UnitedHealth Premium®
Designation Program
Attribution Methods
Resources
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This document should be used in conjunction with the UnitedHealth Premium® Designation Program Methodology document.
It is important to review the entire document to understand the Premium program methodology.
Overview
Attribution methods based on health plan claims data determine which physicians are responsible for care given to patients.
Different attribution methods are used for each of the following measure types used in the Premium methodology:
• Quality Measures
– Preventive Care
– Chronic Disease Care
– Acute Condition Care
– Pregnancy Management Care
– Global Care
– Surgical Care
• Cost Efficiency Measures
– Patient Total Cost
– Patient Episode Cost
Quality Measure Attribution
The Premium program applies the following general principles for attributing quality measures to physicians:
•Quality measures are only attributed to physicians in applicable specialties, including Primary Care, Obstetrics and
Gynecology (OB-GYN), and Other Specialists. Primary Care Physicians (PCPs) include the specialties of Family Medicine,
Internal Medicine and Pediatrics.
•Quality measures are attributed to physicians with significant involvement in the care of the patient. The determination of
significant involvement varies by the physician’s role and the quality measure as noted in the Quality Measure Attribution
Methods table on the following page.
UnitedHealth Premium® Designation Program Attribution Methods
Quality Measure Attribution Methods
The following table provides an example of the type of condition/procedure to which each method applies, whether the method
allows for attribution to a single physician only or to multiple physicians, the physician role(s) eligible for attribution and the specific
criteria for each method.
Attribution
Method
Condition or
Procedure
Example
Single or
Multiple
Attribution
Applicable Physician
Role(s)
Preventive
Care
Breast Cancer
Screening
Multiple
• Identified PCP
• The identified PCP if they had one
or more visits with the patient in the
most recent 12 months used
• Identified OB-GYN
• The identified OB-GYN if they had
one or more visits with the patient in
the most recent 12 months used
• Identified PCP
• Identified OB-GYN
• The identified PCP and/or OB-GYN
if either or both had one or more
visits with the patient in the most
recent 12 months used
• Any physician in an
applicable specialty
including other PCPs,
OB-GYNs and/or
specialists
• All physicians in applicable
specialties with two or more visits
with the patient for the condition in
the most recent 12 months used
Exception: Hypertension and
hyperlipidemia only require one visit
in the most recent 12 months used.
Chronic
Disease Care
Diabetes
Multiple
Attribute the measure to:
Acute
Condition Care
Acute
Bronchitis
Single
• Any physician in an
applicable specialty
including PCPs, OB-GYNs
and other specialists
• The physician who saw the patient
for the condition when only one
physician was involved in the care
Pregnancy
Management
Care
Pregnancy
Management
Multiple
• Identified OB-GYN
• The identified OB-GYN if they
had one or more visits with and
performed one or more pregnancy
related procedures during the
patient’s first two trimesters.
• Family Medicine and
Endocrinology physicians
and other OB-GYNs
• All Family Medicine, Endocrinology
and other OB-GYN physicians with
two or more pregnancy-related
visits during the patient’s first two
trimesters.
Global Care
Medication
Safety
Monitoring (not
specific to a
condition)
Multiple
• Identified PCP
• Any physician in an
applicable specialty
including other PCPs, OBGYNs and/or specialists
• The identified PCP
• All physicians in applicable
specialties with two or more visits
with the patient for any condition in
the most recent 12 months used
Surgical Care
Knee
Replacement
Surgery
Single
• Any physician in an
applicable specialty
including OB-GYNs and
other specialists
• The physician who performed the
primary procedure associated with
the quality measure
2
UnitedHealth Premium® Designation Program Attribution Methods
Identified PCP or OB-GYN
The Identified PCP or OB-GYN is determined using the following process to select the most probable primary care giver.
1. Identify the PCP and/or OB-GYN who performed the most recent physical examination or assessment. The largest number of
services breaks any ties.
2. Identify the PCP and/or OB-GYN who performed the largest number of evaluation and management type visits. The most
recent visit breaks any ties.
3. Identify the PCP who performed the largest number of prenatal, postpartum, or antepartum visits, or routine obstetrical care
services. The most recent service breaks any ties. This step is limited to physicians in internal medicine, family medicine
and pediatrics to account for patients who receive obstetrics and gynecology services from PCPs in specialties other than
obstetrics and gynecology.
The attribution process for PCPs and OB-GYNs stops as soon as one of the physicians meets the attribution criteria. If this
process does not yield an attributed physician in the specialty category, the patient is not attributed to a physician in that
specialty category.
Type of Service
Identified PCP1
Identified OB-GYN2
1. P
hysical Exam or
Assessment
Most Recent:
• Preventive Service or physical exam OR
• Ambulatory visit + medical exam
Diagnosis
Most Recent:
• Preventive service or physical exam OR
• Ambulatory visit + medical exam
diagnosis
Tiebreaker = Largest number of services
Tiebreaker = Largest number of services
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Tiebreaker = Most recent service
Tiebreaker = Most recent service
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Obstetric codes are included in exam or
assessment step above
2. E
valuation and
Management
3. Obstetric Visits
Tiebreaker = Most recent service
PCP includes Internal medicine, family medicine, and pediatrics
OB-GYN includes obstetrics and gynecology
1
2
Cost Efficiency Measures
Patient Total Cost - Patient Attribution
For patient total cost measurement, attribution is based on a hierarchy of services to select the most probable physician(s)
responsible for the patient’s care within each specialty category. Specialty categories are PCP, OB-GYN and Other Specialists
including Allergy, Cardiology, Endocrinology, Nephrology, Neurology, Pulmonology and Rheumatology. Each patient is only
attributed to one eligible physician within the PCP and OB-GYN categories and one physician of each specialty within the Other
Specialists category.
Surgical Specialty Eligibility
OB-GYNs and cardiologists who perform surgical procedures are not eligible for patient attribution for patient total cost if their
surgical cases account for more than 30 percent of their total cases. The percentage is determined by comparing the physician’s
ratio of surgical episodes to total surgical and medical episodes.
3
UnitedHealth Premium® Designation Program Attribution Methods
Attribution Process
The following table shows the hierarchical process to attribute each patient to one eligible physician within the PCP and OB-GYN
categories and one physician in each specialty within the Other Specialist category.
Attribution is based on code sets specific to the specialty category and identified services.
• PCP and OB-GYN attribution is determined based on claims from the most recent calendar year used. If no qualifying services
are found, the previous calendar year is used. OB-GYN patients must be females at least 12 years old.
• Other Specialist attribution is determined based on claims from the most recent calendar year used only.
• For PCP and OB-GYN attribution, the process stops as soon as one of the physicians meets the attribution criteria in the
hierarchy. If this process does not yield an attributed physician in the specialty category, the patient is not attributed to a
physician in that specialty category.
• For Other Specialist attribution, the process identifies an attributed physician for each specialty included in the Other Specialist
category. If this process does not yield an attributed physician in the specialty, then the patient is not attributed to a physician in
that specialty.
Type of Service
Identified PCP3
Identified OB-GYN4
1. P
hysical Exam or
Assessment
Most Recent:
• Preventive Service or
physical exam OR
• Ambulatory visit + medical
exam diagnosis
Most Recent:
• Preventive service or physical
exam OR
• Ambulatory visit + medical
exam diagnosis
Tiebreaker = Largest number
of services
Tiebreaker = Largest number
of services
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Tiebreaker = Most recent
service
Tiebreaker = Most recent
service
Tiebreaker = Most recent
service
Largest combined number of:
• Ambulatory visits
AND
• Supervision services
Obstetric codes are included
in exam or assessment step
above
2. E
valuation and
Management
3. Obstetric Visits
Other Specialist5
Tiebreaker = Most recent
service
PCP includes internal medicine, family medicine, and pediatrics
OB-GYN includes obstetrics and gynecology
5
Specialist includes allergy, cardiology, endocrinology, nephrology, neurology, pulmonology, and rheumatology
3
4
Patient Episode Cost - Patient Attribution
Episodes are characterized as medical (e.g., pharyngitis, diabetes) or surgical (e.g., appendectomy, tonsillectomy). Each episode
reflects a combination of resource utilization, resource mix and unit cost. Costs include all services delivered to a patient. These
include payments to the physician for direct care, to other physicians or clinicians who provided care and for facility costs
and ancillary services that were related. The Premium program applies the following general principles for attributing
episodes to physicians:
• Episodes are only attributed to physicians in applicable specialties.
• Episodes are only attributed to physicians with significant involvement in the care of the patient. The determination of significant
involvement varies between medical and surgical episodes as follows.
4
UnitedHealth Premium® Designation Program Attribution Methods
Medical Episode Attribution
Each medical episode is attributed to the physician who was responsible for generating the highest percentage of services, based
on cost, in the episode. The attributed physician must be in a specialty that typically manages the care of patients for the medical
condition. To make sure there was significant involvement, the attributed physician must be responsible for at least 30 percent of
the total cost of the episode. About 80 percent of medical episodes used for Premium designation are managed by one physician.
Radiologists, pathologists, and anesthesiologists are not recognized as attributed physicians.
Surgical Episode Attribution
Surgical episodes are attributed to the physician who performed the primary surgical procedure. Performing the surgical
procedure constitutes significant involvement and therefore no cost percentage threshold is applied.
Important notes about the UnitedHealth Premium® Physician Designation Program
The information from the UnitedHealth Premium designation program is not an endorsement of a particular physician or health
care professional’s suitability for the health care needs of any particular member. UnitedHealthcare does not practice medicine
nor provide health care services. Physicians are solely responsible for medical judgments and treatments supplied. A Premium
Care Physician or Quality Care Physician designation does not guarantee the quality of health care services members will receive
from a physician and does not guarantee the outcome of any health care services members will receive.
Likewise, the fact that a physician has a Quality Not Evaluated or a Does Not Meet Quality designation does not mean that the
physician does not provide quality health care services. All physicians in the UnitedHealthcare Network have met certain minimum
credentialing requirements. Regardless of whether a physician has received a Premium Care Physician designation, members
have access to all physicians in the UnitedHealthcare Network, as further described under the member’s benefit plan.
The designation of “Quality Not Evaluated” is given when a physician does not practice in a specialty that is evaluated by the
Premium program. It is also given when a physician does not have enough health plan claims data to be evaluated, but it is not an
indicator of the total number of patients treated by the physician or the number of procedures performed by the physician. Rather,
it reflects the statistical requirements of the Premium program, which includes only health plan claims associated with specific
Premium program measures and relevant to the physician’s specialty. In some cases, there may not be enough data to complete
the analytic process from a statistical standpoint.
UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and
should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis
of a sample, there is a risk of error. There is a risk of error in the claims data used in the assessment, the calculations used in
the assessment, and the way the Premium program determined that an individual physician was responsible for the treatment
of the patient’s condition. Physicians have the opportunity to review this data and submit a reconsideration request.
UnitedHealthcare uses statistical testing to compare a physician’s results to expected or normative results. There is a risk of error
in statistical tests when applied to the data and a result based on statistical testing is not a guarantee of correct inference or
classification. We inform members that it is important that they consider many factors and information when selecting a physician.
We also inform our members that they may wish to discuss designations with a physician before choosing him or her, or
confer with their current physician for advice on selecting other physicians.
The information contained in this Premium Attribution Methods is subject to change.
D30027 10/16 PCA18050_20150909 102816 © 2016 United HealthCare Services, Inc.