Attribution Models and Implications HFMA Managed Care Education Committee July 16, 2014 Tim Ford Executive Vice President
Agenda Why Attribution Matters? Medicare’s Attribution Methodology for the MSSP Other Methodologies Attribution and Risk Adjustment Accountability Population Health - 2 -
Why does attribution matter? MOMENTUM AWAY FROM FEE-FOR-SERVICE PAYMENT - 3 -
Purpose ATTRIBUTION ACCOUNTABLITY Cost Quality - 4 -
Perspective Overall accountability, cost and quality, for member’s will increasingly move to providers. There will be a continuum of that shift: Pay for Delegated Model Health Care Partial Capitation Performance Shared Savings (percent of Insurance Issuer (prof services) Incentives premium) (underwriting) Accountability Shared Savings will be the predominate model of accountability in the market for the near future. - 5 -
Payment Model Transformation Fee-for-Service Shared Savings 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 Capitation/Budgets - 6 -
Source Data for Attribution Patient Attribution is inferred from Claims Data • Claims Concerns • – Timeliness Run out – Accuracy Listed NPI - 7 -
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. - 8 -
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 • performance year based on data with a 3-month claims run out. - 9 -
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 - 10 -
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 • - 11 -
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. - 12 -
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) - 13 -
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) - 14 -
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 • or non-ACO provider to which the beneficiary was assigned - 15 -
ACO Assignment Example 1 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional A1 A9999 $454 $654 A1 555555555 $300 $1,900 A1 456565656 $250 $2,500 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 - 16 -
ACO Assignment Example 2 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional B3 333333333 $1,200 $1,250 B3 A5656 $800 $800 B3 A9999 $600 $700 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) - 17 -
ACO Assignment Example 3 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional A3 A9999 $0 $300 A3 555555555 $0 $250 A3 333333333 $0 $200 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) - 18 -
Typical Quarter to Quarter Turnover Quarterly Turnover Analysis 100.00% 100.00% 90.00% 80.00% 82.41% 70.00% 60.00% 50.00% % from Q0/14 Bench % New Beneficiaries 40.00% 30.00% 20.00% 17.59% 10.00% 0.00% Q0/14 Q1/2014 % from Q0/14 Bench 100.00% 82.41% % New Beneficiaries 0.00% 17.59% - 19 -
Reasons for Turnover Table 1-5 Medicare Shared Savings Program Quarterly Beneficiary Turnover Analysis Year 2014, Quarter 1 Reason(s) Beneficiary Not Currently Assigned 1 HICNOs of (1) (2) (3) (4) (5) (6) beneficiaries Beneficiary did assigned in most not receive the Beneficiary had Beneficiary had Beneficiary recent prior plurality of at least one at least one Beneficiary did not have a quarterly report his/her primary Deceased month of Part A- month in a Beneficiary does included in other physician visit and not care services 4 Beneficiary Only Or Part B- group health not reside in the Shared Savings with an ACO currently Flag 3 from the ACO 5 Only Coverage 6 plan 7 United States 8 Initiatives 9 provider 10 assigned 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 - 20 -
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 - 21 -
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 - 22 -
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