Common methods for attributing cardiac care in ACOs may be falling short
Attributing patient care to the correct physician is a critical step in measuring quality and accountability in healthcare, especially as the U.S. moves toward value-based care models. But recent research by David Magid, MD, MPH/MSPH, a professor of cardiology at the University of Colorado, suggests the most common attribution methods used by accountable care organizations (ACOs) may not accurately identify which physicians are providing cardiovascular care.
“There's been a great focus on improving quality of care. We've made a lot of progress in figuring out how to measure quality of care, particularly for people with cardiovascular disease. But once you measure the quality of care, you have to decide who is the responsible or accountable healthcare provider. Our study looked at some of the most common methods being used to attribute patient quality of care to the providers that provide the care," Magid said. "In many cases, the primary method most often used will not actually identify the physician or provider that the patient saw for their cardiovascular care."
Quality attribution challenges in cardiovascular care
Most ACOs and quality reporting systems assign patients to physicians using claims-based “plurality” methods — typically identifying the provider who billed the most visits for a patient in a given year. While that approach may work in some areas, Magid said it breaks down when applied to chronic cardiovascular conditions where patients often see multiple specialists.
"When it comes to cardiovascular disease, there are significant limitations to this approach," Magid explained. "Many patients see both primary care doctors and cardiologists, but the most common methods that are used only assessed primary care providers."
In his study, Magid found that only about 70% of ischemic heart disease patients could be attributed to a single provider using the plurality method. Even more concerning, 40% of patients assigned to a primary care physician had never seen that provider for a cardiovascular-related visit. When both cardiology and primary care visits were included, attribution improved, but not by much. About 20% of patients still could not be linked to a single physician, and 30% were assigned to a doctor who had never treated them for heart disease.
Building better quality of care attribution models
To address these shortcomings, Magid and colleagues are collaborating with Motive Medical Intelligence, a data analytics firm focused on improving care assessment and attribution methods.
"We're trying to develop new methods that take into account whether the patient visits were for cardiovascular disease ... the idea is to try and spread that responsibility across all the providers who are providing that cardiovascular care," Magid explained.
Implications for value-based care
Accurate attribution is not just an academic issue; it’s central to the future of healthcare payment reform. The Centers for Medicare and Medicaid Services (CMS) has proposed that by 2030, most payments should shift from fee-for-service to value-based or bundled models. Under those systems, hospitals and physicians are paid based on quality outcomes and cost efficiency across an episode of care.
"If you're going to provide a standard payment to physicians and you're also going to adjust that payment based on the quality that's provided, you need to make sure that you have the right physicians who are responsible for that patient's care," Magid said. "Our study really speaks to the idea that there are typically multiple physicians involved in the delivery of care, particularly for chronic conditions like cardiovascular disease. You can't often assign responsibility to just one doctor, either because there is no one doctor who saw the patient for the majority or plurality of their visits because they're being receiving care from multiple providers. So it makes sense to not use a method that doesn't accurately assign patients to the providers."
He added that most physicians are willing to be evaluated on quality if they believe the data and attributions are accurate. If a doctor is being measured on patients they never actually treated for heart disease, that is not fair to them. It is not useful to patients or payers either, Magid explained.
Accounting for the heart team approach
Magid noted that many cardiovascular conditions are increasingly managed by teams, not individuals, and new attribution methods need to evolve to reflect that reality. Instead of trying to assign one provider, he said the accountability system needs to include the multiple clinicians who are jointly responsible for the quality of care.
As ACOs, insurers and healthcare systems continue to refine quality metrics, Magid’s research highlights a key gap in the infrastructure supporting value-based care.
"Whether it's the patient, the provider, accountable care organization or just an organization interested in improving quality, it's in everyone's best interest that the methods that we develop not only measure the quality accurately, but also attribute it to the physician or provider or providers who are actually providing the care," Magid said.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]