Part 2: CCGroup Clinical Decision Support System Quantifies "COVID Effect" on Decreased Healthcare Utilization in the United States

This Cave Consulting Group Inc. (CCGroup) study quantifies 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 (MedMarkerstm) used to diagnose and/or treat those medical condition episodes that are seen by PCPs and specialists.

Part 1 results examined the decreased volume of medical condition episodes ? and results were published in a press release on August 25, 2022. Those results showed episode volume decreased 17% attributed to the 2020 COVID Effect. Primary care physician (PCP) episode volume decreased 13%, while specialist episode volume decreased 18%.

Part 2 results published here evaluate the second component of decreased utilization attributed to the 2020 COVID Effect: decreased volume of MedMarkerstm per episode used to diagnose and/or treat medical condition episodes seen by PCPs and specialists. "MedMarkerstm 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," stated Dr. Douglas Cave, President of CCGroup.

Dr. Cave said, "In total, MedMarkertm per episode rates decreased 9% because of the COVID Effect."

• MedMarkertm rates for services greater than $10,000 decreased 11% (range: +9% to -33%).
• MedMarkertm rates for services $2,500-to-$10,000 decreased 11% (range: +5% to -35%).
• MedMarkertm rates for services less than $2,500 decreased 8% (range: +14% to -48%).

"Combining the two components tested in this study, the 2020 COVID Effect reduced medical condition MedMarkertm volume by 27% (or 17% decreased episode volume x 9% decreased MedMarkerstm per episode)," defined Dr. Cave.

Importantly, the CCGroup Clinical Decision Support System (CDSS) depends on medical condition MedMarkerstm and associated Clinical MedMarker Protocol Rangestm to evaluate providers' clinical performance with respect to the following: 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; and steer members to ?preferred' specialists by medical condition procedure based on cost, quality, and access to care.

Dr. Cave stated, "Therefore, we need to quantify the 2020 COVID Effect on MedMarkertm volume to adjust for the COVID Effect on observed provider practice variations. With COVID Effect adjustment, clinical leaders and utilization management teams may determine actual reductions in provider pattern variations."

Study Part 2 (published here) showed a 9% reduction in MedMarkertm volume per episode. This reduction was somewhat higher for more expensive healthcare services as compared to less expensive services. "For a provider group, MedMarkertm rate reductions mean that more CDSS clinical rows will fall within defined Clinical MedMarker Protocol Rangestm ? and pass clinical evaluation. Consequently, without adjusting for the COVID Effect, more provider groups will be classified both as non-outliers with respect to prior authorization and into higher-paying value based payment tiers," mentioned Dr. Cave.

As the COVID Effect diminishes in 2022-2023, true outlier provider groups will return to their outlier status. This is because MedMarkertm rates will again increase to more normal levels. Then, true outlier provider groups will fall outside achievable Clinical MedMarker Protocol Rangestm ? and fail clinical evaluation.

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, we used 2017, 2018, and 2019 medical condition episode volume to control for other potential environmental factors affecting utilization over time. CCGroup removed high-end and low-end outlier MedMarkertm clinical rows based on MedMarkertm utilization volume within each stratification category: >$10,000; $2,500 to $10,000; and <$2,500.

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.