“O, wad some Power the giftie gie us,
To see oursels as others see us!”

The Scottish poet Robert Burns unintentionally captured in that line the two main benefits of clinical profiling in healthcare. First, the gift for healthcare providers to clearly see how they measure against local, regional and national-level benchmarks, and second, for health insurers, employers, health plan organizations and their members to see the same benchmark information.

What Is Clinical Profiling?

Clinical profiling (the term also covers hospitals and healthcare provider networks) is how providers, health insurers, managed care organizations and government agencies use pattern-based performance measures to compare quality of care, service usage, and costs. These comparisons are based on normative or community-based standards.

Clinical profiling provides key performance measure benchmarks to help identify where a provider is underperforming. These measures include member-relevant specifics like inpatient stay durations, mortality rates, service costs, readmission rates, and patient satisfaction.

Who Supports Clinical Profiling?

Three organizations offer performance measures to monitor and evaluate healthcare provider performance:

  • The National Quality Forum promotes and ensures patient protections and healthcare quality improvements with quality measurements and public reports.
  • The Agency for Healthcare Research and Quality maintains the Consumer Assessment of Healthcare Providers and Systems, a survey which assesses patient experiences with hospitals, primary care providers, and nursing homes. The Centers for Medicare & Medicaid Services (CMS) uses these survey results in its online hospital comparison tool and in its provider rating system.
  • The National Council for Quality Assurance is responsible for maintaining the Healthcare Effectiveness Data and Information Set (HEDIS) for special needs providers, covering more than 90 measures of care that affect more than 100 million people in the United States.

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Benefits of Clinical Profiling

Clinical profiling helps members and providers. Here are a few of the ways it benefits each:

Benefits for Members:

  • Clinical profiling gives members meaningful provider comparative data. This empowers them to be well-informed healthcare shoppers. In so becoming, they contribute to the upward pressure on provider quality.
  • Members also benefit when health insurers, employers, and health plan organizations use HEDIS data to evaluate providers and choose which ones to partner with.

Benefits for Providers:

  • Clinical profiling gives providers a measurable framework to objectively evaluate how they are doing in the healthcare marketplace. Although internal quality improvement initiatives are helpful, without the broader context of peer-level comparisons it is hard to know how useful they are.
  • Clinical profiling promotes healthy competition among providers. It shows them where they can or must improve their quality of service to members. It also helps weed out marginal performers, improving the overall level of care.
  • Clinical profiling can reduce the risk of medical malpractice and hospital negligence claims. These claims are based not on individual negligence, but on what an average physician would do. If clinical profiling data reveals below-average member care in any area, the provider has the chance to correct the problem before it becomes a legal issue.

How Are You Using Clinical Profiling?

Clinical profiling is an essential tool to measure provider performance. Are you a health plan or healthcare organization seeking to obtain an accurate profile of your members or patients? It all starts with the quality of member data you obtain. At the top of this page you can choose the Solutions menu option to explore our risk adjustment and quality improvement software and services.

About The Author

Reveleer is a healthcare software and services company that empowers payers in all lines of business to take control over their risk adjustment and quality improvement programs. The Reveleer platform enables payers to independently execute and manage every aspect of provider outreach, retrieval, coding, abstraction and reporting – all under one single platform. Leveraging its technology, proprietary data sets, and subject matter expertise, Reveleer also assists payers with full record retrieval and review services to support financial performance and improved member outcomes.