One of the more challenging concepts that has arisen in health care with the move toward pay for performance is term attribution. A common definition of the term is:
Attribution: The method to which a patient is connected to a health care system, provider, physician or pharmacy and the extent to which that provider takes responsibility for the care of the patient.
While this concept appears simple on the surface, depending on how one defines the word connected, the result is not always consistent or predictable. In health care, patient attribution is typically linked to claim activity. The amount of claim activity and the date in a claim made impact attribution assignment. This can create some interesting connections. Let’s look at a few examples.
Patients that transferred to another pharmacy in January or February and have not had any prescriptions filled in three or four months from our pharmacy are still attributed to us. The patient is likely attributed to both pharmacies at this time.
A patient that came to our pharmacy to receive a nebulizer and the associated acute medications is then attributed to our practice. They came to us because their own pharmacy does not stock or bill for durable medical equipment. Because of the new attribution, the insurance then asks us to do Medication Synchronization on the patient even though another pharmacy fills all of their chronic medications.
A patient that came to our pharmacy to receive a vaccination becomes attributed to us. While this is the only drug product we have ever provided to the patient, their insurance requests us to perform a Comprehensive Medication Review (CMR).
Patients that have passed away continue to be attributed to our pharmacy months after their death.
Attribution, as it turns out, is relative. In some instances, a single claim can generate a connection, resulting in attribution. In other plans, a patient might need to fill a majority of their prescriptions at a pharmacy to be attributed to that provider. There is not hard and fast rule: each plan has their own policies.
Attribution is often sticky — it doesn’t promptly stop if a patient’s claims cease. I call this fringe attribution — a patient is no longer actively using a provider but continues to maintain a connection. Fringe attribution is rational. Claims data doesn’t contain the reason for a change in provider, so attribution often extends for several months before expiring. Even in the case of a patient that has passed away, attribution does not abruptly end. The insurance plan must accept claims for a period of time after death. Often, it takes 6-7 months with no new claims before attribution of the deceased is allowed to lapse.
Fringe attribution can be either good or bad for the provider. For example, being eligible to perform extra services like a CMR can enhance revenue available to a provider. An attributed patient that does not regularly use a provider could either positively or negatively impact the provider’s performance scores. It is well known that a significant portion of healthcare spending happens near the end of life. A recently deceased patient will often negatively impact a provider’s total cost-of-care metrics for several months before their attribution ultimately wanes.
So attribution is a complex concept with many nuances. Because attribution is more and more often linked performance measures, this nuances can impact a practice’s bottom line. For that reason, it is very important to understand how attribution impacts your practices. A better understanding of your practice’s attribution profile allows you to better anticipate changes as they occur so you can Make Every Encounter Count.