Journal Watch: “Patient Assignment and Quality Performance: A Misaligned System”
A review of a recent primary research article on value-based care
Love K, Turner S, Runger G, Adams C, Riley W. Patient assignment and quality performance: a misaligned system. Am J Manag Care. 2024 Oct;30(10):482-487. doi: 10.37765/ajmc.2024.89617. PMID: 39467178. https://www.ajmc.com/view/patient-assignment-and-quality-performance-a-misaligned-system
This article was a retrospective analysis of Medicaid patients at Valleywise Health in Phoenix, Arizona from January 2020 to February 2022. They studied the frequency by which patients assigned by their insurance to a particular practice were also receiving care at that practice. Managed care organizations (MCOs) are contracted with the state to administer Medicaid benefits. Medicaid patients are either assigned to a PCP or can choose and self-declare their PCP. Despite this assignment process, primary care physicians understand the significant difference between those who are “assigned” and those who are “established” patients. Being “established,” typically indicates that a patient has had an office (or telehealth) visit with a primary care provider and an understanding that they will be the provider of the patient’s ongoing care. The assignment listed on an insurance card does not determine the presence of a patient-physician relationship. In the study, the concordance rate (of patients being both established at the organization AND assigned to that same organizations, or true-positives) was a jaw-dropping 15%. I suspect in Washington it is not much better and that the problem is not confined to Medicaid.
Why does it matter? The incongruity presents large issues for those practicing in value-based care contracts. As a physician, if you are “assigned” a patient, you may be fiscally and clinically responsible for their care, even if you’ve never seen them as a patient in your office. If they’ve never been to your office or had a visit with a clinician there, you likely have no information on their health status or needs and the patient does not look to you to help with their needs. You also may not be getting credit for the patients for whom you’re not assigned, but of whom you are taking care (someone else is). This study also showed that quality is on the line; HEDIS measures were more often fulfilled amongst the ‘true-positive’ patients.
It makes sense. How can clinicians and practices help people they’ve never met and don’t know exist? For patients, how can they receive care if they are assigned but don’t have a direct relationship with a care team? Finding a PCP is a burden generally placed on the patient who wants care, and being assigned does not necessarily push one to the head of the line. I saw this story played out in our rural primary care practice’s early efforts to work on quality metrics for our Medicaid-MCO population. We looked at the list of patients from the insurance company who were indicated to have “quality gaps” but it was horrendesly inaccurate, showing we were responsible for patients we’d never seen (and therefore had no ability to address the quality gap). This was a problem. Unfortunately, the financial and time effort required to reconcile our lists made it hardly worth the monetary incentives offered. I’ve also saw the challenge for patients to understand “assignment” vs “established” concepts while working as an urgent care provider, many of whom sought care in that setting because they didn’t have a PCP or their PCP was not accessible. At the end of the visit, I’d ask them whether they had a PCP and/or wanted one. Many wanted a PCP but didn’t know where to start. Seeing that the insurance was listed as Medicaid, I’d have them pull out their insurance card. We’d look to see which clinic they were assigned to and I asked them to start there, hoping that the assignment will at least get them a place in line. As a prior medical director in the same system, I knew that the line for new patients was often quite long and unfortunately, there was little incentive to provide outreach to assigned but unestablished Medicaid patients.
Given the data, what could help improve these gaps? Here are some ideas:
MCOs should perform regular outreach to Medicaid patients about where they are receiving primary care and then cross match it to patient visit codes in the last three years to verify the assignment (improving true positives and reducing false positives) and then match it again with the indicated primary clinic’s list. When there is discordance, investigation/drill down is needed by the MCO. At the very least, it should not be the Primary Care Practice’s sole responsibility.
Create and decide upon standardized definitions across MCOs and primary clinics to indicate how patients are assigned and attributed to a practice. Even if standards aren’t consistent between MCOs, transparency is essential. Some clinics require patients to be seen once a year to be included as “established,” while others are every three years, and some clinics have no standard at all. Clinic criteria may be entirely different than the criteria MCOs use to attribute patients.
Establish regular communication between MCOs and contracted primary care practices about practice capacity. Is the primary care practice taking new patients and in a timely manner? If not, new patients shouldn’t be assigned by the MCO to the practice. Assignment only gives them a PCP in name but without real meaning (i.e. access and a relationship).
Attribute and assign based (at the insurance level) on the clinic rather than on the physician. Clinics may utilize a team approach to care for patients or may be using locums or other care models make recognition of a single person difficult. Patients still want and need continuity of care, but this can be decided at the clinic level rather than the insurance level.
Increase access to patients who are assigned but not established with a PCP at all. Create other ways for patients to “establish” a relationship with a clinic besides a traditional PCP office visit (for example, with a behavioral health specialist, social worker, or a nurse), creating new paths for access and addressing care gaps and also eventually leading to a comprehensive PCP visit.
Acquire new technologies to aid the process. Successful ACOs provide evidence that technology is a key determinant, reducing the burden for practices themselves to provide this reconciliation process.
Today’s patients are mobile. Patient changes in preference, employer, insurer, socio-economic factors, and geography can make it difficult for physicians and clinics to ‘keep track’ of whom they are responsible. I spent many hours as a medical director with our clinic manager working to create and then manage our method of attribution, as well as standardize panel size, transfers and management. These were internal efforts and done with rudimentary technological skills (a basic EHR report and Excel). However, minimal payer-primary care interaction and collaboration left major gaps. Quality and health equity, in addition to payment, are more difficult to address if you do not know for whom you are being held accountable. With the movement towards value-based care, it is even more essential to have alignment and communication around assignment, empanelment and attribution between providers and payers.
