Lessons Learned: There is wide variation in Medical Groups. Some of the
variation relates to inadequate encounter data capture and coding. Some
groups appear to be successful and other unsuccessful in implementing
programs, success is often related to the resources available to the
group e.g. whether the group is part of a larger healthcare delivery
system. Larger groups, part of integrated delivery systems maybe less
dependent on plan programs than smaller groups.
What is working, what isn’t and what changes are being made: Large fully
capitated groups perform better than smaller groups. Risk models which
pass professional and facility risk to medical groups pose a challenge
to plan as data to evaluate programs may be insufficient. CPT coding is
often not specific enough to support evaluation..
Incomplete data from fully capitated medical groups.
Unwillingness to implement plan-based DM programs (CHF).
Smaller groups without resources - The San Diego Right Care Pilot
initiative represents a potential breakthrough in improving the
performance of low scoring medical groups. This program may allow
health plans to collaborate through the RCI with cost effective
community providers to improve clinical performance (HEDIS) and the
health of the HMO population.
Additional resources needed:
Adoption of CPT codes by medical groups.
Capture of lab results data.
Activities health plans and medical groups can take :
Support medical group and physician-specific profiling.