How to measure quality of care at the physician level

January 31, 2024

Is it possible to score individual physician performance?

Today’s healthcare providers are evaluated based on how well they follow evidence-based guidelines—the practices shown to produce better patient outcomes—and whether they achieve those outcomes at a reasonable cost.

But quality isn’t just about measuring the effectiveness of the care delivered, it’s also about measuring the care that isn’t or shouldn’t be delivered. Patients are all too frequently subjected to tests, treatments or even surgeries that simply aren’t shown to offer any benefit and often come with dangerous risks or side effects.

While the need for reliable data at the physician-level is clear, assessing provider performance remains a challenge no matter how you look at it.  

First, measuring a few metrics in isolation simply doesn’t provide a complete view of physician performance over time. Second, providing a complete picture requires more granular data insights than generally what is available via Medicare or other public data sources.  

To understand physician performance, you have to take a much more holistic view. For employers, the level of detail that is needed centers on specialty-specific measures shown to impact patient outcomes. Using insights from physicians and data scientists, the goal is to identify quality measures with the highest clinical impact and apply them across a broad dataset. This approach allows you to look beyond a single episode of care, following a patient's complete healthcare journey.    

The Ideal Framework of Physician Scoring

Conventional quality measures only focus on the process of care and cost. While both are important, they don't capture a third critical domain of care delivery: whether the provided care was necessary in the first place.  

To gain an accurate picture, it is critical to analyze multiple years of data at the individual physician-level across three different domains of clinical performance:

  1. Appropriateness - Are patients receiving the care they need without unnecessary risk?
  1. Effectiveness - Are providers delivering care in accordance with the latest clinical guidelines, and did patients achieve positive outcomes?
  1. Cost - Was care delivered at a reasonable cost relative to physician peers in the community?

Peer Group Comparisons

While appropriateness, effectiveness, and cost are the key measurements to understand physician quality, they cannot be evaluated in a vacuum. In order for it to be considered a clinically validated analysis, these factors must be considered within their respective peer and patient groups. For example, examining cohorts of like patients is necessary to determine how different physicians approach patients with similar clinical symptoms and diagnoses.  

Next, it is important to compare individual performance to local benchmarks to determine how physicians perform relative to their peers in the community where they practice. This state designation should be based on the provider's location in the demographic file at the time of data modeling.

Longitudinal Data Periods

While traditional measures evaluate an episode of care or a timeframe around a surgical procedure, the ideal approach should use a multi-year set of claims data set to follow a patient's complete healthcare journey. To reliably evaluate the appropriateness and effectiveness of the care they received, the analysis must take place over a longer period of time.

Accreditation and Peer Review

Before a measurement approach can be fully validated, a scientific advisory board of recognized clinical experts can help implement and refine clinically validated measures across specialties. Such a board can apply rigorous analytics to ensure the relevance and reliability of the measures, while also providing third party oversight.  

One final step for a measurement system to establish trust and credibility is to have its methodology evaluated from top to bottom. This type of review can take the form of peer-reviewed journals that can verify the quality of its findings based on the level of independent, objective, and defensible approach.

Summary

Measuring the quality of care provided by an individual physician has many challenges, but it is possible. However, a realistic framework for scoring physician performance must go beyond the traditional focus on process of care and cost and also consider appropriateness of care.  

These three key domains of clinical performance - appropriateness, effectiveness, and cost - when measured together can provide actionable and meaningful insights for patients to find the best care option for their families.    

Additional elements like peer group comparisons, local benchmarks, longitudinal data periods, accreditation and peer review by clinical experts are all part of a robust methodology that can establish trust and credibility as a protocol for mass adoption.  

To learn more about Embold Health’s technical framework for measuring physician performance, download our Methodology Whitepaper here.