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Forgotten Patients: ACO Attribution Omits Those With Low Service Use and the Dying

Mariétou H. Ouayogodé, PhD; Ellen Meara, PhD; Chiang-Hua Chang, PhD; Stephanie R. Raymond, BA; Julie P.W. Bynum, MD, MPH; Valerie A. Lewis, PhD; and Carrie H. Colla, PhD
This article compares clinical and utilization profiles of Medicare patients who are attributed to provider groups with those of patients unattributed to any provider group in accountable care organization models.
ABSTRACT

Objectives: Alternative payment models, such as accountable care organizations, hold provider groups accountable for an assigned patient population, but little is known about unassigned patients. We compared clinical and utilization profiles of patients attributable to a provider group with those of patients not attributable to any provider group.

Study Design: Cross-sectional study of 2012 Medicare fee-for-service beneficiaries 21 years and older.

Methods: We applied the Medicare Shared Savings Program attribution approach to assign beneficiaries to 2 mutually exclusive categories: attributable or unattributable. We compared attributable and unattributable beneficiaries according to demographics, dual eligibility for Medicaid, nursing home residency, clinical comorbidities, annual service utilization, annual spending, and 1- and 2-year mortality. We estimated multivariate regression models describing correlates of attribution status.

Results: Most beneficiaries (88%) were attributable to a provider group. The remaining 12% were unattributable. Beneficiaries unattributable to any provider group were more likely to be younger, male, and from a minority group; to have disability as the basis for enrollment; and to live in high-poverty areas. Unattributable beneficiaries included 3 distinct subgroups: nonusers of care, decedents, and those with healthcare service use but no qualifying evaluation and management visits. Many unattributable Medicare beneficiaries had minimal use of healthcare services, with the exception of a small subgroup of beneficiaries who died within the attribution year.

Conclusions: Attribution approaches that more fully capture unattributable patients with low service use and patients near the end of life should be considered to reward population health efforts and improve end-of-life care.

Am J Manag Care. 2018;24(7):e207-e215
Takeaway Points

Given the reliance of alternative payment models on assignment of patients to provider groups, we compared clinical and utilization profiles of patients attributable to a provider group with those of patients unattributable to any provider group.
  • We estimated multivariate regression models describing correlates of attribution status.
  • Most beneficiaries (88%) were attributable to a provider group, whereas 12% remained unattributable.
  • Beneficiaries unattributable to any provider group included 3 distinct subgroups: nonusers of care, decedents, and those with healthcare service use but no qualifying evaluation and management visits.
  • Attribution approaches that more fully capture unattributable patients with low service use and patients near the end of life should be considered to reward population health efforts and to improve end-of-life care.
By holding networks of healthcare providers responsible for the total cost and quality of care for a designated population, the accountable care organization (ACO) model creates incentives to coordinate care across providers, reduce unnecessary spending, and improve the quality of care.1 The ACO model has grown steadily,2 and by January 2017, Medicare held ACO contracts with 525 organizations serving more than 10 million beneficiaries.3 Medicare ACO contract participants that meet quality benchmarks are eligible to share the savings that they generate.4,5 An ACO’s performance is evaluated based on Medicare methods of measurement and attribution. Researchers have evaluated outcomes of ACOs among attributable beneficiaries,6,7 but no study has described unattributable beneficiaries.

In Medicare ACO contracts, beneficiaries are attributed to organizations based on their use of primary care services from eligible providers,8,9 so attribution can influence an organization’s performance under an ACO contract. Among organizations serving patients with complex clinical and psychosocial needs, for example, quality metrics may be hard to achieve, giving organizations incentives to avoid accepting such patients. Conversely, ACO participants that are effectively managing population health may not achieve shared savings for patients who, appropriately, do not use the primary care services that would make them eligible for attribution. ACOs have little financial incentive to deliver preventive care that might decrease the chance that healthy patients are attributed to an ACO.10 As advanced payment models mature to include downside risk, and as models like Comprehensive Primary Care expand, it is important to understand which patients are left out so that policy makers can develop regulations that encourage participation and improved care in new payment models.

To date, we have no information on the composition of patients who are not attributable to any provider group under Medicare Shared Savings Program (MSSP) regulations. This paper examines beneficiary characteristics associated with attribution and compares hospitalization, mortality, and spending across attributable and unattributable beneficiaries. Results from our analyses can guide policy on whether additional actions are necessary to adequately give provider participants incentives to improve population health and to ensure that vulnerable beneficiaries—who may benefit the most from improved care coordination—are not excluded from new payment models.

METHODS

Using Medicare claims and CMS attribution rules for the most widely adopted model, the MSSP,11 we categorized beneficiaries into 2 mutually exclusive groups: patients who were attributable to provider groups and patients who were not attributable to any provider group. We included only beneficiaries with full parts A and B coverage, limiting the sample to those for whom traditional fee-for-service (FFS) Medicare was the primary payer. We combined all beneficiaries attributable to provider organizations (ie, MSSP, Pioneer ACO, and non-ACO medical groups) into a single category because the purpose of our research was to investigate the characteristics of those falling through the cracks of the current attribution methodology. In 2012, Medicare ACO contracts included 32 Pioneer program participants and 114 MSSP participants (over the first performance period from April 2012 or July 2012 through December 2013) that were responsible for more than 2 million beneficiaries.12 Although Pioneer program participants, which were responsible for nearly 700,000 beneficiaries in 2012,13 faced downside risk for spending, virtually all MSSP participants (n = 110) were in Track 1 and eligible for upside savings only.12 We conducted cross-sectional analyses examining characteristics of beneficiaries according to their attribution status.

Beneficiary Attribution to Provider Organizations

Following MSSP’s 2-step attribution process, a beneficiary who has at least 1 face-to-face outpatient evaluation and management (E&M) visit is assigned to the provider group that has the highest allowed charges by primary care clinicians (ie, general practice, family practice, internal medicine, and geriatric medicine practitioners) for those visits.11,14-16 Patients not seeing primary care clinicians are attributed based on visits to qualifying non–primary care clinicians (ie, physicians in other specialties, nurse practitioners, physician assistants, and clinical nurse specialists).11 Beneficiaries who received care only from nonqualifying clinical providers (eg, interventional cardiologists or certified registered nurses) or in nonstandard settings (eg, emergency departments [EDs]) or who had no visits at all were not able to be assigned to any provider group using current MSSP attribution rules; they formed our “unattributable” group.11


 
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