Episode-Based Profiling

Question 1

Episode-Based Profiling

Purpose

Answer 1

• Promotes quality of care and cost efficiency
• Making info available to plan members and giving financial incentives
• Giving pay-for-performance incentives to physicians

Question 2

Episode-Based Profiling

Profiling Process

Answer 2

1. Aggregate member data into episodes of care
2. Actual Cost
3. Attribute responsible physician
4. Expected Cost
5. Cost Efficiency = Actual Cost / Expected Cost
6. Develop quality measures
7. Attribute responsibility for quality opportunities to physicians

Question 3

Episode-Based Profiling

Strengths

Answer 3

• Minimal admin burden for data collection
• Ability to compare performance against defined standards
• Episode view = more patient-centered

Question 4

Episode-Based Profiling

Limitations

Answer 4

• Misidentification of low/high performers
• Variation in claims detail = bias
• Inaccurate Physician Cost Efficiency
• Inclusion of hospitals may impact profiles in high-cost settings
• Most spend = complex chronic illness = little ability to influence consumers
• Cream skimming
• Safety net providers may have disadvantage

Question 5

Episode-Based Profiling

Key Methodological Issues

Answer 5

• Minimum number of episodes required for reliable profiles
• Limited quality criteria available
• Evidence base for performance criteria varies substantially
• Current performance measures = effectiveness, efficiency, safety
  
  • Equity, patient-centeredness, and care coordination = under developed