Attribution Models and Implications

Transcription

1 Attribution Models and Implications HFMA Managed Care Education Committee July 16, 2014 Tim Ford Executive Vice President

2 Agenda Why Attribution Matters? Medicare s Attribution Methodology for the MSSP Other Methodologies Attribution and Risk Adjustment Accountability Population Health - 2 -

3 Why does attribution matter? MOMENTUM AWAY FROM FEE-FOR-SERVICE PAYMENT - 3 -

4 Purpose ATTRIBUTION ACCOUNTABLITY Cost Quality - 4 -

5 Perspective Overall accountability, cost and quality, for member s will increasingly move to providers. There will be a continuum of that shift: Pay for Performance Incentives Shared Savings Partial Capitation (prof services) Delegated Model (percent of premium) Health Care Insurance Issuer (underwriting) Accountability Shared Savings will be the predominate model of accountability in the market for the near future

6 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 -

7 Source Data for Attribution Patient Attribution is inferred from Claims Data Claims Concerns Timeliness Run out Accuracy Listed NPI - 7 -

8 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

9 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

10 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

11 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

12 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

13 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)

14 ACO Assignment: Definition of Primary Care Services Evaluation & Management Services provided at: Office or Other Outpatient settings (CPT ) Nursing Facility Care settings (CPT ) Domiciliary, Rest Home, or Custodial Care settings (CPT ) Home Services (CPT ) 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)

15 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

16 ACO Assignment Example 1 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional A1 A9999 $454 $654 A $300 $1,900 A $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

17 ACO Assignment Example 2 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional B $1,200 $1,250 B3 A5656 $800 $800 B3 A9999 $600 $700 Beneficiary B3 is assigned to a non-aco provider ( ) because it had the highest allowed charges for primary care services provided by a primary care physician ($1,200)

18 ACO Assignment Example 3 Allowed Charges for Primary Care Services ACO Beneficiary Organization ID PCP Professional A3 A9999 $0 $300 A $0 $250 A $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)

19 Typical Quarter to Quarter Turnover Quarterly Turnover Analysis % % 90.00% 80.00% 82.41% 70.00% 60.00% 50.00% 40.00% % from Q0/14 Bench % New Beneficiaries 30.00% 20.00% 10.00% 17.59% 0.00% Q0/14 Q1/2014 % from Q0/14 Bench % 82.41% % New Beneficiaries 0.00% 17.59%

20 Reasons for Turnover HICNOs of beneficiaries assigned in most recent prior quarterly report and not currently Deceased Beneficiary Reason(s) Beneficiary Not Currently Assigned 1 (1) (2) (3) (4) (5) (6) Beneficiary did not receive the plurality of his/her primary care services 4 Table 1-5 Medicare Shared Savings Program Quarterly Beneficiary Turnover Analysis Year 2014, Quarter 1 Beneficiary had at least one month of Part A- Only Or Part B- Only Coverage 6 Beneficiary had at least one month in a group health plan 7 Beneficiary does not reside in the United States 8 Beneficiary included in other Shared Savings assigned Flag 3 from the ACO 5 Initiatives 9 XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX Beneficiary did not have a physician visit with an ACO provider

21 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

22 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

23 Risk Adjustment Models Health-Lynx uses the Johns Hopkins ACGs 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 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):

24 The John Hopkins ACG Model

25 Calculating Savings with Risk Adjustment - Illustration Group Name Attributed Lives Prospective Risk Score 2012 Actual Cost 2012 Predicted Cost Difference Neptune Associates $1,167,057 $1,282,480 ($115,423) Caldwell Associates $3,264,828 $3,122,940 $141,888 Livingston Associates $1,512,273 $1,800,325 ($288,052) Newark Associates $1,163,822 $1,402,195 ($238,373) Orange Associates $1,176,130 $1,336,300 ($160,170) Nutley Associates $1,085,526 $1,262,240 ($176,714) Teaneck Associates $3,693,211 $3,129,840 $563,371 Patterson Associates $17,099,701 $18,386,775 ($1,287,074) Montclair Associates $3,084,742 $3,545,680 ($460,938) Passaic Associates $9,974,260 $10,282,742 ($308,482) Millburn Associates $4,395,767 $5,017,680 ($621,913) Essex Associates $2,872,471 $3,622,960 ($750,489) Verona Associates $1,475,189 $1,541,805 ($66,616) West Caldwell Associates $6,014,086 $6,757,400 ($743,314) Seton Associates $439,333 $360,640 $78,693 Marlton Associates $20,919,691 $20,310,380 $609,311 Oakley Associates $3,864,828 $4,391,850 ($527,022) Cruise Associates $1,433,207 $1,646,455 ($213,248) Nicholson Associates $10,267,169 $9,595,485 $671,684 Springsteen Associates $2,418,799 $2,551,160 ($132,361) 6, $97,322,090 $100,064,852 ($4,025,242)

26 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?

27 The Population Challenge Most Costly 1% Source: MedPAC, A Data Book: Healthcare spending and the Medicare program, June

28 ACO Population Health Management Health Assessment Risk Stratification Predictive Modeling Engagement No or Low Risk Care Continuum Moderate Risk Health Management Interventions High Risk Health Promotion Health Risk Management Care Coordination Chronic Condition Management PCP Attribution Education Health Assessment Prevention Reminders Health Coaching Support Tools/Resources Follow up Assessments Care Gap Intervention Network Steerage Discharge Planning Care Transition Management Case 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

29 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

30 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

31 Utilizing Multiple Dimensions

32 Patient At A Glance Every Patient Has Their Own Story Lists all the doctors the patient has visited Lists all the billed patient visits to inpatient facilities and outpatient offices Lists the patients diagnosed conditions Lists all prescribed medications for the patient Lists all non-physician claims

33 Targeted Patients/Focused Metrics Return to your targets Measure progress against baselines Enforce accountability

34 What is a Better Patient Experience? 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 office 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

35 Findings from Recent Survey of Elderly PerryUndem Survey, April

36 Tim Ford EVP, Health-Lynx