Caveat doctor: how to analyze claims-based report cards

"Report cards" based on claims (billing) data are being widely used to evaluate the quality of care given by providers, even though they often lack sufficient clinical detail to render definitive judgments. Furthermore, their accuracy, especially for outpatient care, is quite variable. Nevertheless, claims data will continue to be used until better clinical information becomes widely available. To determine the suitability of automated claims data for measuring clinical performance, careful attention should be paid to the integrity of the data. Providers profiled by claims-based report cards should ask four questions about the source, robustness, management, and analysis of the data: 1. What are the key characteristics of the data set used to construct the profile? These include the insurer's name, coverage type, time period, geographic area, and number of patients, claims lines, and providers. 2. What clinical conditions and events are being measured and how well? In short, are the patients' conditions and their clinical encounters reasonably well characterized? 3. Is the information about the patients and providers accurate and up to date? 4. Once the insurer receives the medical claim, are data elements deleted or altered in ways that might affect their accuracy and completeness? Ensuring data integrity is not sufficient; the analysis of the data must be scrutinized. Potential pitfalls in analyzing claims data arise in choosing clinically meaningful measures, recognizing important differences in patients and their providers, and making fair comparisons against appropriate benchmarks. Monitoring patient care outcomes is no longer voluntary. By routinely constructing and augmenting profiles using outpatient claims data, provider groups become proactive rather than reactive in evaluating their patients' care.