A Method for Attributing Patient-Level Metrics to Rotating Providers in an Inpatient Setting
BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient.
OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient’s care.
DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign “ownership” of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as “provider day weighted”). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data.
RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics.
CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.
© 2017 Society of Hospital Medicine
DISCUSSION
We found that it is possible to assign metrics across 1 hospital stay to multiple providers by using billing data. We also found a meaningful discrepancy in how well providers scored (relative to their peers) based on the method used for attribution. These results imply that hospitals should consider attributing performance metrics based on ascribed ownership from billing data and not just from attending of record status.
As hospitalist programs and providers in general are increasingly being asked to develop dashboards to monitor individual and group performance, correctly attributing care to providers is likely to become increasingly important. Experts agree that principles of effective provider performance dashboards include ranking individual provider performance relative to peers, clearly displaying data in an easily accessible format, and ensuring that data can be credibly attributed to the individual provider.3,4,6 However, there appears to be no gold standard method for attribution, especially in the inpatient setting. Our results imply that hospitals should consider attributing performance metrics based on ascribed ownership from billing data and not just from attending of record status.
Several limitations of our findings are important to consider. First, our program is a relatively small, academic group with handoffs that typically occur every 1 to 2 weeks and sometimes with additional handoffs on weekends. Different care patterns and settings might impact the utility of our attribution methodology relative to the standard methodology. Additionally, it is important to note that the relative merits of the different methodologies cannot be ascertained from our comparison. We can demonstrate discordance between the attribution methodologies, but we cannot say that 1 method is correct and the other is flawed. Although we believe that our day-weighted approach feels fairer to providers based on group input and feedback, we did not conduct a formal survey to examine providers’ preferences for the standard versus day-weighted approaches. The appropriateness of a particular attribution method needs to be assessed locally and may vary based on the clinical setting. For instance, on a service in which patients are admitted for procedures, it may make more sense to attribute the outcome of the case to the proceduralist even if that provider did not bill for the patient’s care on a daily basis. Finally, the computational requirements of our methodology are not trivial and require linking billing data with administrative patient-level data, which may be challenging to operationalize in some institutions.
These limitations aside, we believe that our attribution methodology has face validity. For example, a provider might be justifiably frustrated if, using the standard methodology, he or she is charged with the LOS of a patient who had been hospitalized for months, particularly if that patient is discharged shortly after the provider assumes care. Our method addresses this type of misattribution. Particularly when individual provider compensation is based on performance on metrics (as is the case at our institution), optimizing provider attribution to particular patients may be important, and face validity may be required for group buy-in.
In summary, we have demonstrated that it is possible to use billing data to assign ownership of patients to multiple providers over 1 hospital stay. This could be applied to other hospitalist programs as well as other healthcare settings in which multiple providers care for patients during 1 healthcare encounter (eg, ICUs).
Disclosure
The authors declare they have no relevant conflicts of interest.
