting.

This way, a physician can identify what information a health plan got wrong, and identify places in the report that point to legitimate tips for practice improvement. While the AMA has policy on the quality measures plans should use and how they should use them, and continues to advocate for that policy, the resource gives physicians the tools to take action on data profiles, and their repercussions, as they now stand.

The hope was that health plans would adopt the standardized form. Many plans, as well as accreditation bodies and business groups are supportive of it. But insurers said they had too much invested in their proprietary forms to make a wholesale switch. As a result, the AMA came up with the “Guidelines for Reporting Physician Data,” which will be formally released during the Association’s June 17-20 Annual Meeting, so that plans may use them to refine their profiles.

The guidelines are designed to encourage greater industrywide standardization of the reporting format and greater transparency of the process used to create reports. Physicians also will benefit from the depth of data available to them, including patient-specific data. As with the standardized reporting form, the guidelines were created with the consultation of physicians, accreditation bodies and the insurers themselves. The documents were developed with the understanding that guidelines could be mutually beneficial to physicians and payers. After all, if physicians don’t understand the forms, they can’t make the improvements insurers seek. Currently, the AMA is seeking formal support from stakeholders for the guidelines.

Meanwhile, the AMA also is working on developing the ability to take insurer-specific payer claims data and have a system convert it into the AMA’s standardized form. That would make it much easier for physicians not only to analyze their own data, but also compare it across insurance companies. There is no release date for that resource, which probably would come at some cost to doctors.

There’s plenty at stake in the data health plans collect and broadcast about doctors. It can be a useful tool, a damaging label or a missed opportunity depending on how it’s handled. That the data as now presented is a mystery to those closest to it — the physicians themselves — is an unacceptable but fortunately a fixable state of affairs.

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External links

Taking Charge of Your Data, American Medical Association (link)

Standardized Physician Data Report, American Medical Association (link)

Guidelines for Reporting Physician Data, American Medical Association (link)

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