Physicians will save you money -- if you give them the info they need

Physician profiling leads to lower supply costs, OR time

When it comes to controlling costs in same-day surgery, the most important decisions are out of your hands. Physician time in the OR determines your scheduling and staffing needs, and physicians dictate their supply and equipment choices.

Yet by providing solid data and a forum for discussion, same-day surgery managers can influence physician behavior, says Ben Rountree, PhD, a health care management consultant based in Benicia, CA. After surgery centers implement "physician profiling," supply costs drop by 4% to 6% and OR time gradually declines, he says.

Physician profiling is not a system of economic credentialing, in which facilities select physicians based on their cost-effectiveness. Rather, it is a method of making comparisons of supply usage and OR time that physicians will view as statistically sound, Rountree says.

That makes profiling a powerful way to influence behavior, he says.

"You don't have to say anything to the docs," Rountree says. "They are very intelligent. They are very oriented to data. They are very competitive. The information alone is motivating toward change."

El Camino Surgery Center in Mountain View, CA, found a receptive audience as it began physician profiling with orthopedic and ophthalmic surgeons last year.

"They don't want to be the most expensive," says Sharon Geffner, RN, El Camino's cost analysis coordinator. "They all have their egos. They don't want to be the doc who's costing three or four times as much."

The key to physician profiling lies in its methodology. It relies on clusters of CPT codes, which recognize the variable complexity of procedures.

For example, an arthroscopy with meniscectomy and debridement can vary from 60 minutes to 130 minutes, including turnaround time, Rountree says. Supply costs also vary substantially. For example, shoulder repair surgery supply costs range from $265 to $850.

"Physicians don't generally do a single procedure when they're in the operating room," he says. "If you look at their data, they'll have two to 12 CPT codes for each case they deal with."

For physicians to consider the OR data to be valid, it must take into account both primary and secondary CPT codes, Rountree emphasizes.

To arrive at clusters, Rountree first sorted El Camino surgical cases into their groups of CPT codes. He began with 1,311 such groups. With the advice of nurses and surgeons, he narrowed those down to the most common groupings. For example, he reduced the orthopedic clusters from 318 CPT groupings to 71. He then compared those 71, statistically, with regard to OR time and supplies used and combined them into 26 clusters that have similar resource consumption. El Camino provided physicians with the cluster descriptions, and physicians made minor modifications in the groups of CPT codes that were combined.

Without those clusters of CPT codes, physicians could argue that their difference in OR utilization related to differences in procedures, says Geffner. "Some of them would say, 'Sure you said an arthroscopy and you showed mine takes a half hour longer, but that's because, in addition, I do this procedure," she says.

Rountree and El Camino's executive director, Nancy Webb-Kessler, RN, MS, are making the clusters available to other surgery centers through the newly created, nonprofit Institute for Ambulatory Care Management in Mountain View, CA. A physician profiling model that uses clusters to produce reports is available for ophthalmology, gynecology, orthopedics, and general surgery. A price has not yet been determined. (For more information, see sources, p. 15.)

Only routine data collection required

The data collection required for physician profiling is simple and already may be gathered for other cost analysis purposes in same-day surgery programs, Geffner says.

The elapsed OR time -- from the time the anesthesiologist begins to the time the patient leaves the OR -- is recorded in the patient record, says Geffner. The OR time includes patient prep as well as the actual surgery, she says. Records also include post-anesthesia care unit (PACU) time -- the time the patient enters the PACU until discharge.

Preference cards are used to keep track of supplies. If the physician makes changes during a case, they are noted by a nurse. Records also reflect the names of physicians who dealt with the patient and the type of anesthesia used, she says.

Collecting good data is critical for physicians to trust in the profiling system, says Webb-Kessler. "If you're going to tell doctors that the cost of doing a procedure is X, you better be sure the figure is accurate," she says.

Physician profiles are produced quarterly using SPSS statistical software from a Chicago company that uses the same name as the software. A pie chart shows a breakdown of the physician's procedures by primary CPT code. Then bar charts show the physician's range of OR time and cost and a comparison of OR time and supply cost with other physicians practicing at the center.

Through the Institute for Ambulatory Management, Webb-Kessler hopes to develop a regional and national database of comparisons related to physician profiling. The research should help physicians make cost-quality decisions, she says.

"If you look at something as simple as arthroscopy blades, they can vary in price by $50, with no difference in their quality," says Webb-Kessler. "If the doctors know there's a difference in price, they will hopefully elect to use the less expensive one."

Physician profiling may sometimes justify more expensive supplies, she says. She recalls one physician who used much more expensive supplies for arthroscopies. Yet the OR time and patient recovery were much quicker.

"The cost of surgery is in part staff time," she notes. "If you can do cases faster, you can add additional cases to the schedule without needing to increase staffing."

Docs warm to idea of profiles

Initially, physicians may be skeptical about physician profiling, Webb-Kessler warns.

"The first reaction is usually, 'Are you going to do economic credentialing?'" she says. "The next is, 'Are you going to try to force us to do something?' The last is, 'This is very interesting.' There was a lot of fear at first that we were going to try to make policy using these numbers."

Instead, El Camino Surgery Center provides the information and a forum for discussion. Rountree suggests presenting the profiles at quarterly meetings for each physician specialty. The meeting may include dinner followed by a slide show, he says.

Each physician receives charts and graphs showing his or her OR time and supply costs and comparisons, without identifying the other physicians. Same-day surgery managers also provide preference cards; one center even uses the preference cards as place cards at the meeting, Rountree says.

After presenting the information, same-day surgery managers can let physicians guide the discussion, he says.

"They're very willing to take a look at the specifics," Rountree says. "Nobody wants to be unreasonably expensive because it looks like waste. It doesn't look like [the differences in OR time and supplies relate] to quality when they're all together" making comparisons, he says.

In some cases, physicians will make changes in their preference cards on the spot. It may take longer -- three or four quarters -- before centers detect changes in OR time, says Rountree. Long-term gains have yet to be measured; the clusters used in physician profiling were developed just a year ago.

As managed care makes greater inroads nationwide, Webb-Kessler predicts that more same-day surgery centers -- and physicians -- will be interested in the profile information. The Institute for Ambulatory Care Management will be the conduit, she predicts. "We want to help people do it without [them] having to be the pioneers," she says. *

For more information on physician profiling, contact:

* The Institute of Ambulatory CareManagement, 2480
Grant Road, Mountain View, CA 94040. Telephone: (415) 988-7990. Fax: (415) 960-7041.

* Ben Rountree, Rountree Consulting, 476 Casey Court, Benicia, CA 94510. Telephone: (707) 747-5354.