Cave Consulting Group, Inc. (CCGroup) initiated this study to quantify the COVID Effect’s impact on decreased U.S. healthcare utilization. Decreased utilization is a function of at least two components: (1) decreased volume of medical condition episodes seen by PCPs and specialists; and (2) decreased volume of key medical services (MedMarkers™) used to diagnose and/or treat those medical condition episodes that are seen by PCPs and specialists. “We examine here only the initial component, decreased volume of medical condition episodes,” stated Dr. Douglas Cave, President of CCGroup.

Dr. Cave continued, “Overall medical condition episode volume decreased 17% due to the COVID Effect.”

• Primary care physicians (PCPs) versus specialists:
  • PCP episode volume decreased 13% (range: -10% to -15%).
  • Specialist episode volume decreased 18% (range: +3.5% to -49%).
• Acute versus chronic medical condition episode volume:
  • Acute medical condition episode volume decreased 19%.
  • Chronic medical condition episode volume decreased 16%.

Dr. Cave stated, “We used the Cave Grouper™ and CCGroup Clinical Decision Support System™ (CDSS) to quantify the COVID Effect. The CDSS examines provider performance and adherence to evidence-based medicine. By PCP and specialty type, the CDSS 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™.”

MedMarkers™ are process of care quality measures, well-defined in clinical guidelines, and also are the key services most associated with cost-of-care in treating a medical condition. Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for a MedMarker™. Ranges are developed by clinical responses obtained from CCGroup National Specialist Panels.

The CCGroup Clinical Decision Support System is used by CCGroup clients for the following strategic needs: limit prior authorization programs to outlier provider groups whose ordering patterns differ significantly from clinically appropriate ranges of clinical practice; implement value based payment based on both cost and quality of care; steer members to ‘preferred’ specialists by medical condition procedure based on cost, quality, and access to care; and appropriate care clinical transformation.

“Significant decreases in MedMarker™ utilization may be attributed to changes in provider group practice patterns or to the COVID Effect. Therefore, decreases attributed to the COVID Effect need to be quantified to better understand changes in provider practice patterns variation over time,” defined Dr. Cave.

A conclusion from this study is that the reduction in episode volume affects the CDSS number of clinical rows a provider group has to evaluate clinical performance. “For example, there currently are 80 clinical rows to evaluate orthopedists’ clinical practice. Lowest-episode volume orthopedic groups generally have between 5 and 25 clinical rows with >10 medical condition episodes (in the baseline years 2017, 2018, and 2019). However, the COVID Effect in 2020 reduces this number to between 3 and 15 clinical rows with >10 medical condition episodes,” mentioned Dr. Cave.

Results for the lowest-episode volume orthopedic groups imply clinical performance will be judged somewhat differently in 2020 as compared to baseline years (as there are fewer clinical rows to evaluate CDSS performance). This finding is not as relevant for the higher-episode volume orthopedic groups.

For this study, CCGroup used the CCGroup-CMS Innovator Project and the 32 million Medicare fee-for-service (FFS) beneficiaries claims data for 2017, 2018, 2019, 2020. CCGroup controlled for differences in Medicare beneficiary case mix by using a marketbasket of relevant, prevalent medical conditions for PCPs and each specialty type. Each marketbasket of medical conditions accounts for greater than 80% of episodes treated by a specialty type. Also, CCGroup used 2017, 2018, and 2019 medical condition episode volume to control for other potential environmental factors affecting utilization over time.

About Cave Consulting Group, Inc. (CCGroup)

CCGroup 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 30 years for health systems, physician groups, clinically-integrated networks, health plans, HMOs, TPAs, and employers.

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