Provider Quality Measurement Review

Purpose of Quality Measurement Review

The Provider Quality Measurement Review offered by the Cave Consulting Group is a cost-effective product to evaluate your current provider (practitioner or hospital) quality rating systems. As leading experts in this field, the Cave Consulting Group will offer constructive feedback on ways for you to improve current provider quality measurement--increasing the accuracy and reliability of your existing measurement tools.

Who Should Perform a Provider Quality Measurement Review?

• Employers and other healthcare purchasers interested in understanding how their provider-network vendors (e.g., PPOs, insurance carriers, HMOs) are monitoring and improving the overall quality of care--versus just obtaining network service price discounts.

• Insurance companies, health plans, and third party administrators (TPAs) interested in improving the quality of their provider networks and the quality of patient care.

• Physician group and physician-hospital organization leaders interested in improving the quality of their healthcare delivery systems.

• All companies that have selected or are in the process of selecting a vendor software system for measuring provider quality of care.

Why Perform a Provider Quality Measurement Review?

A report released in 2001 from the National Academy of Sciences, Institute of Medicine, documented large deficiencies in the quality of health care services in the United States. Subsequently, another report released in November 2002 from the Institute of Medicine stated that the United States health care system is in crisis and that the Bush Administration should immediately test possible solutions--including universal insurance coverage. The report said that the present health care delivery system is incapable of meeting the present, let alone the future, needs of the American public. Individuals are paying more out of pocket and receiving fewer benefits. Receiving access to quality care is a problem for many Americans.

If quality of patient care is to be improved, then employers, insurance companies, health plans and HMOs, and TPAs need to build and maintain continuous quality improvement programs with their network providers. You need to take action and ensure appropriate provider quality monitoring and improvement programs are in place and that positive results have been obtained from these programs.

Prior Project Experience

The Cave Consulting Group has evaluated many different types of provider (practitioner and hospital) efficiency rating systems. We have examined quality-rating systems for organizations delivering care to more than 10 million members nationwide. We know the strengths and weaknesses of the marketed software, groupers, and systems.

From this experience, we have identified at least eight criteria for examining appropriate provider outcomes and process of care quality measurement (see Quality of Care Measurement):

• Well-documented in clinical literature and/or medical guidelines
  
• Clinically relevant to patient outcomes or medical treatment
  
• Easily identifiable using claims data or chart reviews
  
• Quantifiable using claims data or chart review
  
• Prevalent service in the medical condition examined
  
• Variable use between providers
  
• Cuts across service categories (lab, procedures, diagnostic tests, drug)
  
• Financially relevant.

• Quantitative rate per episode or per patient (e.g., mean, mode, median)
  
• Quantitative range per episode or per patient (around the established rate)
  
• Rate and range by physician-specialty type--and not across all specialists
  
• Rate and range by severity-of-illness (SOI) class (per episode or patient)
  
• Formed based on statistical, literature, and expert panel review.

Suggested Project Scope

• Determine whether the Provider Quality Measurement Review will involve practitioners, hospitals, or both.

• Perform an onsite visit to review your current provider quality measurement systems and methods.

• Review a discussion guide to determine the accuracy of your provider quality measurement systems--whereby the guide reviews the applied software packages, methodologies, and quality rating techniques.

• Produce a final report that summarizes the strengths and areas for improvement in provider quality measurement.

Next Steps

Please contact us at the Cave Consulting Group for more information on the Provider Quality Measurement Review. You will gain valuable information from our cost-effective review process.

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