When physicians, executives and trustees look at the pros and cons of assigning a patient's total cost of care to a physician, they can't get bogged down in philosophical arguments over fairness or other concerns about the process, experts say. What's important is how it supports value-based care.

At its most sophisticated, this process — known as attribution —can power new models of fixed payment or full-risk capitation that connect payments to achieving measurable quality goals, in ways that were not feasible in the past. At its simplest, it can introduce the new mindset that providers need to adopt in order to make the adjustment to population health management. And surprisingly, putting the onus for a patient on one physician can help encourage team-based care.

At the outset, administrators have to avoid punitive physician profiling. "We're never tying back a hospital cost or an orthopedist's cost — or an X-ray that an orthopedist did — back to the [primary care physician]. We're tying it to the patient who had the service done," says Christopher Stanley, M.D., vice president for care management at Catholic Health Initiatives, Englewood, Colo. "And that individual, plus all the other individuals that attribute to the physician, is what makes up the panel."

With specific physicians matched up to specific covered lives, actions to remedy a cost or quality concern detected by population-level analysis can be carried out by accountable providers whose patients are found to be contributing to that concern, rather than having administrators be uncertain whose job it is to help fix the problem and who to reward or penalize financially. "The value derived from this certainly does include the financial piece . . . [but] CHI is very focused on [the fact that] it's the right thing to do," Stanley says. "Quality of care improves under this scenario when folks know who they're responsible for, and experience of care does too."

Primary Care Role Changes

Contracts with health plans are aimed at the performance of the entire provider organization, not individual doctors, "and so getting attribution exactly right at the doctor level doesn't really matter so much" in terms of accountability to a payer, says Dana Gelb Safran, senior vice president for performance measurement and improvement, Blue Cross Blue Shield of Massachusetts.

Health plans don't care whether an immunization is done by the attributed doctor or someone else in the network, or even a retail pharmacy in the area, Stanley says. The physician gets credit no matter where the immunization is delivered. That changes his or her role "from a provider of services to a manager of health," he points out. "That's a fundamental shift for a lot of primary care physicians to say, 'I'm responsible for the health and well-being of the individuals who see me as their physician,' rather than, 'I have to provide all of it.' "

Finding a balance between cost and quality improvement incentives will be a challenge for all provider networks, but a five-year test of a global budget model by the Massachusetts Blue Cross showed that it can be done. The so-called "alternative quality contract" did not lock patients into a provider network — they could change physicians if they needed for any reason — though the HMO and point-of-service plans in the test did not have the unrestricted patient choice of a PPO, says Safran. In the first year, all participating provider groups met their budget targets and recorded savings, according to a report of findings published in Health Affairs magazine.

"Before you can have an accountability contract, you have to define who is the population that the provider organization will be accountable for," Safran says. "In an HMO environment, that's very easy." The member tells the health plan who the PCP is, "and everything goes from there." The alternative quality contract that succeeded in the HMO model also can be applied successfully in PPOs — but only if a suitable attribution method is devised to identify members' primary care physicians.

Health plans are supplying attributed claims-based information to provider organizations large and small to support performance improvement. Blue Cross Blue Shield of Michigan, for example, has a Physician Group Incentive Payment program that shares population-insight data with participating provider organizations, leveraging its 2 million attributed lives and identifying the cost-utilization characteristics of target populations for their physician practices. Blue Cross of Michigan used a network comprising 35 critical access hospitals and a few other larger hospitals to model a pay-for-performance program for CAHs and other small rural hospitals, says Ed Gamache, president and CEO of Harbor Beach Community Hospital and also president of the CAH group, the Michigan Critical Access Hospital Quality Network.

Network members can view slices of the attributed population — from the 80,000 lives accountable to CAH physicians statewide to the utilization data by practice — to assess and execute effective responses, Gamache says. Data from claims is two to three months old for identified problems, "so we can't react to it immediately," but it's "a way to start educating [physicians] about how they'll be functioning in the value-based system in the future as we get more sophisticated, as data gets better, and we participate [in value-based approaches]."

The ins and outs of the Blue Cross formula aren't much of a concern. "The thing it does for us right now is identify a sub-population of commercially covered lives that we can focus on and try to develop some of those systems of care that will improve what we do," he explains. "So the fact that the attribution model has some imperfections doesn't really bother me, because it's giving us a chance."

Pulling In Specialists

Once primary care physicians grasp their incentives to do the best for patients at appropriate cost, says Safran, it's in their best interest to work with other clinicians, especially specialists, to team up on care that is measured for purposes of awarding bonuses or other reimbursement. In fact, specialists who aren't participating in a value-based contract could be recruited when they see what they might be missing.

"From the perspective of accountability, it doesn't matter [who does the service]. From the perspective of reward, and what the endocrinologist [or other specialist] is going to see as a benefit to what they contributed to the success, it does matter," she says. "It encourages the specialist to want to be part of the system. In our experience, after the first year of bonuses being paid out, what groups told us is they had the specialists they work with calling them and saying, 'So tell me how I can be more helpful with the contract,' because they want a piece of the action when it came time to receive the incentive rewards."

Specialists will have to earn that action under the new PCP-accountable emphasis. "Doctors have been referring to specialists since time eternal — that's not new. But making those decisions based on a set of clinical parameters or a set of value-based care that they've agreed to is different," says Janet Hughes, senior director of product marketing for Valence Health, a Chicago-based analytics and consulting firm.

"It's not the guy you play golf with; it's the person who has the best ability to treat that asthmatic according to these [parameters]," Hughes says. "Without information, you can't change behaviors. And that's where attribution becomes an essential part of understanding who is watching that patient."

For more on the population health and linking patients to accountable providers, read "Who is Accountable for This Patient?"

John Morrissey is a contributing writer to Trustee.