Attribution Models and Implications HFMA Managed Care Education - - PowerPoint PPT Presentation

Attribution Models and Implications

HFMA Managed Care Education Committee July 16, 2014 Tim Ford Executive Vice President

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Agenda

 Why Attribution Matters?  Medicare’s Attribution Methodology for the MSSP  Other Methodologies  Attribution and Risk Adjustment  Accountability  Population Health

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Why does attribution matter?

MOMENTUM AWAY FROM FEE-FOR-SERVICE PAYMENT

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Purpose

ATTRIBUTION ACCOUNTABLITY

• Cost
• Quality

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 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.

Health Care Insurance Issuer (underwriting) Pay for Performance Incentives Partial Capitation (prof services) Delegated Model (percent of premium) Shared Savings

Accountability

Perspective

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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

 No downside financial risk— e.g. no withholds or paybacks

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Source Data for Attribution

• Patient Attribution is inferred from Claims Data
• Claims Concerns

– Timeliness

• Run out

– Accuracy

• Listed NPI

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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

assigned to the same ACO in the following or preceding years.

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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

• f 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

performance year based on data with a 3-month claims run out.

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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

systems

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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

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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 participating ACO.

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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) – Clinical Nurse Specialist (CNS) – Physician Assistant (PA)

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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

revenue center codes 0521, 0522, 0524, 0525)

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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
• r non-ACO provider to which the beneficiary was assigned

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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 Allowed Charges for Primary Care Services

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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 Allowed Charges for Primary Care Services

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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 Primary Care Services Allowed Charges for

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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

% from Q0/14 Bench % New Beneficiaries

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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 1 XXXX 1 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 XXXX 1 1 XXXX 1 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 Medicare Shared Savings Program

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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

• Allow specialists to be accountable providers

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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.

 There is a prospective risk score – predicting utilization  There is a concurrent risk score – reflects current status  Addresses the issue – My patients are sicker

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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

“Risk-Stratification Methods for Identifying Patients for Care Coordination” Lindsey R. Haas, MPH; Paul Y. Takahashi, MD; Nilay D. Shah, PhD; Robert J. Stroebel, MD; Matthew E. Bernard, MD; Dawn M. Finnie, MPA; and James M. Naessens, ScD, Am J Manag Care. 2013;19(9):725-732

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The John Hopkins ACG Model

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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) Seton Associates 28 1.12 $439,333 $360,640 $78,693 Marlton Associates 1318 1.34 $20,919,691 $20,310,380 $609,311 Oakley Associates 201 1.90 $3,864,828 $4,391,850 ($527,022) Cruise Associates 139 1.03 $1,433,207 $1,646,455 ($213,248) Nicholson Associates 657 1.27 $10,267,169 $9,595,485 $671,684 Springsteen Associates 118 1.88 $2,418,799 $2,551,160 ($132,361) 6,242 1.41 $97,322,090 $100,064,852 ($4,025,242)

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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
• Is there really a “care general”?
• Does assigning one make it so?

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The Population Challenge

Source: MedPAC, A Data Book: Healthcare spending and the Medicare program, June 2010

Most Costly 1% 

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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 Satisfaction

Quality of Life Cost Trend

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Stratifying an ACO Population

 Providers know  Disease based  Chronic Conditions  Hospitalizations/Re-admissions

Utilize a statistically derived risk prediction model that can incorporate multiple dimensions

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Creating Target Lists

Health-Lynx generates high value patient lists that target opportunities for care management interventions. They are:

High Cost Complex Care Management Emerging Risk

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Utilizing Multiple Dimensions

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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

“Patient At A Glance” – Every Patient Has Their Own Story

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Targeted Patients/Focused Metrics

• Return to your targets
• Measure progress against baselines
• Enforce accountability

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“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

• ffice 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.”

What is a Better Patient Experience?

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PerryUndem Survey, April 2014

Findings from Recent Survey of Elderly

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Tim Ford EVP, Health-Lynx tford@health-lynx.com 732-562-7805