Population Health:
The Attribution
Challenge
A Town Hall Event by the C&BI
Population Health-Accountable Care
Task Force
April 29, 2015
HIMSS Town Hall Series
Definition: an informal public meeting that gives
the members of a community an opportunity to get
together to discuss emerging issues and to voice
concerns and preferences for their community.
Attribution – Why is this important?
•
Why does patient attribution matter?
•
Does it matter differently to different groups?
–
To payers?
–
To providers?
–
To patients?
–
To quality directors?
3
Executive Summary
1. There are multiple stakeholders involved in population health
programs including patients, payers, physicians and hospitals.
They may have competing self interests….
2. Ultimate goal should be on improving the health of the population,
enhancing the experience and outcomes of the patient, and
reducing per capita cost of care for the benefit of communities.
3. The specific objectives of the ACO program drives the metrics
which has an impact on the types of physicians that make up the
program.
4. Patient\Physician attribution drives who is in an ACOs cohort of
patients and how those patients are assigned (or not) to individual
physicians.
4
Executive Summary - Continued
5. There is no silver bullet attribution method that applies to all ACOs
or contracts. The same method may not be best from the
perspectives of payers, providers and patients.
6. There are pros and cons to the various approaches that need to be
weighed since they directly impact physicians and patients.
7. For traditional ACOs (i.e., commercial or MSSP) payers typically
drive attribution. You may not have a choice if you want to get in
the game and perhaps that makes life easier…..
8. Patients have choices with their payers and who they see, and
therefore you need a flexible feedback mechanism to update the
attribution assignments.
5
Patient Attribution - Science or Art?
• Attribution formulas and change policies can be a slippery slope
•
Consistent over life of contract
•
Easy to understand, maintain and enforce
• Patient Assignment Challenges (stickiness)
•
Can be controversial since it impacts economics of practices
•
Can be complex given patient types – Medicare (Pham et al, 2007)
•
•
Medicare patients annually see a medium of two PCPs and 5 specialists working in
4 different practices
•
35% of beneficiaries visits each year were with assigned physician
•
Assigned physician changed from year to year for 33% of beneficiaries
Can differ depending an overall health – patients with chronic conditions stray from their
ACOs more compared to others (Brookings 11-10-2014)
• What Types of Physicians or Staff Participate Normally
•
Primary Care
•
Specialists that provide care to patients with certain chronic conditions (Internal
Medicine, Cardiologists and Endocrinologists)
6
Patient Attribution - Science or Art?
• Individual Physician or Physician Group?
• Groups more feasible and reliable but may diffuse responsibility.
• Prospective vs. Retrospective
• Prospective – PCMH, physicians have discretion to assign
patients
• Retrospective – ACO, patients assigned based on past utilization
periods (12, 18, 24 months, etc.,)
• Other Considerations
• Should physicians be able to exclude patients, what are viable
reasons for refusal?
• Patient notification and opt out principles
7
Medicare Shared Savings Program
Breakdown
•
Education and notice of patients on “opt out”
•
Report back to CMS on patients opting out
•
2 year utilization to create attribution
•
Patient attributed at organizational or TIN level, claims
do not often contain NPI making attribution difficult
•
Patients may not be aware that they are assigned to
an ACO and can go outside of network
•
24 months of claims history needs to be loaded
•
Quarterly Updates on Patient Attribution (refresh)
8
Real Attribution Problems Today – Case
Study
• Only around 50% of CMS data is assigned to an
actual PCP
• Large Owned PNO (TIN) may have multiple
practices and offices making patient assignment
difficult
• How can we automatically assign a patient to a
PCP using trumping logic?
1. Inferred match based on 24 months of clinical data and
payer. Named individuals with most encounters. Tie
goes to the most recent.
2. EMR patient to PCP link trumps inferred match #1
3. Manual updates on population tool trump #1 and #2
9
Town Hall Discussion
•
What are your goals for attribution? And does attribution matter
differently to different groups?
•
To payers?
•
To providers?
•
To patients?
•
To quality directors?
•
For a specific program and it’s time frame, do you manage for attributed
patients? Or all possible patients?
•
How do you know if your attribution logic is working well? What are
some of the signs that it is meeting or not meeting your goals?
•
What is the attribution logic differences between a clinically integrated
delivery network and an ACO?
•
How are you using data for your patient-to-provider matching logic?
10
Next Steps
Let’s continue the conversation
and learning
• Blog posts
• Key findings and take-aways
• Articles
FY15 C&BI Leadership Information
Committee Chair:
JD Whitlock, MPH, MBA, CPHIMS
Vice President, Clinical & Business Intelligence
Mercy Health
JDWhitlock@mercy.com
Population Health-Accountable Care Task Force Co-Chairs:
William Beach, MBA, MLA, PhD
Jennifer Jackson
Regional Director, Regulatory Readiness, Northern Region, Senior Director, IT Population Health Data Solutions
St. Joseph Health System
Banner Health
William.Beach@stjoe.org
Jennifer.Jackson@bannerhealth.com
Community Co-Chairs:
Michael Brooks, BS, MBA, CPHIMS
Specialist Leader
Deloitte Consulting LLP
mibrooks@deloitte.com
Mike Berger, PE, CPHIMS
Chef Analytics Officer
Affinity Health Plan
Mberger@affinityplan.org
HIMSS Community Organizers | Staff Liaisons:
Shelley Price, MS, FHIMSS
Director, Payer & Life Sciences, HIMSS
sprice@himss.org
Nancy Devlin
Senior Assoc., Payer & Life Sciences, HIMSS
ndevlin@himss.org
Thank you!