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The American Journal of Managed Care December 2018
Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
From the Editorial Board: Jonas de Souza, MD, MBA
Jonas de Souza, MD, MBA
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Currently Reading
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Relationships Between Provider-Led Health Plans and Quality, Utilization, and Satisfaction
Natasha Parekh, MD, MS; Inmaculada Hernandez, PharmD, PhD; Thomas R. Radomski, MD, MS; and William H. Shrank, MD, MSHS
Primary Care Burnout and Populist Discontent
James O. Breen, MD
Adalimumab Persistence for Inflammatory Bowel Disease in Veteran and Insured Cohorts
Shail M. Govani, MD, MSc; Rachel Lipson, MSc; Mohamed Noureldin, MBBS, MSc; Wyndy Wiitala, PhD; Peter D.R. Higgins, MD, PhD, MSc; Sameer D. Saini, MD, MSc; Jacqueline A. Pugh, MD; Dawn I. Velligan, PhD; Ryan W. Stidham, MD, MSc; and Akbar K. Waljee, MD, MSc
The Value of Novel Immuno-Oncology Treatments
John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
Medicare Advantage Control of Postacute Costs: Perspectives From Stakeholders
Emily A. Gadbois, PhD; Denise A. Tyler, PhD; Renee R. Shield, PhD; John P. McHugh, PhD; Ulrika Winblad, PhD; Amal Trivedi, MD; and Vincent Mor, PhD
Provider-Owned Insurers in the Individual Market
David H. Howard, PhD; Brad Herring, PhD; John Graves, PhD; and Erin Trish, PhD
Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty
Jennifer Meddings, MD, MSc; Shawna N. Smith, PhD; Timothy P. Hofer, MD, MSc; Mary A.M. Rogers, PhD, MS; Laura Petersen, MHSA; and Laurence F. McMahon Jr, MD, MPH

Patient Attribution: Why the Method Matters

Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Reliable identification of the physician–patient relationship is necessary for accurate evaluation. Standardization of evidence-based attribution methods is essential to improve the value of healthcare.

Objectives: To assess the impact of 5 commonly used patient attribution methods on measured healthcare cost, quality, and utilization metrics within an integrated healthcare delivery system.

Study Design: Cross-sectional analysis of administrative data of all patients attributed (by any of 5 methods) and/or paneled to a primary care provider (PCP) at Mayo Clinic Rochester (MCR) in 2011.

Methods: We retrospectively applied 5 attribution methods to MCR administrative data from January 1, 2010, to December 31, 2011. MCR is an integrated healthcare delivery system serving primary care and referral populations. The referral practice is geographically colocated but otherwise distinct from 6 primary care practice sites that include pediatric, internal medicine, and family medicine groups. Patients attributed by each method were compared on their concordance with PCP empanelment, quality measures, healthcare utilization, and total costs of care.

Results: The 5 methods attributed between 61,813 (42%) and 106,152 (72%) of paneled patients to a PCP at MCR, although not necessarily to the paneled PCP. There was marked variation in care utilization and total costs of care, but not quality measures, among patients attributed by the different methods and between those paneled versus not paneled. Patients with more primary care visits were more likely to be attributed by all methods.

Conclusions: Reliable identification of the physician–patient relationship is necessary for accurate evaluation of healthcare processes, efficiencies, and outcomes. Optimization and standardization of attribution methods are therefore essential as health systems, payers, and policy makers seek to evaluate and improve the value of delivered care.

Am J Manag Care. 2018;24(12):596-603
Takeaway Points

We retrospectively applied 5 commonly used patient attribution methods to 2 years of integrated healthcare system data. Patients attributed by each method were compared on concordance with provider empanelment, quality measures, utilization, and total cost.
  • The proportion of patients correctly attributed to their paneled provider ranged from 22% to 45%.
  • There was marked variation in care utilization and total costs by method.
  • Quality compliance rates were comparable across attribution methods.
Our study extends previous research by evaluating the effects of existing primary care attribution methods on quality, utilization, and cost within an integrated healthcare delivery system. Standardized attribution methods are essential to improve value.
Healthcare providers are increasingly profiled on the value of their care through publicly reported performance metrics, including clinical care outcomes, utilization indices, and costs of care.1,2 Seeking the best perceived value of health services drives the demand for reporting reliable provider metrics. Physician groups use these measures to make practice decisions regarding resource allocation, population health management innovations, and quality improvement efforts.3 Providers whose performance demonstrates high value may attract more patients, benefit through pay-for-performance contracts, and serve as exemplars of high-value care. Large employers use narrow networks, high-deductible plans, and tiered employee cost sharing to steer individuals toward high-value providers.4 Accurate and reliable healthcare quality and cost measures are required to calculate the value of medical care for all stakeholders.

However, these performance measures can vary dramatically depending on the way that patients are attributed to providers.5-7 Accurate and reliable identification of the physician–patient relationship is therefore a key component of evaluating and delivering high-value care and is at the core of population health management. Although several white papers have been published on attributing patients to providers,8,9 no standard exists,9 resulting in a variety of attribution methodologies used by different organizations for a range of purposes. Because these attribution methods use varying dimensions to identify and attribute patients, the resulting outcome, utilization, and cost metrics vary.6 At the same time, healthcare organizations are increasingly linking patients prospectively with providers to enable population health management, responsibility, and continuity of care.10-12 Criteria for patient empanelment vary across institutions and introduce yet another alternative for patient attribution. If metrics of care quality and efficiency are to be used to evaluate and compare clinicians and practices, the healthcare system would benefit from a better understanding of attribution methodologies and their ramifications on resulting comparisons.

Prior studies have examined the impact of varying attribution methodologies on primary care provider (PCP) patient mix, performance rankings,13 and cost profiles.14 Patient attribution is particularly challenging in integrated healthcare delivery systems with colocated primary and specialty care, as most attribution methods were designed for primary care or medical home settings.15 Although methods have been proposed for episode attribution (eg, Dowd et al,16 CMS Medicare Access and CHIP Reauthorization Act episode cost measurement17), primary care attribution methods are being applied to multispecialty and integrated care delivery systems.18 In these situations, specialty care may superficially meet the criteria of primary care attribution algorithms, although it falls outside the intended scope and dramatically alters the measured performance of institutions on publicly reported measures.5,19

Patients, health systems, providers, policy makers, and payers who consume this information need to be cognizant of how differences in attribution methods affect the way that healthcare is measured, evaluated, and reported. Our study examines how specifications of 5 representative primary care attribution methods influence measured clinical quality, care utilization, and total costs of care among primary care patients in an integrated healthcare delivery system with robust primary and specialty care practices. We evaluate attribution through 5 methods applied retrospectively, with previously established Mayo Clinic Rochester (MCR) PCP patient assignments. Our objective was not to propose a gold-standard approach for patient attribution, but rather to assess how variation in methods affects measured indices of care quality, utilization, and cost. Because these metrics are used to assess individual provider, group, and system performances, we first assess the accuracy of patient attribution to their true paneled PCPs (as these are the providers tasked with optimizing their care) and then examine differences in quality, healthcare utilization, and costs among the attribution methods and compare paneled and unpaneled patients.

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