Physician profiling using outpatient pharmacy data as a source for case mix measurement and risk adjustment

Abstract

Pharmacy data are a potential source of information on the health risks of members in a managed care organization (MCO). Reasons why these data can serve as a basis for case mix measurement of MCO populations are reviewed. Several pharmacy-based case mix measurement systems (CDS, KPARx) are summarized. Applications of pharmacy-based case mix systems for profiling of primary physician panels in an MCO are discussed and illustrated with several examples.