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, amednews 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.

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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.

The network will offer proof of measurable, consistent quality standards as a drawing card when it markets its products to plan sponsors, Tannenbaum said.

"Our ultimate goal is not to be punitive but rather to identify problem areas from a quality perspective that will have some cost benefits as well," he said.

The network doesn't expect strong opposition to quality measurement from doctors, he added, because the plan has a strong connection with the medical community. Unlike physician profiling by HMOs that may be seen as penny-pinching and meddling, the Georgia initiative will be "kinder and gentler" and designed to give physicians every chance to improve their practice methods, he said.

Still, Tannenbaum added that "we do have the ultimate stick" -- the threat of refusing to renew doctors' contracts if they don't heed the PPO's guidance on quality control. Georgia has no "any willing provider" law that would prevent managed care networks such as 1st Medical from excluding doctors who seek to join them.

Compiling quality reports on doctors will be useful to plan sponsors but also to the doctors, said Doug Patten, MD, a general surgeon in Cordele, Ga., and chair of the PPO's board of directors.

"The natural tendency in all of us is to resist [quality profiling] and say, 'There's something that explains the data,' but I think there's also something in all of us that makes us want to improve," he said. "[But] for someone who won't improve, this is a recredentialing issue."

The PPO also is interested in selling health care quality research based on its database analysis to employers seeking more control of their health care spending. The PPO's database of claims information for Georgia patients is so vast that its value as a research and measurement tool is obvious, Dr. Patten said.

"We've never been this close to having this much data and control over it, especially with the state [employees]," he said.

Gil Grossman, MD, director of professional affairs for Emory Clinic and a 1st Medical board member, said the main mission of the new institute would be quality research to assist payers rather than recredentialing.

"We think the information that will be accrued from this effort down the road will be enormously helpful and will be very powerful, particularly because of the [size of the] network," he said.

But 1st Medical shouldn't expect too much systemic improvement if it merely plans to exclude some physician "outliers," said William Bornstein, MD, PhD, chief quality officer at Emory Healthcare. Dr. Bornstein is not affiliated with the PPO.

"Historically many of the payers have looked at overutilization, but I think they are more credible when they are looking at other factors as well," he said. "Then the immediate gut reaction isn't, 'Ah, they're just doing this for financial reasons.' "

A strategy of "chopping off the tail of the curve" by banning doctors who fall outside of quality guidelines will have some effect, but not much, he said. The data must be used to find ways to offer incentives to all doctors to improve their methods, thereby "shifting the curve," he said.

Excluding some doctors "is analogous to looking for defects in cars instead of making great cars," he said. "You don't build great cars that way. You don't get better care that way." The PPO should pay attention to cases of underutilization and not only those doctors who use medical resources too much, Dr. Bornstein said -- for instance, physicians who don't order enough appropriate lab tests for their diabetic patients.

The quality institute and plans for profiling haven't been announced formally to 1st Medical's doctors yet, Tannenbaum said. No physicians likely will see any effect on credentialing until at least the second quarter of 2005, he said. Some may not be affected until even later because doctors in the network go through recredentialing every three years.