SAN MATEO, Calif.--(BUSINESS WIRE)--Nov 17, 2020--

Clinically integrated networks (CINs) are comprised of employed health system physicians and independent community-based physicians. Most recently, CINs have focused on three major tasks: establish access to care by building out networks to cover geographic regions; build information technology infrastructure to exchange patient electronic health records and clinical data; and contract with third-party payers to receive value-based payments (based on quality and cost savings).

“Contracted value-based payments have been upside-risk oriented. However, both the Centers for Medicare & Medicaid Services (CMS) and health plans are rapidly moving to downside-risk contracts. With this movement, CINs’ next major task is to tier their broad-based networks on efficiency (cost of care) and effectiveness (quality of care) – particularly for CIN specialists,” stated Dr. Douglas G. Cave, President/CEO of Cave Consulting Group, Inc. (CCGroup).

Dr. Cave continued, “Tiering is of immediate importance because CINs will significantly improve their current cost and quality balance.” The most efficient/effective specialists are placed in CIN Tier 1, while the remaining physicians are placed in CIN Tier 2.

Successful CIN tiering is comprised of three initiatives: (1) utilize the most accurate, accepted, actionable and transparent efficiency/effectiveness measurement methods and advanced analytics; (2) access large, external claims-based datasets in order to measure over 70% of practicing physicians; and (3) employ a clinical decision support system to direct CIN Tier 2 physicians on how to obtain Tier 1 status.

“For several decades, CCGroup has remained the market leader in reliably and accurately measuring physician and health system efficiency. CCGroup has many patents protecting its provider efficiency method, analytics, and software. The basic foundations for the CCGroup patents relate to the use of medical condition episodes-of-care, analysis of a relevant set of medical conditions for PCPs and specialists, and proper weighting of those medical condition episodes-of-care to derive overall physician efficiency scores,” asserted Yuri Alexandrian, COO/CIO of CCGroup.

“With respect to the second initiative, large complete datasets are needed to generate enough episodes-of-care to measure physician efficiency and effectiveness. The CCGroup-CMS Innovator Project allows our CIN clients access to all Medicare fee-for-service and Medicare Advantage claims through the CMS Virtual Research Data Center – including all acute care, post-acute care, physician visits, procedures, and pharmacy services. There are more than 60 million beneficiaries. We have multiple years of claims data that includes all 50 states and the District of Columbia,” mentioned Dr. Cave. In addition, our CIN clients may license commercial datasets that are run through our market-leading efficiency and effectiveness methods and analytics.

He continued, “We have accurate overall efficiency scores for more than 75% of all practicing PCPs and specialists. This allows our clients to successfully tier their CIN networks to prepare for downside-risk contracts.”

“Once a CIN is successfully tiered, Tier 2 physicians need to understand how to achieve Tier 1 status for legal reasons and utilization improvement. This initiative entails implementing a clinical decision support system based on medical condition, clinically appropriate ranges of clinical practice,” defined Mr. Alexandrian.

“Our market-leading, clinical decision support system is CCGroup UR/UM-View™. The foundation is MedMarkers™ and Clinical MedMarker Protocol Ranges™. MedMarkers™ are process of care quality measures, well-defined in clinical guidelines. However, they also are the key services most associated with cost-of-care in treating a medical condition. For instance, upper gastrointestinal endoscopy is the main MedMarker™ in treating GERD (or heartburn),” stated Dr. Cave.

Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for a MedMarker™. These ranges are developed by presenting the CCGroup National Comparative MedMarker Database™ results to CCGroup National Specialist Panels. Each specialist on a CCGroup National Specialist Panel is asked to review medical condition MedMarker™ results. Then, they decide the percentage of patients where a MedMarker™ service is likely clinically warranted.

Dr. Cave confirmed, “Tier 2 physicians want to understand the services they need to focus on to reduce unwarranted practice variations. The medical condition MedMarkers™ answer this need. Also, physicians want to know the appropriate level of utilization that does not represent potential under- or over-utilization of services. Clinical MedMarker Protocol Ranges™ answer this latter question.”

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 28 years for health plans, health systems, HMOs, physician groups, CINs, ACOs, TPAs, and employers.

Mr. Yuri Alexandrian,



SOURCE: Cave Consulting Group, Inc.

Copyright Business Wire 2020.

PUB: 11/17/2020 11:00 AM/DISC: 11/17/2020 11:01 AM

Copyright Business Wire 2020.