Physician Profiling, Guiding Principles

Preamble

The AAFP defines physician profiling as an analytic tool that uses epidemiological methods to compare physician practice patterns across various quality of care dimensions (process and clinical outcomes). Cost, service and resource utilization data are dimensions of measuring quality, but should not be used as independent measures of quality care. The ultimate goal is to deliver high quality, evidence-based care to improve clinical outcomes.

It is important to recognize that physician profiling is not intended to be used to address issues of physician competency, including the dimensions of medical knowledge, skills and competence. Such issues should be addressed by the appropriate public and private credentialing bodies that exist for these purposes.

AAFP believes that transparency in health care cost and quality information to physicians, patients, and employers is important and supports such efforts provided that the data aggregation and analysis is consistent with the AAFP Performance Measures Criteria policy. These criteria encompass the framework in which physician profiling data is collected, analyzed, and utilized.

Family physicians must have an opportunity to review payer performance profiles prior to them being publicly reported. Payers must establish and communicate a reasonable, formalized reconsideration process in which physicians can appeal their performance rating/designation(s).

Guidelines

Ideally, any physician profiling system/program should:

  1. Have as its purpose to assess and improve the quality of patient care and clinical outcomes.
  2. Clearly define what is being measured.
  3. Select measurement goals which are actionable so that physicians can easily interpret and act as needed to achieve the stated measurement goal.
  4. Involve physicians in the development of performance measures, feedback process, and appeals process.
  5. Explicitly describe the data sources on which measurement is based, e.g., administrative/claims, medical records, surveys, etc.
  6. Clearly report on the validity, accuracy, reliability and limitations of data utilized when reporting profiling results and when providing physician feedback. This may include:
    1. detailing the steps taken to ensure data accuracy and fair physician attribution of costs of care,
    2. clearly defining the peer group against which individual physician performance is being measured/compared,
    3. disclosing data limitations, e.g., the impact of an "open access" product in which the primary care physician may have little or no control over resource utilization,
    4. describing the assignment of patient populations to either individual or physician groupings,
    5. using an appropriate sample size to assure validity,
    6. including appropriate risk adjustment and case mix measures, and
    7. establishing and reporting data using meaningful time periods for data collection.
  7. Utilize criteria for comparison purposes that are based on valid peer groups, evidence-based statistical norms and/or evidence-based clinical policies.
  8. Identify individual patients who are not receiving indicated clinical interventions and provide interventions to improve physician performance relative to stated measurement goals.

(1999) (2012 COD)