Physician Profiling and Risk Adjustment

From The Critics

Reviewer: William R. Hendee, PhD(Medical College of Wisconsin)
Description: This is an anthology of articles in which current efforts to use patient and resource consumption data to improve the quality and cost-effectiveness of clinical care in managed care organizations are discussed. It is a second edition; the first edition was published two years ago.
Purpose: The purpose is to examine physician profiling and risk adjustment as assets in controlling resource utilization in healthcare institutions, especially managed-care organizations. The text serves this purpose very well. Valuable information and insight into effective healthcare management at the balancing-point of quality and cost is presented.
Audience: The text is highly technical in a managerial/business sense, and is not intended for the curious novice. For persons in senior management positions in healthcare organizations, it is essential reading. The contributors are all well-known experts in their disciplines.
Features: The book is divided into five sections: theoretical considerations in physician profiling and risk adjustment; fundamentals of case mix and risk adjustment; physician profiling and risk adjustment of outpatient care; case mix adjustment for inpatient care; and measuring episodes of illness. Of particular interest to me were the topics on physician profiling (7 chapters), public disclosure (12 chapters), The American Medical Accreditation Program (AMAP), and risk adjustment technology for capitation. Other readers will undoubtedly find additional chapters of interest. The book contains a detailed index, and is presented in an attractive hard-copy format.
Assessment: This book is essential reading for senior healthcare administrators responsible for managing clinical services, especially managed-care operations and capitated-care contracts. A variety of issues associated with resource utilization and risk management are addressed that are rapidly changing as managed-care plans and insurance companies continue to shift increasing financial risk onto healthcare providers. I cannot imagine a senior-level healthcare administrator who would not benefit from reading several, if not all, of the chapters in this book.

William R. Hendee

This is an anthology of articles in which current efforts to use patient and resource consumption data to improve the quality and cost-effectiveness of clinical care in managed care organizations are discussed. It is a second edition; the first edition was published two years ago. The purpose is to examine physician profiling and risk adjustment as assets in controlling resource utilization in healthcare institutions, especially managed-care organizations. The text serves this purpose very well. Valuable information and insight into effective healthcare management at the balancing-point of quality and cost is presented. The text is highly technical in a managerial/business sense, and is not intended for the curious novice. For persons in senior management positions in healthcare organizations, it is essential reading. The contributors are all well-known experts in their disciplines. The book is divided into five sections: theoretical considerations in physician profiling and risk adjustment; fundamentals of case mix and risk adjustment; physician profiling and risk adjustment of outpatient care; case mix adjustment for inpatient care; and measuring episodes of illness. Of particular interest to me were the topics on physician profiling (7 chapters), public disclosure (12 chapters), The American Medical Accreditation Program (AMAP), and risk adjustment technology for capitation. Other readers will undoubtedly find additional chapters of interest. The book contains a detailed index, and is presented in an attractive hard-copy format. This book is essential reading for senior healthcare administrators responsible for managing clinical services, especially managed-care operations andcapitated-care contracts. A variety of issues associated with resource utilization and risk management are addressed that are rapidly changing as managed-care plans and insurance companies continue to shift increasing financial risk onto healthcare providers. I cannot imagine a senior-level healthcare administrator who would not benefit from reading several, if not all, of the chapters in this book.

Janice M. Lato

This book is a thorough review of case mix adjusted clinical information methodologies, both inpatient and outpatient. It includes perspectives on how the various parts of the healthcare industry use the data. The purpose is to provide a review of case mix methodologies and identify the strengths and weaknesses of the utilization of case mix data. The book contributes information in an objective fashion to the debate physicians/hospitals have with payors that data collected does not reflect patient severity. This book is intended for individuals who work with case mix data. The book includes information from a variety of settings and experts throughout the country. The authors and contributors are knowledgeable about the subject matter. Illustrations are used within chapters to describe methodologies or findings. There are a sufficient number to make the book easier to read. Because the book is very technical, this helps the reader. There is an index at the back that is very helpful in locating specific items. There is not a reference listing since experts are used for each chapter. This book is a significant resource for persons within hospitals, group practices, and payors who work with case mix data. For others, the book would be a reference to be used periodically. The book describes many available severity adjustment systems and summarizes the current state of physician profiling.

Booknews

Shows health care management professionals how to use outcome data responsibly and accurately, in sections on public disclosure of risk- adjusted data; fundamentals of case mix and risk adjustment; risk adjustment for outpatient care; and case mix adjustment for inpatient care. Discusses issues such as using profiling data as a quality management tool to improve physician performance, releasing data to the media and the public, and adjusting hospital and physician capitation rates using risk-adjusted data. Contains case studies, and tips for success and avoiding common problems. Annotation c. Book News, Inc., Portland, OR (booknews.com)

4 Stars! from Doody