A Town Hall Event by the C&BI Population Health-Accountable Care Task Force April 29, 2015 Population Health: The Attribution Challenge

HIMSS Town Hall Series Definition: an informal public meeting that gives the members of a community an opportunity to get together to discuss emerging issues and to voice concerns and preferences for their community.

Attribution – Why is this important? 3 Why does patient attribution matter? Does it matter differently to different groups? –To payers? –To providers? –To patients? –To quality directors?

Executive Summary 4 1.There are multiple stakeholders involved in population health programs including patients, payers, physicians and hospitals. They may have competing self interests…. 2.Ultimate goal should be on improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities. 3.The specific objectives of the ACO program drives the metrics which has an impact on the types of physicians that make up the program. 4.Patient\Physician attribution drives who is in an ACOs cohort of patients and how those patients are assigned (or not) to individual physicians.

Executive Summary - Continued 5 5.There is no silver bullet attribution method that applies to all ACOs or contracts. The same method may not be best from the perspectives of payers, providers and patients. 6.There are pros and cons to the various approaches that need to be weighed since they directly impact physicians and patients. 7.For traditional ACOs (i.e., commercial or MSSP) payers typically drive attribution. You may not have a choice if you want to get in the game and perhaps that makes life easier….. 8.Patients have choices with their payers and who they see, and therefore you need a flexible feedback mechanism to update the attribution assignments.

Patient Attribution - Science or Art? 6 Attribution formulas and change policies can be a slippery slope Consistent over life of contract Easy to understand, maintain and enforce Patient Assignment Challenges (stickiness) Can be controversial since it impacts economics of practices Can be complex given patient types – Medicare (Pham et al, 2007) Medicare patients annually see a medium of two PCPs and 5 specialists working in 4 different practices 35% of beneficiaries visits each year were with assigned physician Assigned physician changed from year to year for 33% of beneficiaries Can differ depending an overall health – patients with chronic conditions stray from their ACOs more compared to others (Brookings ) What Types of Physicians or Staff Participate Normally Primary Care Specialists that provide care to patients with certain chronic conditions (Internal Medicine, Cardiologists and Endocrinologists)

7 Individual Physician or Physician Group? Groups more feasible and reliable but may diffuse responsibility. Prospective vs. Retrospective Prospective – PCMH, physicians have discretion to assign patients Retrospective – ACO, patients assigned based on past utilization periods (12, 18, 24 months, etc.,) Other Considerations Should physicians be able to exclude patients, what are viable reasons for refusal? Patient notification and opt out principles Patient Attribution - Science or Art?

Medicare Shared Savings Program Breakdown 8 Education and notice of patients on “opt out” Report back to CMS on patients opting out 2 year utilization to create attribution Patient attributed at organizational or TIN level, claims do not often contain NPI making attribution difficult Patients may not be aware that they are assigned to an ACO and can go outside of network 24 months of claims history needs to be loaded Quarterly Updates on Patient Attribution (refresh)

Real Attribution Problems Today – Case Study 9 Only around 50% of CMS data is assigned to an actual PCP Large Owned PNO (TIN) may have multiple practices and offices making patient assignment difficult How can we automatically assign a patient to a PCP using trumping logic? 1.Inferred match based on 24 months of clinical data and payer. Named individuals with most encounters. Tie goes to the most recent. 2.EMR patient to PCP link trumps inferred match #1 3.Manual updates on population tool trump #1 and #2

Town Hall Discussion 10 What are your goals for attribution? And does attribution matter differently to different groups? To payers? To providers? To patients? To quality directors? For a specific program and it’s time frame, do you manage for attributed patients? Or all possible patients? How do you know if your attribution logic is working well? What are some of the signs that it is meeting or not meeting your goals? What is the attribution logic differences between a clinically integrated delivery network and an ACO? How are you using data for your patient-to-provider matching logic?

Next Steps Let’s continue the conversation and learning Blog posts Key findings and take-aways Articles

FY15 C&BI Leadership Information Committee Chair: JD Whitlock, MPH, MBA, CPHIMS Vice President, Clinical & Business Intelligence Mercy Health Population Health-Accountable Care Task Force Co-Chairs: William Beach, MBA, MLA, PhDJennifer Jackson Regional Director, Regulatory Readiness, Northern Region, Senior Director, IT Population Health Data Solutions St. Joseph Health SystemBanner Health Community Co-Chairs: Michael Brooks, BS, MBA, CPHIMS Mike Berger, PE, CPHIMS Specialist LeaderChef Analytics Officer Deloitte Consulting LLPAffinity Health Plan HIMSS Community Organizers | Staff Liaisons: Shelley Price, MS, FHIMSSNancy Devlin Director, Payer & Life Sciences, HIMSSSenior Assoc., Payer & Life Sciences, HIMSS

Thank you!