Why it's critical for Primary Care First participants to control and understand leakage

Patients' primary care visits outside of their attributed primary care office, also called “leaked” patient visits, can have unintended consequences for Primary Care First participants. Beginning July 2022, PCF Cohort 1 will face a reduction in population-based payments based on their leakage rate. The payment adjustment will be based on their 2021 claims data and will roll forward quarterly.

To calculate your leakage rate, divide the number of qualifying visits and services your attributed beneficiaries have made to care centers outside of your practice (for example, visits to urgent care centers) by the total number of qualifying visits and services your attributed beneficiaries have made.

Calculating primary care leakage with claims data alone comes with some unintended challenges. Unfortunately, some circumstances can unfairly and negatively impact a practice’s leakage rate:

1. Nuances classifying care delivered by provider team members: It’s difficult to distinguish if certain types of providers are providing primary care alone based on their primary National Plan & Provider Enumeration System taxonomy code. Therefore, CMS determined that visits to a physician assistant will not count toward leakage. However, we believe additional revisions to this definition are needed to accurately exclude specialty care services from counting toward leakage when care is delivered by nurse practitioners. 
2. Observation stays can inadvertently be captured as leakage: CMS should implement an exclusion for encounters delivered in the outpatient hospital setting to avoid observation stays from potentially counting toward a practice’s leakage rate. 
3. Flawed definition of a practice: CMS currently defines a practice in the PCF program by Tax Identification Number and physical location. This means that if a primary care practice spans multiple floors within a building or uses coverage circles, each location is treated as a separate and distinct practice. Any visits between these locations will therefore contribute to the leakage rate. By expanding the definition of a practice, organizations would not be penalized in these circumstances.

Given the gray areas in determining leakage, PCF participants should closely monitor their leakage rates and visits that could be considered leakage. Monitoring and evaluating claims data will be critical for practices to drill down into why leaked visits occur, including identifying where patients are going and which services they receive when they go to external practices. This information will enable practices to implement changes to support patient retention.

By keeping an eye on leaked visits, providers can experience clinical benefits as well. Since leakage can cause non-coordinated fragmented care and limit provider visibility into patient history and medical records, high leakage increases risk for unnecessary utilization and misdiagnosis.

Going forward, practices and supporting stakeholders must advocate for specific methodological revisions to the leakage calculation for a fairer application of the payment adjustment so the program remains fiscally viable for participants.

Need support in accurately evaluating and monitoring performance data to assess your practice’s leakage? Contact DataGen today to learn how you can determine which patients are leaking through, which providers they're seeing and what services they are receiving.