Attribution Models and Implications
HFMA Managed Care Education Committee July 16, 2014
Tim Ford
Agenda
Why Attribution Matters?
Medicare’s Attribution Methodology for the MSSP
Other Methodologies
Attribution and Risk Adjustment
Accountability
Why does attribution matter?
Purpose
ATTRIBUTION ACCOUNTABLITY
Cost
Overall accountability, cost and quality, for member’s will increasingly move
to providers.
There will be a continuum of that shift:
Shared Savings will be the predominate model of accountability in the
market for the near future.
Payment Model Transformation
Fee-for-Service
Shared Savings
Capitation/Budgets
Continue to be paid fee-for-service payments
Opportunity to earn additional value based payments if total
costs are less than projected
Source Data for Attribution
• Patient Attribution is inferred from Claims Data
• Claims Concerns
– Timeliness Run out – Accuracy
Medicare’s ACO Beneficiary Assignment
• Preliminary prospective assignment with final retrospective beneficiary
assignment
– Beneficiary assignment is determined in the benchmark years of the agreement period and then re-determined retrospectively at the end of each performance year.
• A beneficiary assigned in one year of the program may or may not be
ACO Beneficiary Assignment Schedule
• CMS will make preliminary beneficiary assignments to an ACO at the
beginning of a performance year based on the most recent four quarters of available data.
• On rolling four-quarter basis, CMS will continue to assign patients to an
ACO, and will provide an updated list of beneficiaries.
• Final assignment for financial reconciliation will be determined after the
ACO Assignment Data Requirements
• List of participants
• Names and identifiers (Taxpayer Identification Numbers [TIN], CMS
Certification Numbers [CCN], and National Provider Identifier [NPI])
• Identifiers needed to identify claims submitted by the ACOs
• Identifiers are checked for veracity using PECOS and other CMS data
ACO Assignment: Beneficiary Eligibility
A beneficiary is eligible to be assigned to a participating ACO if the following criteria are satisfied during the assignment period:
• Beneficiary must have a record of Medicare enrollment
• Beneficiary must have at least one month of Part A and Part B enrollment,
and cannot have any months of only Part A or Part B
• Beneficiary cannot have any months of Medicare group (private) health
plan enrollment
• Beneficiary must reside in the United States including Puerto Rico &
Territories
• Beneficiary must have a primary care service with a physician at the ACO
Assignment of a Beneficiary to an ACO
If a beneficiary meets the eligibility criteria, the beneficiary is assigned to an ACO using a two-step process:
• Step (1): If the beneficiary has at least one, and overall the plurality of
their primary care services furnished by a primary care physician at the participating ACO (measured by Medicare allowed charges), then the beneficiary is assigned to the participating ACO.
• Step (2): Applies to beneficiaries who have not received any primary
care services from a primary care physician. If the beneficiary has at least one primary care service furnished by an ACO physician at the participating ACO, and have received more primary care services from ACO professionals (physician regardless of specialty, NP, PA or CNS) (measured by Medicare allowed charges) relative to any other ACO or non-ACO individual or group, the beneficiary is assigned to that
ACO Assignment: Individual Provider Types
• Primary Care Physicians (PCP)
– Internal Medicine – Family Practice – General Practice – Geriatric Medicine
• Other physicians (M.D., D.O.)
• ACO Professionals include both of the above types of physicians plus:
– Nurse Practitioners (NP)
ACO Assignment: Definition of Primary Care Services
• Evaluation & Management Services provided at:
– Office or Other Outpatient settings (CPT 99201 – 99215) – Nursing Facility Care settings (CPT 99304 - 99318)
– Domiciliary, Rest Home, or Custodial Care settings (CPT 99324 - 99340)
– Home Services (CPT 99341-99350)
• Wellness Visits (HCPCS G0402, G0438, G0439)
• Clinic visits at RHC/FQHCs or by their providers in selected settings (UB
ACO Assignment: Notes for following examples
• Organizational ID
– Is the A# for each ACO—all TINs and CCNs on an ACO’s participant list are associated with the ACO’s A#
– TIN or CCN for non-ACO practices and providers
• For each beneficiary assignment example, the top row indicates the ACO
ACO Assignment Example 1
• Beneficiary A1 is assigned to ACO A9999 because A9999 had the
highest allowed charges for primary care services provided by a primary care physician ($454) even though two other non-ACO practices had higher allowed charges provided by ACO
professionals
ACO Beneficiary Organization ID PCP Professional
A1 A9999 $454 $654
A1 555555555 $300 $1,900
A1 456565656 $250 $2,500
ACO Assignment Example 2
• Beneficiary B3 is assigned to a non-ACO provider (333333333) because it
had the highest allowed charges for primary care services provided by a primary care physician ($1,200)
ACO
Beneficiary Organization ID PCP Professional
B3 333333333 $1,200 $1,250
B3 A5656 $800 $800
B3 A9999 $600 $700
ACO Assignment Example 3
• Beneficiary A3 did not receive any primary care services from a primary care physician. So A3 is assigned to ACO A9999 on the basis of the highest allowed charges for primary care services provided by ACO professionals ($300)
ACO Beneficiary Organization ID PCP Professional
A3 A9999 $0 $300
A3 555555555 $0 $250
A3 333333333 $0 $200
Typical Quarter to Quarter Turnover Q0/14 Q1/2014 % from Q0/14 Bench 100.00% 82.41% % New Beneficiaries 0.00% 17.59% 100.00% 82.41% 17.59% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00%
Quarterly Turnover Analysis
Reasons for Turnover
(1) (2) (3) (4) (5) (6) Beneficiary did
not receive the plurality of his/her primary
care services4 from the ACO5
Beneficiary had at least one month of Part A-Only Or Part B-Only Coverage6 Beneficiary had at least one month in a group health plan7 Beneficiary does not reside in the United States8 Beneficiary included in other Shared Savings Initiatives9 Beneficiary did not have a physician visit with an ACO provider10 XXXX 0 0 0 0 0 0 1 XXXX 1 0 0 0 0 0 1 XXXX 0 0 0 0 0 0 1 XXXX 0 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 XXXX 0 1 0 0 0 0 0 XXXX 0 1 0 0 0 0 0 XXXX 0 0 0 0 0 0 1 XXXX 0 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 XXXX 0 1 0 0 0 0 0 XXXX 0 0 0 0 0 0 1 XXXX 0 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 XXXX 0 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 XXXX 0 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 XXXX 1 0 0 0 0 0 1 XXXX 0 1 0 0 0 0 0 Year 2014, Quarter 1
Reason(s) Beneficiary Not Currently Assigned1
Deceased Beneficiary
Flag3
Table 1-5
Quarterly Beneficiary Turnover Analysis HICNOs of beneficiaries assigned in most recent prior quarterly report and not currently assigned
Alternative Methodologies to Retrospective Attribution
Prospective
Set at beginning of measurement period – no
adjustments
Set at beginning of measurement period –
retrospective adjustment
Fluid
Changes month to month
Non-PCPs
Attribution is Not Effective Without Risk Adjustment
Risk adjustment methodologies are essential to describing an
attributed population.
A global risk score can be calculated for each beneficiary with 1.0
being the average.
Risk Adjustment Models
DISCUSSION
We assessed 6 risk instrument methods based on administrative and demographic data. We evaluated the performance of the 6 models against one another to assess the ability to predict future healthcare utilization. We concluded that the ACGs produced a more accurate prediction of future healthcare utilization relative to the other models.
All risk prediction models for hospitalization had fair predictive value, with (Johns
Hopkins) ACG having the highest overall predictive C statistic at 0.73 and the HCC model having the lowest predictive C statistic at 0.67.
Health-Lynx uses the Johns Hopkins ACGs
Calculating Savings with Risk Adjustment - Illustration
Group Name Attributed Lives
Prospective Risk Score 2012 Actual Cost 2012 Predicted Cost Difference Neptune Associates 68 1.64 $1,167,057 $1,282,480 ($115,423) Caldwell Associates 292 0.93 $3,264,828 $3,122,940 $141,888 Livingston Associates 101 1.55 $1,512,273 $1,800,325 ($288,052) Newark Associates 89 1.37 $1,163,822 $1,402,195 ($238,373) Orange Associates 83 1.40 $1,176,130 $1,336,300 ($160,170) Nutley Associates 112 0.98 $1,085,526 $1,262,240 ($176,714) Teaneck Associates 243 1.12 $3,693,211 $3,129,840 $563,371 Patterson Associates 765 2.09 $17,099,701 $18,386,775 ($1,287,074) Montclair Associates 188 1.64 $3,084,742 $3,545,680 ($460,938) Passaic Associates 376 2.38 $9,974,260 $10,282,742 ($308,482) Millburn Associates 432 1.01 $4,395,767 $5,017,680 ($621,913) Essex Associates 358 0.88 $2,872,471 $3,622,960 ($750,489) Verona Associates 109 1.23 $1,475,189 $1,541,805 ($66,616)
West Caldwell Associates 565 1.04 $6,014,086 $6,757,400 ($743,314)
Should Attribution be to Individual PCPs?
Is it effective to focus accountability at the PCP level:
Medicare beneficiaries see an average of more than five
unique providers
23% of Beneficiaries have more than 5 chronic
conditions
Patients don’t always share
The Population Challenge
Source: MedPAC, A Data Book: Healthcare spending and the Medicare program, June 2010
ACO Population Health Management Health Assessment Risk Stratification Engagement Predictive Modeling Care Continuum Moderate Risk
No or Low Risk High Risk
Health Management Interventions
Health Promotion • PCP Attribution • Education • Health Assessment • Prevention Reminders Health Risk Management • Health Coaching • Support Tools/Resources • Follow up Assessments
• Care Gap Intervention
Care Coordination • Network Steerage • Discharge Planning • Care Transition Management • Case Management Chronic Condition Management • Individualized Health Coaching
• Empowerment for Self Management • Provider Collaboration • Health Promotion Operational Measures Health Behaviors Health Outcomes Patient
Stratifying an ACO Population
Providers know
Disease based
Chronic Conditions
Hospitalizations/Re-admissions
Creating Target Lists
Health-Lynx generates high value patient lists that target opportunities for care management interventions.
Lists all the doctors the patient has visited
Lists the patients’ diagnosed conditions
Lists all the billed patient visits to inpatient facilities and outpatient offices
Lists all prescribed
medications for the patient Lists all non-physician claims
Targeted Patients/Focused Metrics
Return to your targets
Measure progress against baselines
“Team Care” Description
Some doctors and health care systems are changing to a new model of
providing health care that is more centered on the patient. In this type of care, your primary care provider takes the lead in all of your health care. His or her team would work with you to get all the care you need, schedule
appointments, and communicate with all of your providers.
If you were in a hospital, for example, your primary care provider would be in contact with the hospital and help oversee what care you need and what
follow-up you would need. There would also be a point-person in your doctor’s office you could call at any time to ask questions, understand your health, and help you get the health care you need. This is often called “team care.”
PerryUndem Survey, April 2014
