Editor’s note:This is the second of two articles on the importance of accurate patient attribution. Read the first article at http://bit.ly/35PjZHL.
Whether you are in a value-based payment model or not, payers are collecting and analyzing claims data to measure your performance. You may be eligible for pay-for-performance incentives or in a risk-based contract, but regardless of how you are paid, your data are being used to rank your “value” to the health care system.
Understanding how quality measures are calculated is essential to survive and thrive in the current health care environment. Commercial and public payers are required to report their quality performance to the National Committee for Quality Assurance via Healthcare Effectiveness Data and Information Set (HEDIS) measures. However, payers can’t provide care, so they need physician practices to improve performance for their HEDIS numbers to improve. HEDIS was never intended to apply to individual pediatricians or practices; it was intended to apply to the health plans. While the downstream effect is not our fault, it continues to be our problem.
Each quality measure has technical specifications with a numerator and a denominator. There are inclusion and exclusion criteria for which patients count (your attributed panel) in the denominator. In addition, most measures have a timeframe for when patients show up in the denominator and for the reporting period. Inconsistencies can impact measurement.
Another factor is whether the payer uses a rolling year, a fiscal year or a calendar year. If the denominator is inaccurate, your performance can be significantly impacted. Smaller practices with smaller attributed panels can be affected disproportionately as even a few patients can skew your performance metrics.
For any measure related to preventive care, the denominator of patients attributed to your practice must be accurate and there has to be a clear understanding of the time bounds of the measure. Quality improvement measures work well for Medicare recipients because once you qualify for Medicare, you always qualify for Medicare and are in the denominator. This is not true for patients who go on and off Medicaid or Medicaid managed care organization plans, or for patients with private insurance coverage when parents change carriers or employers.
Recommendations for accurate measurements
- Payer attribution methods must be transparent. If we do not understand how payers attribute patients to our denominators, our improvement efforts are hindered.
- National standards are needed to define reasonable pediatric attributions such as maximum age. For example, it is unreasonable to include the 37-year-old who you saw as part of a lactation consultant visit to your pediatric practice.
- Have rolling years for annual well visits (for patients ages 3 years and up) or national standards to define one well visit per calendar year, not a minimum of 365 days between well visits.
- For preventative health measures, performance should be attributed to the health professional providing the well visit, regardless of where that child is assigned.
- Physicians should have the ability to provide clinical data to dispute performance for common issues such as birth dose of hepatitis B vaccine missed because it was given in the hospital, rotavirus vaccine ineligibility due to extended stay in the neonatal intensive care unit or vaccines administered while the patient was covered by a different plan.
- For immunization metrics, International Classification of Diseases, Tenth Revision, Clinical Modification information should be accepted in claims data as exceptions in the denominator if parents/caregivers refuse vaccines (Z28.82: Immunization not carried out because of caregiver refusal).
- For index prescription start date measures, performance must be attributed to the provider prescribing the inappropriate antibiotic not the office to which the child is assigned.
- Practices must be incentivized to achieve and maintain a high performance against a known target.
- Eliminate percentile performance compared to peers, which can become statistically insignificant as measures top out.
- Assure practices that their work to improve will result in additional payment.
- Incentivize non-high performing practices for incremental improvement because every child deserves access to high-quality pediatric care.
- Eliminate metrics based on incomplete/inaccurate data such as using evidence of oral contraceptive use or pregnancy test as a proxy for sexual activity in the chlamydia measure.
- Use adequate payment for services as quality measurements such as separately recognized and paid CPT codes such as 96217: Brief emotional/behavioral assessment (e.g., depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument for depression screening in relevant measures.
For every infant, child and adolescent to have access to high-quality care in a medical home, it is increasingly important to ensure value-based payment models support the important work of quality improvement. That cannot be accomplished effectively without understanding the denominator and which patients the payer is attributing to the practice. In addition, there must be standardized provisions to reconcile the attributed panel between the payer and the practice.
Drs. Kressly, Barabell and Schonfeld are members of the AAP Payer Advocacy Advisory Committee.
