Introduction
There are several reasons to empanel your patients, from building the patient-provider relationship to getting started with risk stratification . In his article, “The 10 Building Blocks of High-Performing Primary Care” Dr. Bodenheimer describes empanelment as “the basis for the therapeutic relationship that is essential for primary care.” Establishing a consistent relationship between the patient and the assigned provider helps to build trust and allows the provider and the care team to learn more about the patient, which can result in improved outcomes and patient experience. Additional reasons to attribute your patients:
In Preparation for Risk Stratification:
Patients needs are often dictated by their individual health status, behaviors, and social determinants. Risk stratification groups individuals with similar attributes so that you can determine the resources needed to provide adequate care.
Determine Your Denominator for Reporting:
As you begin to monitor and report quality and process outcomes for internal monitoring, as an Accountable Care Organization (ACO), or for value-based contracts, the patient panel provides you with the denominator needed to accurately report quality measures associated with the population.
Monitor Total Cost of Care:
Under an ACO or other value-based contract, the patient attribution methodology is documented to ensure reporting and incentives are paid based on an accurate listing of beneficiaries or patients. The assigned provider will be held accountable for the health outcomes and potentially the total cost of care for each patient attributed by the payer to that specific provider.
Commercial payers also attribute patients to a provider based on claim activity however, the Health Care Payment Learning and Action Network (HCP-LAN) recently published a white paper to address the inconsistencies of attribution between programs. In their “Accelerating and Aligning Population-Based Payment Models: Patient Attribution”, the HCP-LAN identifies patient attribution as “a foundational component of population-based payment model because it both designates the population for whom a provider will accept accountability in a population-based payment model, and forms the basis for performance measurement, reporting, and payment.” As a foundational component, the HCP-LAN, makes the following recommendations for all payer programs along the spectrum of the advanced payment model framework.
Getting Started with Patient Attribution
Before you begin to assign or attribute the patients in the practice, consider the following:
- Who will have their own panel? Physicians only or will you include Physician Assistants (PAs), Nurse Practitioners (NPs), Nurses (RNs)?
- Does your state require physician oversight for PAs, NPs, and RNs?
- Is the Medical Director or Practice Manager comfortable assigning panels to non-physician providers?
- Where in the EMR will you document the assigned provider?
- Who will be responsible for documenting, monitoring, and updating patient panels? It is recommended this process be developed and access restricted to a few key personnel.
- How frequently will panels be reviewed?
- Under what circumstances would you close a panel to new patients?
- When do you need to complete the empanelment process?
The answers to these questions will identify which providers will be assigned patients, how this assignment will be communicated to other members of the care team, when the process should be complete, and will begin to establish the process for maintaining provider patient panels.
The definition of an “active patient” may already be determined by your system or network, but if not:
Medical Group Management Association (MGMA) defines an active patient as having “one visit in the last 24 months, not including nurse visits”.
The Centers for Medicare & Medicaid Services (CMS) defined active patients under the Comprehensive Primary Care (CPC) initiative as “patients who have sought care within the last 24 to 36 months, allowing inclusion of younger patients who have minimal acute or preventive health care needs.”
If neither of these options works for your practice, create or customize a standard definition and communicate it to the rest of the team to ensure everyone is following the same definition. Once you have distinguished between Active and Inactive patients, note or identify the inactive patients in your EMR in a searchable and reportable field for further outreach.
Ideally, the patient preference drives the attribution process. However, you have limited opportunities to ask the patient who he or she identifies as his or her primary care physician.
1. At each check-in, ask the patient who they consider as their PCP. If the patient does not know, then refer back to the patient’s record and make sure they are assigned to a PCP.
2. Explain to the patient how they were assigned to their PCP and ask if that is satisfactory.
3. Add this question to your new patient intake forms if it is not already listed. If it is listed, make sure it is at or near the top of the page.
4. Document the preferred physician in the patient’s medical record.
NOTE: This module provides guidance for utilizing Dr. Mark Murray’s 4-Cut Method to attribute patients however, this is just one method. Each payer you work with has implemented its own methodology on which to base its value-based payments. You may elect to utilize one of your payer’s methodology, the HCP-LAN methodology, or another source. Generate a report of active patients for the time frame selected, 18, 24, or 36 months, from your practice management system and include the following column headers:
- Patient Name
- Date of Birth
- Date of Visit
- Assigned Primary Care Provider
- Provider Seen
- Sort the report by Assigned PCP to identify those patients who have not been assigned.
- Re-assign these patients and any patients assigned to physicians or providers who are no longer with the practice based on Murray’s 4-Cut Method:
| Cut | Report Description | PCP Assignment | ||
|---|---|---|---|---|
| 1st Cut | Patients who have only seen one provider in the time frame reported | Assign to that provider. | ||
| 2nd Cut |
| Assign to the provider seen the most. | ||
| 3rd Cut | Patients who have seen two or more providers equally. | Assign to the provider who performed the last physical exam. | ||
| 4th Cut | Patients who have seen multiple providers. | Assign to the last provider seen. |
Source: Murray M, Davies M, Boushon B. Panel size: How many patients can one doctor manage? Fam Practice Mgmt. 2007;14(4):44-51.
Engage the physician and the care team throughout this process to review the list and provide feedback, as needed.
Once panels have been identified, monitor scheduling and patient wait times to ensure each provider has not exceeded his or her capacity. Assignments may need to be adjusted before settling on a final panel.
The panel manager is responsible and accountable for the ongoing management and clean-up of the panel(s).
- Identify a panel manager who:
- Runs a panel report and is accountable for reporting outliers
- Reviews transfer-of-care requests including:
- Patient-initiated requests
- Provider-initiated requests
- Track patient status including death, transfers of care, and changes to the practice management system.
- Monitors provider status changes (e.g., transfer, termination, sabbatical, medical leave) and re-assigns the patient(s) to another provider based on capacity.
- Notifies the affected patient(s) of any changes to their assigned PCP.
- Coordinates panel management and balance (open and close panels) as appropriate, based on practice size.
Other Considerations for Empanelment:
What is a “perfect” panel size?
Determining the perfect panel size (a panel size is defined as the number of individual patients assigned to the care of a specific provider) depends on the size and goals of your practice.
Is the provider a new graduate?
Is the medical director or practice manager comfortable with assigned panels to non-physician providers (NPPs)?
NCQA only extends PCMH recognition to NPPs if they are assigned to panels.
Patients and providers will come and go, requiring panels to be monitored and periodically adjusted. To effectively manage these changes, a process should be developed and an individual should be assigned to ensure panels are kept up to date and adjusted as needed. See Empanelment: Managing Provider Panels for more information.
