• Jack Resneck, Jr., MD, is professor and vice chair of the University of California (UCSF) Department of Dermatology, and holds a joint appointment at the Philip R. Lee Institute for Health Policy Studies. An impassioned advocate for physicians and patients, his leadership at UCSF includes oversight of the medical center’s Medicare physician quality reporting efforts. Jack is a new member of NQF’s Board of Directors and recently served on NQF’s Attribution Committee, which created a guide to help healthcare stakeholders develop, select, and evaluate appropriate attribution models. He is also a trustee of the American Medical Association.

    NQF spoke with Jack about the importance of attribution, which is a method that assigns accountability for the care of a patient in order to measure quality or cost. Accountability can be assigned to a single provider or shared among providers, including individual clinicians, groups of clinicians, or facilities.

    NQF: Why is attribution important in healthcare?

    JR: Healthcare delivery increasingly relies on measures of quality, cost, and value, particularly with the expansion of value-based purchasing, public reporting, accountable care organizations, and alternative payment models. These measures can affect providers’ reimbursement and reputations, as well as guide future policy decisions.

    In today’s healthcare system, where multiple providers may care for a patient—either for their overall health or for a particular episode of care—it’s vital that responsibility is assigned accurately in measurement. This means ensuring that attribution models assign accountability to the providers who are truly able to influence care and outcomes. It also means measuring outcomes that are within a provider’s control.

    If done well, attribution can help reward entities that are working hard to provide high-quality and efficient care, and can motivate or support important improvement work. If done poorly, attribution can penalize clinicians and groups unfairly, potentially interrupting high-quality care delivery systems.

    NQF: What does NQF’s model selection guide do?

    JR: NQF’s new guide provides a roadmap to ensure that many different stakeholders—including measure developers, those implementing measures, and those being measured—are on the same page when it comes to assigning accountability for patient outcomes.

    NQF’s Attribution Committee found that while there’s no one-size-fits-all approach to assigning attribution, there are attribution models that meet a high bar in terms of accuracy. The NQF Attribution Model Selection Guide can help encourage the use of such models, which have transparent methods, undergo sufficient testing, rely on robust and accessible data, and fairly attribute patients and outcomes. These are the models we should look to for measures used in programs that involve public reporting or affect payment.

    NQF: What role do patients play in attribution?

    JR: Keeping patients informed and engaged in their care is vital to their health. People should know which doctor they see is ultimately responsible for their care, and payers have the responsibility to inform patients about their accountable providers. In the future, there may be some measures where patients have a role in confirming that they have been assigned to the right provider or entity. However, it’s too early to say how often or for which measures that may make sense without some robust testing of those models.

    NQF: Moving forward, how can we address physicians’ concerns about attribution and fair measurement?

    JR: Now that we have strong recommendations in the report, we need to make sure measure developers and implementers are held to these standards. We should refine and re-evaluate models and allow for fair and open adjudication processes. Models that don’t yet have adequate quality data or that aren’t yet proven to be accurate should be released for testing, experimentation, and use in quality improvement—but not high-stakes reporting or payment.

    Physicians want to be held accountable for the quality of care we provide, but it is important that measures be accurate and meaningful, and that the burden of reporting not be too high. If measure developers and implementers create measures that are fair and make sense, then physicians will use them.

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