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Related Experiment Videos

Using claims data to select primary care physicians for a managed care network.

P Nathanson1, M Noether, R J Ozminkowski

  • 1Aetna Health Plans, Hartford, CT.

Managed Care Quarterly
|March 4, 1995
PubMed
Summary
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A new system ranks primary care physicians (PCPs) by comparing their service use to a predictive model. This helps managed care networks select PCPs who align with expected patient care patterns.

Area of Science:

  • Health Services Research
  • Medical Informatics
  • Health Economics

Background:

  • Managed care networks require efficient methods for selecting primary care physicians (PCPs).
  • Objective evaluation of PCP practice patterns is crucial for quality assurance and cost management.
  • Existing selection methods may not adequately account for patient complexity.

Purpose of the Study:

  • To develop and validate an insurance claims databased profiling system for selecting new PCPs.
  • To rank PCPs based on the congruence of their outpatient service utilization with a predictive model.
  • To facilitate informed PCP selection within a managed care network.

Main Methods:

  • Developed a profiling system using insurance claims data.
  • Employed a mathematical model to predict outpatient service utilization.

Related Experiment Videos

  • Adjusted predictions for patient factors including age, sex, and case mix.
  • Ranked PCPs by comparing actual service use to model predictions.

    • Main Results:

    • The system successfully ranked PCPs based on their adherence to predicted service utilization.
    • The ranking incorporated adjustments for patient demographics and clinical complexity.
    • This method provides an objective measure for PCP performance evaluation.

    Conclusions:

    • Insurance claims data can be effectively utilized to profile and rank PCPs.
    • A model-adjusted approach offers a more equitable and accurate method for PCP selection.
    • This system supports evidence-based decision-making in managed care network development.