Evaluating Clinical Outcomes to Distinguish High-Performing Physicians

Posted on 12.02.14

The first in a three-part blog series looking at what characteristics make up best-in-class physicians

The words “high-performing physician” may be easy to say, but how do you find one? And how do you recognize one, when he or she does cross your path?

In order to determine which physicians to include in Harbor Health Systems’ One MPN, clinical and behavioral outcomes are examined in order to find the best-in-class physicians.

When Harbor Health Systems examines what makes a physician “high-performing,” we came up with the following four characteristics to review:

  • Clinical outcomes
  • Behavioral outcomes
  • Quality of office interaction
  • Fulfilling Regulatory requirements

When examining a physician’s clinical outcomes to determine whether they are high-performing, these criteria must be part of that analysis:

  • Review their case mix/stratification
  • Compare to like specialties within the same jurisdiction. If you’re a California physician, you’re only being compared to other California physicians in that jurisdiction. There are also different guidelines for each state, so it makes sense to compare physicians in the same jurisdiction.
  • Drill down into tertiary specialties (tight groupings of similar practices). Harbor has identified certain CPT codes to help drill down to tertiary specialties, for example, spinal surgery CPT codes. Spinal Surgery CPT codes, done in a certain frequency by a physician will yield that physician to be a spine surgeon. Whether their primary certification is orthopedics or neurology, if they’re identified as a spine surgeon, that’s what they’re compared to. Harbor has identified nine different tertiary sub-specialties.
  • Define inclusion by actual treatment codes in claims and bills
  • Look at statistical measures of claim and paid data
  • Review claim duration. Claims have a beginning, a middle treatment period, an observation period, and an ending. Claims left open because an injured worker is reticent to have the claim closed is a real problem – it’s important to have a claim duration that’s reasonable and to have that claim closed after appropriate treatment.
  • Analyze the incurred total expense. Depending on what you look at today, Harbor has seen figures where the medical spend is 45 to 65 percent of the total claim cost. That’s a big portion of which Harbor controls, and there are also indemnity costs. So Harbor is actually responsible at looking at the total cost of the claim.
  • Examine TTD days. Getting someone back to work and increasing activities will shorten treatment and yield better results.
  • Note the litigation rate of that physician. Some injured workers will favor litigation regardless of the quality of care provided, and Harbor looks at the outliers. If you have a podiatrist, for example, where the podiatry litigation rate in California is eight percent, and this particular individual has fifteen percent, this is an outlier and we look into this as a pattern of practice.
  • Review the recidivism rate. Recidivism, the reopening of the claim once it’s closed, is an important factor to consider. The industry only wants to pay for appropriate and necessary medical care but cutting things short and closing a claim is going to cause recidivism, so Harbor examines that too.

Looking at these various clinical factors will help to determine whether a physician meets Harbor’s requirements to be included in the Harbor One MPN, and whether these physicians can truly be considered high-performing.

Selecting the best doctors means you can be confident your injured workers are always in the best hands.

Stay tuned for our next blog which will take a closer look at behavioral outcomes of high-performing physicians.

To learn more about how Harbor Health Systems can help lower claims costs for your organization, contact us today at (949) 273-7020.

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For more information, please contact info@harborsys.com