Georgia PPO to use claims database to assess quality

The plan says friendly but firm physician profiling will uphold standards and aid employers. But some wonder whether that would produce true systemic improvement.

By Robert Kazel, AMNews staff. Nov. 3, 2003.

One of the leading PPOs in Georgia plans to harness its storehouse of claims data to assess the quality of its physicians, and doctors who fall outside professional norms may face exclusion from the network at recredentialing time.

But the network says its methods will be uniquely "kind and gentle" and that its doctors will prefer a homegrown variety of quality profiling to those imposed by national HMO plans headquartered outside the state.

Atlanta-based 1st Medical Network, which covers 650,000 patients, is planning to create a nonprofit health care quality institute that will use the PPO's database -- amounting to 1.7 million claims and growing -- as the raw material for utilization review research. The process will include the identification of doctors consistently found to be deviating from best practices, and the network may refuse to renew the credentials of those who continue to fall short of expectations, said Kenneth A. Tannenbaum, 1st Medical president and CEO.

1st Medical, which is for-profit, is owned by several large medical groups and hospitals, including the Emory Hospitals and Piedmont Medical Center in Atlanta. The network connects doctors and hospitals to patients but is not a payer or insurance company, instead contracting with self-insured employers, public agencies, small insurers and third-party administrators that want access to its 14,000 doctors. About two-thirds of the network's patients are employees of state government or the state Board of Regents and their families.