UHG was an early user of provider profiling and documented the value of the technology for improving quality of care in an early publication on these initiatives (Leatherman, et al., 1991). Today, these applications have evolved into a comprehensive provider rating system focused on primary care as well as specialty physicians. The goal of this system is to empower consumers and their physicians with information. The leaders of the initiative recognize that not all health care is the same and physicians may not know how they are doing compared with their peers. Furthermore, consumers want information but may not know how to get it, or how best to use it.
The provider rating system to be evaluated uses two dimensions of performance – quality and efficiency. Each dimension is represented by a star to consumers. One star denotes a high-quality provider and two stars denote a high-quality and high-efficiency provider. The quality and efficiency scores are created by a five-step process based on claims data available to UHG from all lines of their health insurance business:
- Twenty-four months of data are collected and analyzed on all physicians in the specialties eligible for designation.
- The quality screens are applied based on specialty and, where applicable, focus of care provision.1
- Only those physicians who meet/exceed the quality criteria are designated by a quality star and move on to the efficiency analysis.
- Episodes/procedures are analyzed for cost efficiency by benchmarking to market specialty averages and are case mix/severity adjusted.
- Those who meet or exceed market cost criteria are designated by two stars.
Once the data are synthesized, the ratings are made available to providers and consumers. Providers receive on-line performance reports with patient-level detail available for further exploration. A Medical Director is also available to discuss quality and efficiency improvement opportunities. Figure 1 illustrates the range of provider-specific scores of interventional cardiology practices in Cleveland, OH, based the two dimensions of quality and efficiency.
Figure 1 – UHG Provider Quality and Efficiency Distribution
Figure one presents an example graphic of UHG analytic tools. The graphic illustrates is a multicolor bubble graph showing the the range of provider-specific scores of interventional cardiology practices in Cleveland, OH, based the two dimensions of quality and efficiency.
Figure 2 – Example of Individual Physician Report
Figure two is an example of a page of output from UHG analytics. The chart shows a variety of statistics relating to pay-for-performance systems.
Recently, UHG introduced a ‘Practice Rewards’ pay-for-performance system to reward demonstrated performance. Figure 2 presents an illustration of provider-level reporting.