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How Care Management Can Preserve and Increase Your Medicare Attributed Beneficiaries

Key takeaways:

• Accurate beneficiary attribution ensures providers are held accountable for patients they treat regularly under shared savings programs.
• Patients enrolled in a care management program are more likely to be attributed to the practice offering care management. 
• Accurate attribution also increases continuity of care for patients and ensures quality measures are addressed. 

Shared savings programs, from the Medicare Shared Savings Program to many Accountable Care Organizations, rely heavily on attributed beneficiaries to evaluate practices’ quality of care.  Accurate beneficiary attribution ensures providers are receiving additional funds, or having funds taken away, based on patients whose outcomes they have influence over. 

When providers don’t receive credit for all of the Medicare patients they’re serving each year, shared savings revenue may slip and providers may face lower overall quality scores. These consequences can also occur when a patient is inaccurately attributed to a provider who they don’t interact with. 

Patients enrolled in a care management program are more likely to be attributed to your practice, and care management gives those patients regular, proactive care, ensuring that attribution is accurate. We’ll break down the factors that impact accurate attribution and how you can use care management to improve your shared savings performance, regardless of which program you participate in. 

Challenges of Accurate Beneficiary Attribution 

Beneficiaries not being properly attributed year over year, sometimes called attribution slippage, can be caused by multiple factors. Michael Cantor notes in the Journal of General Internal Medicine that inaccurate attribution can occur due to patients:

• Not having a designated PCP
• Seeking care from providers across multiple health systems
• Having different data stored in multiple places (claims data, data from different EHR systems) 

Attribution slippage can also occur when patients have trouble scheduling or attending regular appointments with their provider and so switch to a different one, when patients need to visit multiple providers across multiple networks, or when there are delays or errors in claims data or EHR record-keeping. Care management programs offer a solution to many of these challenges.

Patients Not Seeing The Same Provider Regularly

Patients may see a provider for one appointment when they’re sick but be unable to make it to subsequent appointments or their Annual Wellness Visit. If a Medicare beneficiary stops seeking regular, preventive care or chooses to seek care from another source, like an urgent care facility, they may be attributed to the incorrect provider or to no provider at all.

Advanced Primary Care Management, one of CMS’s care management programs, explicitly requires that the provider offering the program serve as the patient’s primary point of care. The majority of the time, the provider offering APCM will be the patient’s Primary Care Provider, though there may be an exception if the patient’s primary point of care has a different specialty.

Regardless, APCM ensures that patients receive preventive care from the same provider multiple times each year, which makes them likely to be attributed to that provider at the end of the year or beginning of the next year. 

Chronic Care Management doesn’t specify that the patient’s provider must serve as their primary point of care. However, since the patient will receive preventive care every month, which will be recorded in claims data and should be recounted in the EHR, they will likely be attributed to the provider who offers them CCM. This could be a Primary Care Provider, or a specialist they see frequently, such as a cardiologist, neurologist, or endocrinologist. 

Multi-Network or Disjointed Care

Many patients require a mix of primary care providers and specialists to manage their chronic conditions. Ideally, the patient’s care team will all belong to the same health network, continually communicate, and share the patient’s health records with one another. 

However, this is sometimes not the case. If patients seek out specialists and primary care on their own, they may see providers across multiple networks, who don’t share information with one another. This could lead to medication contraindications or conflicting care instructions. 

Many patients also seek support from urgent care providers when sick, who may belong to yet another health system. Chronic Care Management and Advanced Primary Care Management assist with patient care by ensuring that care is coordinated across primary care providers, specialists, and urgent care providers, and that all of a patients’ medications and care instructions are stored in one place.

Care managers can then notify the patient’s care management provider about any medications they’ve been prescribed or care instructions they’ve been given by other providers. With this awareness, a patient’s primary point of care can coordinate their care plan and medications to prevent harmful contradictions. 

The provider offering care management is also likely to have the patient attributed to them, since their care team is reaching out monthly (for CCM) or on a regular basis (for APCM). This helps the attribution match the reality of the patient’s care: they are attributed to the provider whose care team coordinates care for them. 

Data Confusion and Delays

The information contained in a practice’s EHR may differ from the patient’s claims data, either because there has been a lag in entering data or because patients’ data is scattered across many different EHRs and practices. When this occurs, practices could expect to have patients attributed to them who later aren’t, or could see patients who they didn’t expect to be accountable for attributed to them. 

Different value-based care models also vary in the model they use to assign beneficiaries. Some ACOs use prospective attribution, assigning patients at the start of each year based on visits from the prior year. Others use retrospective attribution, assigning patients at the end of the year based on who provided the majority of their care in the preceding year.

If a VBC model uses prospective attribution, providers can suffer from patients who they served last year no longer coming to them for care, leading to them being responsible for patients they haven’t actually treated. On the other hand, retrospective attribution can lead to providers not being certain of who they’re held responsible for until they are assigned beneficiaries at the end of the year.

Care management programs require that care managers update the patients’ care plan and document care received, and the practice must submit claims to receive reimbursement. This means that, at least for care management, the patient will have multiple claims, with clear documentation, from a single provider. This greatly increases their chances of attribution to that provider. 

Without care management or another proactive solution, all of these challenges can lead to attribution declining: which, in turn, can lead to weakened quality performance and shared savings revenue. 

Consequences of Inaccurate or Declining Attributed Beneficiaries

Inaccurate beneficiary attribution or beneficiaries declining over time can have patient care and financial implications for practices.

If one ACO or alternative payment model insists a patient’s cardiologist is responsible for their care, while another only looks at their Primary Care Provider, the provider’s care teams could be left uncertain about who should be following up on preventive care and adjusting the care plan to ensure the patient’s long-term health. 

Inaccurate or unattributed beneficiaries also impacts practices’ quality scores. If practices care for patients who are not attributed to them, their quality scores won’t benefit from the work they put into ensuring those patients receive vaccinations, screenings, blood pressure readings, and other preventive care. 

Being held accountable for patients they’ve never seen could also lower a practice’s quality scores. If the patient visits them once and never again, or has not visited them recently, the provider’s care team has limited opportunities to ensure they receive the care planning and proactive care they need. 

When quality measures fall, practices may not receive extra revenue from their quality program. If you participate in two-sided risk arrangements, you may even lose revenue you previously had, which can have negative impacts on the patients you serve. 

How to Increase Attribution and Shared Savings with Care Management Programs

There are a few strategies practices can use to increase their attributed beneficiaries:

• Encourage patient engagement between appointments
• Coordinate care across providers
• Address quality measures and proactive care

By engaging patients between appointments, practices make it more likely that patients will choose to return to them when they’re ready for an Annual Wellness Visit, physical, or follow-up exam. Additional visits to the office increase the patients’ chances of being correctly attributed to their primary point of care. 

Care coordination can address the issue of patients being assigned to the wrong provider because they need support from multiple specialists. Ideally, the patient’s primary care provider and all of their specialists will share health records, medication lists and care plans with one another, ensuring the patient receives consistent care. 

When continuity of care is established, providers can refer the patient back to other members of the same network or health system. This ensures that patients see the same providers consistently and don’t have to repeat all of their health information at each visit. It also helps with accurate attribution. 

Addressing quality measures, such as screenings and vaccinations, can also improve attribution by increasing the number of times patients visit their main provider, and therefore increasing the chance they’ll be attributed to that provider. 

Care management programs like Advanced Primary Care Management and Chronic Care Management can assist with patient engagement, care coordination, and quality measures to help practices increase their attribution—but which care management program is best depends on what quality programs you participate in. 

Quality Programs Supported by Chronic Care Management

Chronic Care Management can support practices participating in MIPS or in various ACOs. Federally Qualified Health Centers and Rural Health Clinics are also able to participate in Chronic Care Management.

Chronic Care Management’s strength lies in its ability to address care continuity, engagement, and quality measures for a variety of quality programs. Patient engagement is established through monthly outreach to each patient and offering all enrolled patients a 24/7 care line.

Even if patients don’t choose to use the care line, a good care management partner will offer proactive outreach in a variety of formats. ChartSpan reaches out to CCM patients every month via a variety of methods, including text, email, voicemail or phone call. This helps patients remain engaged.

Care management also requires 20 minutes of work dedicated to each patient, each month. This work can support care continuity, since care managers might spend time updating the patient’s care plan, adding new medications or changes in treatment regimen, or reconciling records from multiple providers so all of the patient’s information is consolidated in a central location.

Finally, care management programs can address a variety of quality measures, depending on which measures your MIPS program or ACO emphasizes. Some of the most common include:

• Diabetes: Glycemic Status Assessment Greater Than 9%
• Screening for Depression and Follow-Up Plan
• Controlling High Blood Pressure
• Adult Immunization Status

Care managers can perform initial screenings or ask whether patients have had a recent screening, vaccination or assessment. If they have not received one within the recommended time frame, the care manager can help them make an appointment with their provider.

By addressing care gaps and improving quality scores, Chronic Care Management increases practices’ chances of receiving shared savings revenue. Directing patients back to their provider for preventive care also increases the chances of patients being correctly attributed to that provider. 

Quality Programs Supported by Advanced Primary Care Management

APCM has stricter rules around quality programs than CCM does. MIPS-eligible clinicians must join the Value in Primary Care MVP, an ACO, or another Advanced Alternative Payment Model. This is good news for ACO REACH and ACO LEAD members, who can take advantage of APCM. 

RHCs and FQHCs are exempt from this requirement and may rely on their own quality programs instead. Regardless of which quality program they choose, however, APCM participants must join a quality program and perform population health analytics. This requirement leads to increased use of preventive services and improved quality scores.

Quality teams must examine the population of APCM patients as a whole and identify which quality measures they can address to achieve the largest gains in population health. This may include preliminary assessments performed remotely, like depression screenings, or referrals back to the provider for vaccinations, cancer screenings, blood pressure or A1C readings, and more in-depth screenings.

By making quality a mandatory component of the program, APCM addresses quality measures more directly than CCM does. But like CCM, it supports improvements in quality scores for shared savings revenue and attribution through referring patients back to their provider on a regular basis.

Increase Your Correctly Attributed Beneficiaries through Care Management

When patients aren’t correctly attributed to your practice, you’re held accountable for the costs and outcomes of patients you don’t serve or are not given credit for the patients you do serve. This can lead to decreased quality scores, lower shared savings revenue, and a less cohesive patient experience.

Care management programs address this challenge by making your practice a central point of care that enrolled patients hear from consistently and rely on for care coordination and preventive care. By engaging patients on a regular cadence and referring them back to your practice for follow-up or preventive care, care management programs nearly guarantee that patients will be correctly attributed to your practice.

To learn more about quality measures and shared savings, visit our guide to how APCM impacts quality programs.