The expansion of Value-Based Care has brought health plans, providers, and patients into alignment in their desire to achieve quality care and improved health outcomes. As a result, incentives for providers, such as shared savings and quality bonuses, are increasingly tied to outcomes that demonstrate the delivery of high-quality care. Health plans measure outcomes by evaluating the performance of a provider’s patient population in a method known as Attribution. Attribution is used to assign patients, encounters, and episodes of care to a specific provider, creating a sense of accountability over the person’s total health rather than the treatment provided. This shift in performance payment alignment has raised the importance of accurate and reliable attribution data. For example, CMS’s 2022 quality metric for colorectal screening is written as, “The percentage of adults 50-75 years of age who have had the appropriate screening for colorectal cancer.” This calculation implies that the provider can account for the total number of patients that are eligible for this screening during a performance period. While this method may seem straightforward, determining a provider’s panel is not always simple.
In 2021, more than a decade since the passage of the Patient Protection and Affordable Care Act that propelled the movement toward population health payment models, 42% of Medicare beneficiaries are enrolled in Medicare Advantage plans, and enrollment has doubled over the past decade. Despite high enrollment, it was not until 2017 that formal guidance on attribution models was published by the National Quality Forum, and even then it was recognized that no standard methodology had been defined. By 2020, over 150 different attribution models were proposed or in use. Health plans do not have any obligation to share with providers their methodology for determining attribution, often claiming this methodology is proprietary information. The lack of clarity has caused an overwhelming sense of confusion among practices determined to meet the 5-star rating.
Imagine you are an independent practitioner, already working overtime just to meet the needs of your community, and are just getting used to documenting appropriately in your electronic medical record system. Now, your health plan partners inform you that payment will now be tied to how well you are managing your population and not just the care you provide for the population. You open your EMR and note that you have 5,000 patients in your system enrolled with a specific health plan (from years of not maintaining an up-to-date inventory of existing patients) yet the health plan explains you only have 1,500 patients you are responsible for. How are you supposed to achieve a measure claiming that 75% of your eligible patient population had received a colorectal screening during the performance year if you do not know which patients you are held accountable for? While it may seem overwhelming, there are certain steps that practices can take to ensure they are meeting the expected outcomes and gaining that coveted 5-star rating.
It’s not only providers who find themselves in downside risk models that must piece together their attribution story using a “do-it-yourself” mentality across health plans. In a survey published by the National Quality Forum, 40% of physicians noted an inability to determine if a patient was attributed to them. While plans may not be willing to share all the details of how they built their attribution model, they actually really want to provide the practice with as much information as is needed to meet their performance expectations. In a survey performed by CAQH, a non-profit alliance of health plans, 37% of providers noted they were able to obtain attribution information from the health plans on a monthly or quarterly basis. A provider needs to ensure they are working with the most up-to-date information the health plan is able to provide them. It can help to set up a regular cadence to receive such attribution lists from each health plan.
While this information may be available, it is important to remember that providers are not just working with one plan, but many. Providers may be receiving lists throughout the year at not only irregular intervals but also irregular delivery forms that make this complicated for them and their staff to manage. The plan will often share the attribution lists they have associated with the provider at a given time, through a proprietary web portal or via e-mailed attachments. In most instances, providers or staff must physically seek out the information. For an independent provider with limited administrative support or time, obtaining this information can be prohibitive. Once the information is received, staff have even less time to review the data provided and consolidate it into a single manageable data source.
Fortunately, many health plans do understand the challenges put on providers to meet their value expectations. Plans and private companies have begun to invest in technology to help streamline this process for the practices and provide real-time information on their expectations. Providers should ask their health plan partners what technical tools they may be able to offer the practice to gain the intelligence needed in a timely manner. A provider may also choose to look for a plan-agnostic solutions and data feeds that can help them to aggregate all their information into a single-streamlined source. Without the industry improving this process for providers, value-based care delivery will never meet the expected outcomes.
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