Protecting, maintaining and
improving the health of all Minnesotans
Defining the Unit of Analysis – What is a Provider?
Draft Recommendation – Nov. 19, 2012
What Is The Issue?
Provider organizations are not all organized in similar fashion. For example, there are health systems in
which particular types of patients are only seen at or admitted to a specific practice location (clinic or
hospital). The first iteration of Provider Peer Grouping (PPG) analysis showed that such differences in
organizational structure within health systems may impact the results of cost and quality reporting and
comparisons for clinics and hospitals. Analyzing insurance claims data in ways that do not incorporate
those organizational nuances may create an unfair advantage or disadvantage (introduce a bias) in the
results for certain providers.
What Past Decisions Have Been Made?
1) Members of the 2009 PPG Advisory Group concluded that consumers would receive more useful
information by looking at results in which they could compare specific clinics or hospitals rather than
results for care systems or medical groups more broadly. The rationale for this conclusion was that
internal differences can and do exist across facilities and clinics within a care system and that those
differences are important to consumers.
There was a perceived common understanding of “hospital” and “clinic” to mean a single place of
service for the delivery of health care. Operationalizing this concept initially seemed relatively easy.
2) Hospitals: While the analysis compares Critical Access hospitals (CAH) and Prospective Payment
System (PPS) hospitals in separate peer groups, initially single stand-alone hospitals were compared
within those peer groups rather than selectively rolled up into a combined hospital entity and then
compared. (The analysis did not allow the existence of separate units within a single hospital
campus to exist as smaller “independent” hospitals.)
3) Clinics: The 2009 Advisory Group recommended that, wherever possible, peer grouping should
occur at the clinic site level, although there were concerns among the Group about the practicality
of doing so. Group members recommended peer grouping at the medical group level only if clinic
site peer grouping was not feasible. In fact, the advisory group recommended comparing individual
physicians/surgeons on certain analyses, but because CMS rules prohibit analysis in which physician
Medicare incomes can be calculated, this approach was not pursued.
Analysis has been progressing based on the original assumption that individual clinics would stand
alone for purposes of cost and quality comparisons. Clinics and staff are self-identified through
registration under the State Quality Reporting and Measurement system. Clinics with staffing
capacity to provide mostly specialized care are not included in the PPG reporting framework.
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Protecting, maintaining and
improving the health of all Minnesotans
What Are The Options?
Hospitals:
Option 1: Define hospitals by distinct practice location (the current option), or
Option 2: Combine certain hospitals within care systems that exist as physically separate practice
locations within a medical campus but nonetheless use a business/practice model, operating as if they
are one hospital with more than one location, each of which specializes in a certain type of patients.
Clinics:
Option 1: Define primary care clinics by separate physical practice location and with reference to
information about physician staff and outputs gathered from physician registry (the current option), or
Option 2: Combine certain clinics within care systems that exist in separate physical locations but
nonetheless use a business/practice model operating as if they are one single clinic with more than one
location, each of which treats a certain type of patient.
What Are the Considerations (advantages/disadvantages)?
1) Changes will require devising an operational method to identify providers using the shared facility
practice model and the additional burden this may place on providers to provide better information
about their practice / business model.
2) Certain data needs to be available at the unit of analysis to support the decision;
3) Evaluate the impact against the goal of making reasonable comparisons for provider performance;
4) Impact of the decision on provider ability to identify areas for improvement efforts at particular
practice locations needs to be considered;
5) Impact of the decision on consumer capacity to understand peer grouping reports and make
informed decisions in selecting a health care provider; and
6) For consistency with PPG principles, current community practice in cost and quality reporting
methods need to be considered as part of the decision.
Specific Questions on Which We Seek Advisory Group Input
1) Should certain hospitals with separate practice locations within a care system be combined when
functioning as a single entity within a medical campus?
2) Should certain clinics within a care system be combined to create a single practice location?
For questions 1 and 2 address the following:
a. Always or Never and why?
b. Only under certain practice, organizational, or structural conditions
• What specific conditions?
• How can we identify those conditions and combinations?
• How might this practice of combining for some but not for all effect the results of
the cost and quality measures and their comparison across systems?
85 East Seventh Place • PO Box 64882• St. Paul, MN, 55164-0882 • (651) 201-3560
http://www.health.state.mn.us
An equal opportunity employer
Protecting, maintaining and
improving the health of all Minnesotans
(Draft) Advisory Committee Recommendation:
Note: The committee discussed only how to define the hospital unit of analysis and deferred the
discussion of defining the clinic unit of analysis to be part of the broader clinic peer group selection.
•
The committee recommended Option 1 for defining the unit of analysis for hospitals, agreeing
that defining hospitals by distinct practice location is the best option. Their arguments in favor
of this recommendation were:
o Defining a hospital by practice location will make more sense to consumers than
defining them by their systems. Consumers would really prefer to see procedure-level
costs, not hospital-level and certainly not system-level.
o Since there is enough volume to do the analysis at the individual facility level,
aggregating them seems like going backwards.
85 East Seventh Place • PO Box 64882• St. Paul, MN, 55164-0882 • (651) 201-3560
http://www.health.state.mn.us
An equal opportunity employer