SAN MATEO, Calif.--(BUSINESS WIRE)--Primary care physicians (“PCPs”) can more effectively manage the total cost of care when managing the healthcare needs of a covered population. Cave Consulting Group (“CCGroup”) reached this conclusion after evaluating the performance of several health plan accountable care and value-based reimbursement programs.
“On average, PCPs are involved in treating 57% of all prevalent medical condition episodes of care. This means patients are self-referring to specialists 43% of the time,” stated Dr. Douglas G. Cave, President of CCGroup.
He continued, “For those medical conditions with significant practice variations, PCPs are involved in treating only 40% of the patient episodes of care. Examples of medical conditions with significant practice variations are low back pain, degenerative joint disease, headaches, derangement of knee, hernias, and ischemic heart disease.”
Of the 40% of patient episodes seen by PCPs with significant practice variations, PCPs referred 35% of these episodes to specialists. Therefore, PCPs are ‘solely involved’ in treating only about one in four medical condition episodes with significant practice variations.
“For the 35% of episodes referred to specialists by PCPs, we observe that only 50% of the specialists are practicing efficiently and effectively. This finding implies that PCPs may refer to specialists based on criteria other than efficiency and effectiveness,” defined Dr. Cave.
Dr. Cave stated, “Under accountable care, PCPs need to become more active participants in treating medical conditions with significant practice variations. PCPs need to be informed of the medical conditions and services with the most practice patterns variation. For these conditions, PCP involvement needs to be increased from the current 40% of patient episodes to at least the 90% level. Then, quantitative clinical pathways should be developed that define the appropriate time for a specialist referral. When a referral is appropriate, PCPs need to refer to efficiently and effectively practicing specialists. In this manner, PCPs can more effectively manage the total cost of care of a covered population.”
About Cave Consulting Group, Inc. (CCGroup)
Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 26 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.