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Provider Ranking System: Background & Methodology


What is Quality Medical Care?

After years of research, Provider Ranking System™ (PRS) has created a better way to look at the problem, “What is Quality Medical Care?” It is generally not clear from the medical record whether the patient got better and returned to their desired life’s activities. Most quality measures use adverse events, such as mortality rates, hospital readmissions, and other bad outcomes. However, these should almost never occur, so they tell you nothing about over 90% of doctors and other medical providers.

When quality measures are based on adverse events, Risk Adjustment (RA) is critical. Otherwise, doctors avoid more risky patients, those most needing treatment and healthcare equity. Furthermore, recent research has shown that the largest impacts on outcomes are the effects of Social Determinants of Health (SDOH), and SDOH are not generally covered in Risk Adjustment (RA) methodologies.

Social Determinants of Health (SDOH)

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. Examples of SDOH include safe housing, transportation, and neighborhoods; Racism, discrimination, and violence; Education, job opportunities, and income; Access to nutritious foods and physical activity opportunities; Polluted air and water; Language and literacy skills; and Family/home environment, including substance abuse, physical abuse, etc.

SDOH also contributes to wide health disparities and inequities. For example, people who don’t have access to grocery stores with healthy foods are less likely to have good nutrition. That raises their risk of health conditions like heart disease, diabetes, and obesity, and it even lowers life expectancy relative to people who do have access to healthy foods. Research indicates that an estimated 20% of health outcomes are linked to medical care; the remaining 80% stem from socioeconomic, environmental, and behavioral factors referred to as Social Determinants Of Health (SDOH)[1].

Example of Provider Quality Measures Gone Wrong

Try this thought experiment: Which doctor is better, a physician treating a healthy population in a well-off suburb, with few adverse events, or the one working at the free clinic downtown where the population has lacked adequate healthcare, so they justifiably have higher complication rates? Measures of quality based strictly on adverse effects will unfairly penalize the second doctor.

The PRS solution is to use a quality predictor that is 100% available on all doctors and other medical providers, namely, level of experience in each service that they perform, the fair, transparent and accurate choice for ranking providers. PRS is the one ranking methodology most likely to be understood and accepted by providers. It creates a level playing field, where experience is the best predictor of success. No one is good at everything, but doctors are generally very good at what they practice most.

Other Attempts to Measure Quality

Other attempts to measure quality have looked at what doctors should not do, specifically unnecessary care. While medical necessity using evidence-based guidelines is important, it’s more important to find the right provider to deliver necessary medical care. The best doctors know their specialty well, diagnosing and treating like conditions with evidence-based medicine. Without physician quality, utilization management against guidelines is simply cost control in a fee-for-service model, with little impact on health outcomes or value. Nonsurgical care is not always the best option, but these methodologies tend to give better rankings to doctors who avoid expensive surgeries.


Using Level of Experience

PRS uses a predictor of quality that is available for every medical provider: level of experience. This is backed by the medical evidence as the best proxy measure to predict good health outcome, See Does Practice Make Perfect in Healthcare? The same logic applies to all types of medical providers, including physicians, physical therapists, nurse practitioners, hospitals or ambulatory care centers.

Experienced doctors also know when not to do a procedure, and because they are busy performing successful procedures, they are not looking to add inappropriate procedures.

Identify High Performing Providers

Higher performing providers do not cost more. When considering better outcomes, they cost less. With PRS, it is possible to identify high-performing medical providers to lower healthcare costs through improved health outcomes. PRS covers over one million providers per year for ten years. For every reimbursable service they perform, providers are ranked nationally, regionally, & locally. Hospitals were added for 2023, with affiliated doctors graded by specialty.

The most important ranking is by procedure. For any HCPCS code (doctors and other medical professionals), or for any DRG code (hospitals), providers are ranked nationally and locally. The zip3 code (first three digits of the zip code) has been defined as a generally appropriate commuting distance for medical care, typically 30 to 60 minutes. If there are not enough providers in that area, a digit can be dropped to display zip2 ranking, which tends to be an entire state or section of a larger state, typically a drive of a few hours. Finally, a national ranking would be the next level, requiring more travel, but possibly necessary to get the best treatment for some, particularly difficult or rare cases.

The Composite Ranking Score (CRS)

While the most important ranking is by procedure, PRS also offers rankings within each medical specialty, using a Composite Ranking Score. Besides physician specialties, such as Cardiology or Orthopedic Surgery, this specialty ranking also ranks organizations, such as Ambulance Services, Ambulatory Surgical Centers, Clinical Labs, Home Infusion Therapy Services, Hospices, Hospitals, and Independent Diagnostic Testing Facilities. The Composite Ranking Score (CRS) is the weighted average percentile score for all procedure rankings for a provider, 0 to 100%. The score is calculated first for each procedure listed on the Provider Ranking by HCPCS table, where, for example, 100% means no providers ranked higher, 92% means only 8% ranked higher, while 45% means 55% ranked higher. These scores are averaged for all the procedures listed for a medical provider on the Provider Ranking by HCPCS table, after weighing by approved dollars for that provider, to give weight to the procedures that are most significant for each provider. Then, to calculate the Ranking of CRS by Medical Specialty, the CRS percentile is ranked for all providers within the same medical specialty. The CRS may be displayed as a rounded percentile, but when ranking, the actual score is used, which is accurate to 4 digits. Grade A+ is CRS>95, A is CRS>85, A- is CRS>80, B+ is CRS>75, B is CRS>65, B- is CRS>60, C+ is CRS> 55, C is CRS>45, C- is CRS>40, D+ is CRS>35, D is CRS>25, D- is CRS> 20, and F is the rest.

Data Sources

Like other medical provider quality rating solutions, PRS starts with CMS data, as this is the largest single source of data in the United States, with consistent quality assurance. In addition, PRS is adding data from other sources, after necessary cleaning and quality control, including claims clearinghouse data, all-payer claims databases, and workers’ comp claims.

Additional Quality Measures

Aside from the proprietary rankings created by PRS, as discussed above, PRS includes other quality measures inside the application as well for comparison, including:

  • Hospital CMS Star Rating: 1 to 5 stars (grades of F to A).
  • Physician CMS MIPS score (Merit-based Incentive Payment System), ranging from 0-100, based on process measures for quality, interoperability, cost, and improvement activities; the score is used by CMS to adjust reimbursement, with a score under 30 resulting in up to 7% lower payment, and over 75 resulting in up to 7% higher payment.
  • Hospital Physician Affiliations & Grades, with an overall grade and a grade for each medical specialty affiliated with that hospital.
  • Repeat Rate for medical procedures on the same patient.
  • Average billed amount, or list price (or Chargemaster price for hospitals), and the ratio of that to approved amounts, to weigh the inclination of a provider to overcharge, impacting out of network costs.
  • Average Risk Score of Patients, ranging from 0.3 to 9.0 (1 is average).

There is also considerable detail in PRS on each provider, location, education, their patients, and their procedures, and this should be used in decision making about providers.

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