Patient Attribution: Why It Matters More Than Ever
How payers assign patients to you will affect how your practice is evaluated and paid for value in the future.
Fam Pract Manag. 2016 Nov-Dec;23(6):25-30.
Author disclosure: no relevant financial affiliations disclosed.
When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, physicians hailed the demise of the sustainable growth rate formula, which had for many years threatened annual cuts in Medicare reimbursement. Now that MACRA regulations have been finalized, we are learning the extent to which Medicare payment will be transformed.1 Our payments will now be directly connected to the quality and cost of the care we provide. Those of us who provide higher quality, lower cost care will be paid more, and those who do not will be paid less. To accomplish its stated goal of tying 90 percent of all Medicare payments to quality or value by 2018, the Centers for Medicare & Medicaid Services (CMS) must know exactly which Medicare patients are yours – and which are not.2
The process that commercial and government payers use to assign patients to the physicians who are held accountable for their care is called attribution. Think of the patient lists that insurers send in the mail. If you review them at all, some names you recognize, some leave you scratching your head, and some are missing. Yet those lists will increasingly affect how much you are paid, regardless of whether the patients named on them are seen in your office. Understanding how attribution works is an important first step to succeeding in the new payment environment. Knowing which patients are attributed to you by each payer and how value-based payment programs affect different segments of your patient population will help you target your health care team's resources most effectively.
Which patients are yours?
When we think about whose patients are whose, many perspectives come into play. For example, I may see Mrs. Smith every fall and spring for her allergies, but she may see another physician every summer for her annual physical. Mrs. Smith may consider both of us “her doctor,” but her insurance company may not see it that way. The insurer may attribute her to the physician who performed her most recent annual wellness visit or to the one who saw her most recently. Attribution approaches vary, but they share common elements:
Timing. Attribution can be prospective, meaning the payer tells you at the beginning of the measurement year what patients you will be responsible for over the next 12 to 24 months. It can also be retrospective, meaning you find out at the end of the year which patients are in your panel and payers measure your care by looking back at the previous 12 to 24 months. According to the National Quality Forum, two-thirds of implemented attribution models use retrospective timing.3
Type of attribution rule. Some payers attribute patients to the physician who provided the majority of the patient's care. If no physician provided more than 50 percent
1. Medicare Program; MIPS and APM Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. https://qpp.cms.gov/docs/CMS-5517-FC.pdf. Published Oct. 14, 2016. Accessed Oct. 20, 2016.
2. Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. Health and Human Services website. http://bit.ly/1QhLv5b. Published Jan. 26, 2015. Accessed Oct. 20, 2016.
3. Ryan A, Linden A, Maurer K, Werner R, Nallamothu B. Attribution Methods and Implications for Measuring Performance in Health Care. Washington, DC: National Quality Forum; 2016. http://bit.ly/2e3MSsz. Accessed Oct. 20, 2016.
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