Attribution and Market Share, A Story of Growth: Part 1

Many provider organizations had a 2021 goal to increase attribution to ultimately gain market share. If that’s still on your to-do list, surely there are a few questions you’ll want answered. Do you even need to increase attribution? How do you do that? Does it matter who you’re bringing into your provider organization? What are ways you can increase attribution? It’s important that you get the right information in front of you before you jump to conclusions. Keep in mind, this is a two-part blog, so you’ll want to read both of them in their entirety to truly get the full picture of what we’re going to discuss. I’m going to start by focusing specifically on attribution, and then I will work my way into market share in the final blog.


Organizations should always strive to increase their population, and there are a few reasons for this. First, you need to stay above 5,000 beneficiaries to even be considered an ACO in MSSP. There’s a specific reason for this, and it has to do with mitigating variability through having a larger “n.” The larger your beneficiary roster, the less a singular individual can significantly impact your overall performance. CMS prefers to avoid programs with too much variability; therefore, the cutoff is set at 5,000 beneficiaries per official guidelines. There’s a “Shared Savings and Losses & Assignment Methodology” .pdf you can look at for more detail, but Cliff’s Notes version is, essentially that it’s too risky to allow low-beneficiary provider organizations to enter into the ACO program. That’s why the Direct Contracting Entity (DCE) was born. Standard DCEs are required to have 5,000 beneficiaries, but the volume decreases for New DCEs to 1,000 in Performance Year (PY) 1 and 2, increased by 1,000 each year thereafter, with a maximum of 3,000 beneficiaries aligned via claims in any baseline year. High Needs Population DCEs are required to have a minimum of 250 beneficiaries for Performance Year 1, increasing to 1,400 by PY6.

Second, a portion of your patient population will always contend with natural beneficiary loss (people move, die, and change insurance). Therefore, you’ll consistently need to replenish those lost beneficiaries.

Third, the more lives you have attributed to your organization, the more leverage you have in negotiations with value-based contracts and other business vendors. More market equals more power, and that is what gaining market share is all about.

So, the answer to the above header is, unequivocally, yes. You do need to increase your attribution, but how do you go about doing that? You can break your overall population down into three separate groups:

  1. People that are currently attributed to your provider organization, and your provider organization is looking to maintain their attribution.
  2. People that were attributed to you, but you’ve lost their attribution; as well as people that have seen your providers but are not attributed to your organization (assignables).
  3. People that you haven’t seen at all (and never had); we call this group of people “Net New.”

Group 1: There are a series of reasons your provider organization might lose beneficiaries:

  • Uncontrollable Natural Loss (mentioned above): Beneficiaries who move out of your area, beneficiaries who die, beneficiaries who leave Medicare for Medicare Advantage, etc.
  • Controllable Loss: These are beneficiaries who are not seeing their primary care provider, and/or beneficiaries who are seeing multiple providers in your area that are part of your provider organization. Those beneficiaries may be lost due to plurality of care.

Starting with uncontrollable loss, while you can’t directly affect it, it’s important to stay aware of it through actionable lists. Be proactive, know who has moved out of state, know who has passed away in the last year, and know who has changed healthcare plans. In fact, if you have multiple value-based contracts, it’s good to know who has changed from Medicare to Medicare Advantage. They are still your patients, so it’s not like you’ve physically lost them. Equally important is that you’ll still be managing those beneficiaries, but now you’ll be doing that under a different set of rules.

Turning our attention to what you can control, CMS states that 70% of the Medicare population has two, or more, chronic conditions. Therefore, if each practice has 70% of its Medicare population with 2 or more chronic conditions, then 70% of the population should be seen at least once per quarter in order to properly manage their chronic conditions. The reason I dropped these particular factoids here is because they should be catalysts to address your churn (the ingress and egress of your beneficiaries, which you want under control) AND bolster attribution by seeing patients at least once per quarter all while simultaneously addressing quality of care. If you’re losing attribution to this segment of your population because you’re not seeing them, then why not set them up for an Annual Wellness Visit and ensure they are scheduled for a subsequent visit.

Attribution logic always favors those who deliver the most amount of primary care services. Thus, if your beneficiaries aren’t seeing your primary care providers at least once a year, it’s almost guaranteed that you’ll lose their attribution. (For more information on implementing an Annual Wellness Visit initiative, just click this link.) Also, be the absolute best care they’ve ever had so that your patients want to come back.

Now you’ve ensured you’re on your way to preventing that loss of attribution, but you’re also bringing them back in to continually manage any conditions they may have. That’s going to have a significant impact on the patients’ quality of care, hospital admissions, risk scoring, attribution, and then eventually the financial end of the equation. Then as they leave their follow-up visit, continue scheduling them one quarter out.

Group 2: This group is comprised of beneficiaries whom you’ve lost attribution of, or patients you are seeing in the office but haven’t gained plurality of services for. Your first thought should be, “How do I get those I’ve lost to come back?” This can be accomplished through various retrospective analyses with the simplest version being that of calling former patients and speaking with them. Consider having a personable front desk staff member or patient advocate call those patients to assuage any prior negative feelings and encourage that patient to return for services. You would be surprised at how often patients leave offices purely based on customer service issues.

Your provider organization may have lost beneficiaries over the last year, since many people deliberately avoided seeing their provider out of fear of COVID-19. We recommend reaching out to those patients who you haven’t seen recently to discuss all of the other components of care that these patients need. Bring them in, work on forming a solid physician-patient relationship, and genuinely try to learn about how they’re feeling. This is also the most opportune time to discuss the care your beneficiaries are receiving from various specialists to address any unnecessary, or duplicative, services. You’ll discover if they’ve been visiting any providers outside of your network, and that ability to see beyond your own walls empowers providers to continue to have those meaningful, data-based discussions with their other patients. It gets you to the “why” of care while shining a light on network utilization.

Now, there’s another segment of people in Group 2 you’ll want to look at. We officially refer to them as “Assignables.” Remember, the difference between someone attributed and not attributed might just be that one primary care visit, so it’s important to schedule those beneficiaries as soon as possible. Thankfully, Salient Healthcare has a network management module that can show you who your assignable beneficiaries are. It’s not uncommon to see double the amount of assignables as you have currently assigned beneficiaries, so there’s usually a lot of opportunity to increase attribution here.

Group 3: Now what about everyone else? The key to surveying the rest of your market and getting them to join you is ultimately about looking at other practices. The benefit of adding “Net New” beneficiaries is that you gain leverage in contract negotiations when you have a larger (and high-performing) provider network.  Attribution is a key theme throughout all levels of population health, and in order to assume risk, it needs to be a major consideration.


Ryan Mackman

About the Author

Ryan Mackman, MBA, MHA - Business Consultant

Ryan Mackman has been an ACO business consultant team member with Salient since March 2018. In this role, he acts as a solution trainer, marketing and sales consultant, as well as Value Based Payment strategist. His skillset helps augment Salient’s efforts at the ACO and physician practice level.

Leave a Reply

Your email address will not be published. Required fields are marked *