Efficiency and Quality Measurement

Example Project: Improve Efficiency of Practitioner Network

We have worked with leading health plans and physician-hospital organizations on improving the efficiency and quality of their practitioner networks. In this capacity, the audit of each practitioner's medical claims data and charts focused on quality of care and cost-effectiveness of service delivery--two components of care that are inextricably linked because patients are often subject to health risks associated with unnecessary procedures and tests. In each case, a consistent, valid method for measuring practitioner practice patterns variability was employed.

On one assignment, we worked with a large health plan and employed a well-published, claims-based episode of care methodology to identify dermatologists, orthopedists, and cardiologists that had a significantly different practice pattern from their immediate peer group. A subsequent chart audit validated the medical claims results. Several practitioners from each specialty type were eventually deselected from the network.

Experience

• Developed a patented system that integrates all inpatient, outpatient, ambulatory, and prescription drug claims data into episodes of care by medical condition (Cave et al, Patent Number 5,970,463). The system was designed to accurately and reliability measure practitioners' efficiency and quality of care

• Worked with health plans and physician-hospital organizations to evaluate practitioners' efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.

• Worked with health plans and physician-hospital organizations on strategies to improve practitioners' practice patterns through feedback programs, and to deselect practitioners' from networks.

• Familiar with the any willing provider laws, freedom of choice laws, and the Health Care Quality Immunity Act.

• Performed speaking engagements for trade organizations on practitioner efficiency and quality measurement, and published many articles in peer-reviewed journals and trade journals on the topic.

• Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology--providing a strong clinical, statistical, and methodological background.

Select Topic Public Speaking

International Business Communications/Infoline, Negotiating and Profiting with Risk Contracts, Chicago, Illinois. October 1993. Controlling Increases in the Volume and Intensity of Medical Services.

Human Resources Administration, San Francisco, California. July 1993. Managed Care for Hospitals: Applying Continuous Quality Improvement Principles.

UniHealth America, Medical Advisory Board, Laguna Niguel, California. May 1994. Improving Performance Through Physician Profiling Systems.

Group Health Association of America, Group Health Institute, Navigating Reform: HMOs and Managed Care in a Time of Transition, Miami Beach, Florida. June 1994. Small-Area Variations in Patterns of Treatment for Prevalent Medical Conditions.

California Medical Association, Quality Management in Ambulatory Care, Newport Beach, California. June 1994. Identifying What to Improve.

Grove Hill Medical Center, Risks of Capitation, New Britain, Connecticut. November 1994. Maximizing the Rewards of Full-Risk Capitation.

International Business Communications/Infoline, Clinical Practice Guidelines and Critical Pathways, San Diego, California. April 1995. Using the Diagnostic Cluster Approach to Develop an Effective Continuous Quality Improvement Program.

Self-Insurance Institute of America, SIIA Annual National Educational Conference and Exposition, Dallas, Texas. November 1996. Higher Quality Care Through Patient Management: Baseline Measures and Performance Monitoring.

American Association of Health Plans, Information Management Conference Exposition, San Diego, California. November 1996. Quality and Information Management Through Claims Data Analysis.

American Association of Health Plans, Information Management and Technology Conference, Orlando, Florida. November 1998. Considerations For Building a Clinical Data Warehouse.

American Medical Association, AMA CPT-5 Workshop Meeting, Chicago, Illinois. June 1999. CPT Involvement in Developing Methodologies for Physician Profiling.

Select Topic Articles

Cave, Douglas G. 1992. Evaluating Health Plan Efficiency. Compensation and Benefits Management 8(3), pp. 14-18.

Cave, Douglas G. 1993. Volume Performance Standards in the Private Sector. Medical Interface 6(6), pp. 117-118.

Cave, Douglas G. and John D. Abel. 1994. Do HMO or Indemnity Providers Treat Prevalent Medical Conditions More Cost Efficiently? Medical Interface 7(5), 135-142.

Cave, Douglas G. and Edward C. Geehr. 1994. Analyzing Patterns-of-Treatment Data to Provide Feedback to Physicians. Medical Interface 7(7), pp. 117-128.

Cave, Douglas G. 1994. Analyzing the Content of Physicians' Medical Practices. The Journal of Ambulatory Care Management 17(3), pp. 15-36.

Cave, Douglas G. 1994. Pattern-of-Treatment Differences Among Primary Care Physicians in Alternative Systems of Care. Benefits Quarterly 10(3), pp. 6-19.

Cave, Douglas G., David Hom, and John J. Mahoney. 1995. Pitney Bowes: Using Comprehensive Cost Information to Build Provider Networks. Benefits Quarterly 11(2), pp. 2-8.

Cave, Douglas G. 1995. Small-Area Variations in the Treatment of Prevalent Medical Conditions: A Comparison of Three Cities in the Northeast. The Journal of Ambulatory Care Management 18(3), pp. 42-57.

Cave, Douglas G. 1995. Profiling Physician Practice Patterns Using Diagnostic Episode Clusters. Medical Care 33(5), pp. 463-486.

Anderson, Susan C. and Douglas G. Cave. 1996. The Gatekeeper Effect on Managing Acute Medical Conditions. Medical Interface 9(9), pp. 122-129.

Cave, Douglas G. 1998. The PPS/QualityMonitor. St. Louis, Missouri. Practice Patterns Science.

Cave, Douglas G. 1999. Today's Managed Care Market: Benchmark Results for Prescription Drug Guidelines: Part 1. Compensation and Benefits Management 15(1), pp.66-72.

Cave, Douglas G. 1999. Today's Managed Care Market: Benchmark Results for Prescription Drug Guidelines: Part II. Compensation and Benefits Management 15(3), pp. 68-73.

Cave, Douglas G. 1999. The PPS/GreenBook: Prevalence Rates and Practice Patterns. St. Louis, Missouri. Practice Patterns Science.

Cave, Douglas G. 2000. Today's Managed Care Market: Benchmark Results for Medical Care Guidelines: Part I. Compensation and Benefits Management 16(1), pp. 57--62.

Cave, Douglas G. 2000. Today's Managed Care Market: Benchmark Results for Medical Care Guidelines: Part II. Compensation and Benefits Management 16(3), pp. 49-54.

Cave, Douglas G. 2000. The PPS/QualityMonitor. St. Louis, Missouri. Practice Patterns Science.

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