Physician Profiling

Physician Profiling

Physician profiling is a method used primarily by health plans to compare the practice patterns of physicians on specific measures of cost and quality. Profiling is usually accomplished retrospectively using claims or administrative data.

Over time, physician profiling programs have evolved from health plans providing doctors with confidential reports to using profiles in conjunction with insurance products to label doctors with star ratings or place them into tiered provider networks.

The MMA supports efforts to measure the cost and quality of physician groups or clinics, when such analyses are valid, reliable, and useful. However, the MMA opposes individual physician profiling efforts until research shows they can be done accurately. The MMA also does not support the tiering of physicians if information is not made available on the methodology used to assign tiers, and if validated benchmarks are not used when making quality comparisons.

Minnesota Physician Profiling Programs

Medica Premium Designation Program A Medica program that provides public displays of cost and quality performance, based on claims data alone, at the individual physician level.

Minnesota Provider Peer Grouping State of Minnesota program designed to measure the cost and quality of care provided by physician clinics and hospitals. The program's goal is to strengthen incentives for consumers to choose high-quality, low-cost health care providers.

Tiering In response to pressure from employers to hold down costs, all three of Minnesota's largest health plans — Blue Cross and Blue Shield of Minnesota, HealthPartners, Medica — and the state of Minnesota have created tiered networks at the medical group, health system or care system level.


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