https://immattersacp.org/weekly/archives/2010/05/18/5.htm

Physician cost profiling systems frequently come to different results

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Health plans using different cost profiling rules may assign the same physician into different tiers anywhere from 17% to 61% of the time.

Researchers applied one default rule and 11 alternatives to a claims database submitted to four commercial health plans (including managed care, preferred provider organizations and indemnity products) in Massachusetts. They then compared the effect of the alternatives on whether the care assigned to a physician was provided by that physician or by his or her colleagues and on cost categories to which each physician was assigned. They reported results in the May 18 Annals of Internal Medicine.

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The study sample included 13,761 physicians who delivered 5.6 million episodes of care to 1.1 million patients. Among patients, 91% saw multiple physicians and 61% saw five or more physicians. Among episodes, 54% involved multiple physicians and 9% involved five or more physicians. The data set included more than 80% of the people with commercial health insurance in Massachusetts.

Methods to create cost profiles and assign physicians to cost categories closely followed those used by health plans. Researchers created standardized prices, constructed episodes of care, tallied the cost of each episode, assigned responsibility of care, calculated the expected cost profiles and placed physicians into categories: low (below 25th percentile), average (25th to 75th percentile), high (above 75th percentile) or low sample size (less than 30 episodes.)

Across the 12 attribution rules, the percentage of episodes that could be assigned to physicians ranged from 20% to 69%, and the percentage of physicians with a sample size less than 30 episodes ranged from 39% to 66%. The mean percentage of a physician's billed professional costs that were included in the physician's own cost profile ranged from 13% to 60%, and the mean percentage of professional costs included in a physician's cost profile that were actually billed by that physician ranged from 37% to 73%.

To determine disagreement in cost categories, researchers included the 9,741 physicians (71%) from the sample who had 30 or more episodes under any of the 12 rules. Rates of disagreement between the default rule and alternate rules ranged from 17% to 61%. The highest disagreement rates were associated with patient-based (range of disagreement, 47% to 61%) and multiple-physician (range of disagreement, 35% to 53%) rules.

Researchers concluded that those who assign cost categories to physicians must be transparent about the rules they use to make decisions.

“Our results help to explain why some physicians question cost profile attribution rules,” researchers wrote. “No more than 60% of a physician's billed costs were included in cost profiles under any rule, and of the physician costs assigned to a physician, up to two thirds were billed by other physicians. These findings might make physicians less responsive to efforts to use cost profiles to decrease spending.”