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4-step process to identify high-value primary care providers

Karen Way, Health Plan Analytics, Consulting Practice Lead, NTT DATA
Written by: Karen Way

The goal of healthcare providers is to deliver quality care. However, with recent regulatory changes, as well as evolving technological capabilities and collaborative work environments, healthcare models are being challenged and profitability has been impacted.

To improve profitability without sacrificing benefits or raising premiums, providers should steer members to high-value primary care practices.

Research by The Peterson Center on Healthcare and the Clinical Excellence Research Center at Stanford Medicine found that using a collaborative team approach to patient-centered care, high-value primary care practices can help prevent complications and hospitalizations that drive up the cost of chronic disease care, which lowers total spending per patient.

By identifying and increasing the number of high-value primary care teams in a provider network, costs can be controlled without compromising quality and benefits.

What is a high-value primary care team?
High-value practices are based on teams of caregivers, all practicing at the top of their licenses, which is why the phrase “primary care teams” is emphasized over “primary care physicians.”

By utilizing a collaborative team-based approach, physicians have more flexibility to focus on the complex needs of chronically ill patients, while PAs or APRNs manage the daily routine needs of patients.

This management style of shared responsibility is at the heart of the teams’ ability to reduce overall costs. Not only will this minimize the need for hospitalizations and specialist referrals, but it will also provide constant monitoring and improve patient well-being.

Identifying teams using analytics
In order to identify high-value primary care teams, quality and cost of care must be analyzed, which is now more readily available due to regulatory pressure.

Use the following four-step process to identify high-value primary care providers.

  • Designate patients to appropriate healthcare providers.
    Attributing patients to specific healthcare providers narrows the overall list of possible high-value primary care teams. While there are several methods for attribution, one useful method from the Centers for Medicare & Medicaid Services (CMS) attributes patients for the creation of the Quality and Resource Use Reports (QRUR’s). The high-value primary care team vetting process will include specialists who care for people with specific chronic diseases such as kidney failure, congestive heart failure or diabetes. These specialists will need to be sorted from primary care physicians, and used for comparison against peers to identify high-value members within a particular field.
  • Calculate clinical performance rates for quality care analysis.
    Organizations can use their own means for measurement, or use pre-defined measure sets such as Healthcare Effectiveness Data and Information Set (HEDIS) or Medicare Advantage Stars ratings. While this data is reported at the health plan level to CMS and the National Committee for Quality Assurance (NCQA), these results can be implemented at the provider level as well. In fact, more than 90 percent of all U.S. health plans use HEDIS to report data to maintain their accreditation by NCQA.
  • Assess the annual cost per patient for each healthcare provider.
    Cost per patient is relative and can be calculated in many different ways. Due to this indefinite variable, it’s useful to refer to existing measurement practices (such as that found in QRUR reports) or use relative value units (RVU’s) when calculating annual cost per patient. The primary factor for determining total costs involves the risk levels for each patient. To establish a baseline for cost data comparison, physicians should be compared in regard to practice similarities. For example, a physician who treats older patients with heart diseases is likely to have a higher annual cost per patient than a physician who treats younger patients with asthma.
  • Use quality of care and the cost per patient findings to rank healthcare providers.
    By establishing who can deliver higher quality care scores at lower patient costs will determine high-value providers. However, do not expect to see large numbers of high-value teams. The Peterson Center on Healthcare study referenced initially surveyed approximately 15,000 practices and was able to identify only 11 that met high-value criteria. Results will vary based on the methodologies used and whether the comparisons are conducted between providers in the healthcare plan or against national benchmarks. Either way, expect the numbers to be small.

What to do after identifying the high-value primary care teams?

Once the high-value primary care teams have been identified, there are several opportunities to use the data to benefit organizations and health plan memberships. Start by informing members about high-performing practices and the benefits available – most notably lower out-of-pocket expenses for high-quality healthcare.

Since not all potential patients will fit the criteria of these practices, sharing this collaborative, team-approach with other providers will hopefully have a trickle effect on how those providers work with patients as well.

The combined use of financial incentives, investments in support services and establishment of performance standards can also encourage physicians to improve their practices and personal approaches. For example, several health plans have already adopted incentive programs for providers, such as Humana, United Healthcare, BCBS of Minnesota and WellPoint. Pennsylvania-based Highmark is the most recent insurer to offer such a program.

Determining which high-value primary care options to choose from may involve additional data analysis; however, it will lead to more efficient health plans with a diverse network of high-value primary care teams. This in turn will benefit everyone from patients to providers, as the healthcare industry lowers costs while moving from fee-for-service to value-based care.