Protecting, maintaining and improving the health of all Minnesotans Date:
August 5, 2010
To:
Rapid Response Team Members
From:
Katie Burns, Health Economics Program
Subject:
Provider Peer Grouping Issues
Thank you for your feedback with respect to the two issues we brought forward for your
consideration. Your thoughtful input caused MDH to consider several interrelated issues and we
now return to you with one methodological decision and to provide greater clarity around the
scope of the provider peer grouping analysis along with some additional information and request
for comment on the different attribution approaches.
Decision on Issue #1: Non-Users
MDH has decided to exclude patients without any medical claims (non-users) in the first
iteration of provider peer grouping. RRT members indicated some differences in opinion about
the desirability of including non-users, but were virtually unanimous in their opinions that even
if we wanted to include them in the first round of peer grouping, we lack sufficient years of
claims data to support credible linkage of these non-users to a clinic based on prior utilization of
a specific provider. MDH leaves open the possibility of including non-users in future iterations
of peer grouping.
Scope of Total Care Analysis
During the June 15, 2010 RRT meeting and in subsequent written comments, RRT members
raised key questions about the scope of the total care physician clinic analysis. Specifically, the
questions centered were related to whether specialists may or may not be included within the
scope of total care peer grouping.
MDH has determined that total care peer grouping will focus on clinics that offer primary care,
whether they are primary care only or are multi-specialty groups that offer primary care among
their other services 1 . To be clear, specialists will be included in peer grouping, but that will occur
within condition-specific peer grouping. In addition, the care provided by specialists will also be
within scope of the total care analysis, but the cost of that care will be attributed back to the
clinic responsible for that patient using an attribution rule yet to be determined. MDH’s larger
time, as some specialty clinics obtain certification as health care homes, those clinics will
also fall within scope of the total care analysis as they would be expected to coordinate/provide
primary care-like services. 1 Over
General Information: 651‐201‐5000 • Toll‐free: 888‐345‐0823 • TTY: 651‐201‐5797 • ww.health.state.mn.us An equal opportunity employer goal is to preserve the ability to have one peer group for the total care physician clinic analysis
and this approach will provide a comparable cohort of physician clinics.
Implications for Attribution Rules
MDH wanted to revisit the attribution rule issue with RRT members as we recognize that having
greater clarity around the scope of the analysis may impact RRT member feedback on this
methodological issue. As we have explored this issue internally and with our analytical partners
at Mathematica, we considered the advantages and disadvantages of various attribution
approaches in greater detail and wanted to share this information with you as well. The attached
memo from Mathematica outlines the potential attribution rules we shared with you in June with
some additional information about the implications of using them.
Additional Opportunity for Feedback
MDH would appreciate your feedback given the clarification we have provided around the scope
of the total care peer grouping analysis and the implications of various approaches to attribution.
Please send your comments to [email protected] by 4:30 pm on August 16, 2010. Please
call Katie Burns at 651.201.3562 with any questions you may have.
MEMORANDUM
TO:
Katie Burns, MDH
FROM:
Nyna Williams and Randy Brown, Mathematica
SUBJECT:
Follow-Up Recommendations for Attribution of Patients to
Medical Clinics and Groups
DATE: 8/6/2010
Purpose of Memo
This memo presents recommendations for attribution of patients and costs to physician
clinics or medical groups in the total care peer grouping analysis, following up on written
comments from the Rapid Response Team (RRT) regarding the recommendations we presented
to them on June 15 and a decision by MDH to focus the total care peer grouping analysis on
primary care clinics. Our presentation to the RRT was based on our June 13 memo. 1
Likely Outcomes of Attribution Rules
In our earlier memo and presentation to the RRT, we recommended attributing patients to
providers using a rule that distributes the cost of that patient’s care across all providers involved
in that patient’s care. This approach is called the multiple-proportional rule and it would attribute
the costs of patient care based on the percentage of Evaluation and Management (E&M) visits. A
second option presented to the RRT was an approach that would attribute all costs of a patient’s
care to the one physician clinic or medical group that billed for the greatest number of E&M
visits for that patient, with the added criterion that the provider billed for at least 30 percent of
annual E&M costs for the patient (the plurality-minimum rule). A third option is to attribute all
costs for a patient’s care to all physician clinics or medical groups that billed for any E&M visits
for the patient, as long as the provider billed for at least 30 percent of the annual E&M costs for
that patient (the multiple-even rule).
Given the decision by MDH to focus the total care peer grouping analysis on primary care
clinics, MDH asked that we address the likely outcomes of the different attribution rules to better
inform their decision. We continue to recommend using the multiple-proportional attribution
rule, for the following reasons. Under either the plurality-minimum rule or the multiple-even
rule, we feel it is likely that the patients who get attributed for use in the total care analysis will
differ from those who do not get attributed, because the rule would be more likely to exclude
patients who go to multiple clinics (because none of their providers would reach the threshold).
1
Zutshi, Aparajita, Eric Schone, Randy Brown, and Mary Laschober. “Recommendations for Attribution of
Total Care and Chronic Condition Cost Measures to Provider Clinics/Groups.” Princeton, NJ: Mathematica, June
13, 2010.
MEMO TO:
FROM:
DATE:
PAGE:
Katie Burns
Nyna Williams and Randy Brown
8/6/2010
2
Those who go to multiple clinics are likely to be sicker (higher cost) and heavier users of
specialty clinics, or individuals who are most dissatisfied with their care from the providers seen
initially. So it is likely that some of the higher cost patients would be excluded from the total
care analysis, even if their care was coordinated through a primary care clinic. Differences across
providers in the proportion of patients excluded may result in reduced validity of the cost
estimates. In addition, it is almost certain that fewer patients will get attributed (especially if
there is a minimum threshold for attribution), resulting in reduced reliability of the cost
estimates. This loss in sample may be substantial, depending on how high the minimum
threshold is set. While the Provider Peer Grouping Advisory Group prioritized credibility of
attribution rules over the numbers of patients attributed, RRT members should be aware that
including fewer patients and some of the sicker patients may affect the reliability of the cost
analysis, depending on how significant the loss in sample may be.
Perhaps the most important unintended consequence of the plurality-minimum rule is the
argument we made in our earlier memo about adverse incentives for providers to collaborate on
coordinating care. While one could argue that using an attribution that makes every practice that
sees a given patient share responsibility for that patient could result in no one assuming
responsibility for managing the patient’s care, it is certainly the case that if the attribution
approach assigns a practice no responsibility for some patients it treats, that practice has no
incentive to share information or collaborate with the practice that is trying to manage those
patients. Furthermore, a practice will not know in advance if they are going to bear full
responsibility for a given patient with complex conditions who sees multiple providers, so it will
be unclear which patients they are supposed to be managing (unless the practice is an HMO). 2
cc: Project Team
2
One commenter asked why we would consider attributing a managed care patient to a provider other than that
designated by the HMO or chosen by the patient. At a practical level, the consolidated data warehouse does not
include information regarding designation or selection of a primary care provider. Moreover, one would expect that
a patient would generally get attributed to the clinic where his or her selected or designated primary care provider
practices. And finally, using different attribution methodologies for managed care and fee-for-service patients could
cause variations in provider rankings that may be due to differences in methodology rather than differences in costs
of providing care.