The Health Care Payment Learning Action Network (HCPLAN) has released a white paper on patient attribution within alternative payment models (APMs).  HCPLAN work products will be considered by the Centers for Medicare and Medicaid Services (CMS)  for implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) and other health care payment reform initiatives.  This white paper was developed by the Population-Based Payment Work Group and documents principles and recommendations for patient attribution.

Patient attribution has been one of the most challenging elements in developing and implementing payment reform models such as accountable care organizations. Providers have been urging application of prospective attribution and more flexibility to “recruit” or incentivize participation by patients. CMS has been reluctant to yield the ability of Medicare fee-for-service beneficiaries to choose any Medicare provider, which favors retrospective or concurrent attribution.

Moreover, commercial insurance models usually are based on “open-access” that allow choice of providers (although many insurance plans increasingly offer options for “narrow networks” of providers in exchange for lower insurance premiums and co-payments). Shifting these commercial models to value-based payments present similar challenges.

The white paper makes the following recommendations:

  • Encourage patient choice of a primary care provider;
  • Use a claims/encounter-based approach when patient attestation is not available;
  • Define eligible (primary and specialty care) providers at the beginning of the performance period;
  • Provide transparent information to patients about their attribution;
  • Prioritize primary care providers in claims/encounter-based attribution;
  • Consider subspecialty providers if no primary care encounters are evident;
  • Use a single approach for attribution for performance measurement and financial accountability;
  • Use the patient attribution guideline nationally for commercial products;
  • Alignment among commercial, Medicare, and Medicaid populations may be possible with adjustments; and
  • Regardless of whether prospective or concurrent attribution is used, providers should receive clear, actionable information about patients attributed to them.

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