physician profiling

Do you know that there are methods in progress to change your (practice) behavior and improve your efficiency and quality of care?  These performance measures are known as “physician profiling”.  Have you ever received a report of your performance?  Were you given the opportunity to explain unusual circumstances if you were deemed an “outlier?”

According to Nancy Nielsen, MD, speaker of the AMA House of Delegates, just because physicians might be unaware of the profiling “doesn’t mean it’s not being used to calculate your efficiency.” (quoted in Ref. 1)

What is physician profiling?

There are two general categories of physician profiling: burgeoning cost-containment/quality of care profiling and profiling implemented in 1990 by the National Practitioner Data Bank (NPDB). I’ll be writing on the NPDB in the coming month, so here I focus on cost containment/quality of care profiling.

Cost containment/quality of care physician profiling is an analytical method used to compare physician practice patterns across quality of care dimensions, often in an attempt to constrain spending and reduce inpatient length of stay.

Physician profiles track practice patterns of a single physician or a group. Typically, practice efficiency is measured in terms resource use or length of stay for the population served. The resulting profile is then compared with a norm that is either based on practice (such as profiles of other physicians) or on standards (such as practice guidelines).(2)(3)

Your physician profile gets used in a variety of ways.

MedPAC (Medicare Payment Advisory Commission), an independent federal body established by the Balanced Budget Act of 1997 to advise Congress on Medicare, recommended that physicians’ resource use be measured as a way of encouraging physicians to reduce the “intensity of their practice.” Reducing intensity of practice is considered to have been achieved if there are fewer diagnostic services provided, fewer subspecialists used, less use of hospital and intensive care units (ICUs) as a site of care, and if fewer minor procedures are performed. This recommendation was based on studies that show that greater resource use in defined geographic areas did not improve health, when measured on a population basis (4).

Physician practice profiles are also used by private insurance companies (Amednews). Insurers track billing and coding habits, and raise a flag when these deviate from practice standards or norms. It’s not uncommon for an insurance company to notice shifts in billing practices: such shifts often happen for several practices at once, typically after a widely attended seminar on billing.

Of course, pharmaceutical companies also rely heavily on physician prescribing profiles (usually tracked by DEA number). That prescribing details are available to pharmaceutical companies is often surprising – but it has become an invaluable tool in their marketing programs. Pharmaceutical companies target the top quartile prescribers of their drugs, and actively market to them.

Implications for physicians.

Whether you know about these profiles or not, they can affect your practice: Negotiations with insurance payers may hinge on your “hidden” profile, how hard pharmaceutical companies lobby to control your prescribing habits, and whether you feel pressure to “reduce the intensity” of your practice.

According to Sheldon Greenfield, MD (University of California, Irvine), the “P” word involves serious considerations, with a highly charged political backdrop. Because of the nature of the profiles, it is difficult to challenge the methodologies, errors (damage to physicians’ livelihood, misguided, wasteful efforts to improve care) and the reactions caused by the various purposes of profiling (accountability, quality improvement and pay for performance).

Despite the use of profiling, there is only limited data on how it actually affects the practice of medicine (5). Does reducing the “intensity of their practice” (read improving the efficiency) improve the quality of care? We will need hard data on its effects on post-operative complications, re-hospitalizations rates, and morbidity.  Will the reward for “efficiency” ultimately amount to decreasing or ignoring quality of care?



1) AMNews:  July 10, 2006.  Insurers using more physician profiling, delegates told.  Amednews


2) physician profile. asp

3) Issues in Profiling Physician Performance, Sheldon Greenfield, MDF, Academy Health 2006 Annual Meeting.

4) AdvaMed Position:  Medicare Incentives for Efficiency and Provider Profiling (Advanced Medical Technology Association)

5) BMC Health Services Research 2006, 6:45 (


Topics #DEA number #MedPAC #physician profile #prescribing information #quality of care