Cave Consulting Group, Inc. (CCGroup) has determined that 30% of specialists should receive relaxed prior authorization and utilization management (PA/UM). At issue is that many health plans and other payers have yet-to-implement an evidence-based, clinical decision support system to gold card network specialists.
“Health plans and health systems spend well over $1 billion annually in PA/UM administrative and processing costs. This administrative burden is why health plans need to objectively and clinically relax current PA/UM efforts over the next several years,” stated Dr. Douglas G. Cave, President/CEO of Cave Consulting Group, Inc. (CCGroup). Significant pressure for relief comes from the American Medical Association (AMA) with the 2019-2020 PA/UM Reform Principles, 50 provider healthcare organizations, and the Federal Government with the Regulatory Relief Coalition Bill.
Dr. Cave defined, “Main reform principles are that health plans should restrict PA/UM programs to outlier providers whose ordering patterns differ significantly from their peers; and health plans should offer providers at least one clinically-based alternative to PA, such as ‘gold-carding’ based on clinical decision support systems. Non-outliers are identified through the implementation of a clinical decision support system that retrospectively examines provider performance and adherence to evidence-based medicine.”
“By specialty type, the CCGroup Clinical Decision Support System examines clinical rows of practice for many medical conditions. A clinical row is comprised of a medical condition, an associated MedMarker™, and an established Clinical MedMarker Protocol Range™ – defined further below. There are 58 clinical rows to evaluate cardiologists’ clinical practice. Then, depending on the number of clinical rows passed, an objective ‘Pass’ (non-outlier provider) or ‘Fail’ (outlier provider) is assigned to each specialist,” mentioned Yuri Alexandrian, COO/CIO of CCGroup.
He continued, “As seen in the table below, we examined the Fail rates (outliers) for specialists practicing in five states: Michigan, New York, Ohio, Pennsylvania, and Virginia. When specialists need to pass only 80% of all clinical rows, then 29% of orthopedists, 25% of cardiologists, and 32% of ophthalmologists are classified as outliers. However, if the desired pass rate threshold is increased to 95% of all clinical rows, then 71% of orthopedists, 66% of cardiologists, and 67% of ophthalmologists are classified as outliers.”
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Percent of Outlier Specialists in Five States |
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Outliers (Fail) When Require |
Outliers (Fail) When Require |
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| Specialty Type | 80% Pass Rate | 95% Pass Rate |
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Orthopedists |
29% |
71% |
|
Cardiologists |
25% |
66% |
|
Ophthalmologists |
32% |
67% |
“With fairly strict clinical row standards (95% required pass rate), the CCGroup Clinical Decision Support System shows that up to 30% of orthopedists, cardiologists, and ophthalmologists are non-outlier providers (receive a ‘Pass’ for PA/UM),” declared Dr. Cave. These specialists should be relieved of current PA/UM efforts. Moreover, those specialists that are outliers (‘Fail’ for PA/UM) now understand the objective, process of care patterns needed to obtain a ‘Pass’ in the future.
“We are having success in negotiations to relax PA/UM when clinically appropriate. At this time, pass rates are being set at about 95% of all clinical rows, or fairly strict, as the relief process is getting started. Health plans do not want to lose the PA/UM sentinel effect – important to control unnecessary utilization today,” acknowledged Dr. Cave.
CCGroup has remained the market leader in offering an accurate, vetted, and transparent clinical decision support system to improve the cost-effectiveness of payer PA/UM programs. Medical condition MedMarkers™ and associated Clinical MedMarker Protocol Ranges™ are the foundation of the CCGroup Clinical Decision Support System.
“CCGroup is the only company in the market that has developed MedMarkers™ for all prevalent medical conditions treated by each physician specialty type,” asserted Mr. Alexandrian. MedMarkers™ are process of care quality measures, well-defined in clinical guidelines. However, MedMarkers™ also are the key services and procedures most associated with cost-of-care in treating a medical condition. MedMarker™ technology is protected under USPTO Patent Numbers 8,301,464 and 8,751,283 and 9,881,129 and 10,319,474.
“Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for MedMarkers™. These ranges are developed by presenting the CCGroup National Comparative MedMarker Database™ results to CCGroup National Specialist Panels,” defined Dr. Cave. Clinical MedMarker Protocol Range™ technology is protected under USPTO Patent Number 10,867,361.
The CCGroup Clinical Decision Support System objectively Pass/Fail ranks all 50 of the top specialty and sub-specialty types.
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 29 years for health plans, health systems, HMOs, physician groups, CINs, ACOs, TPAs, and employers.
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