The National Quality Forum has published a guide to help providers and payers determine how to measure who is responsible for patient quality and outcomes in value-based purchasing.

This accountability, known as attribution, is an important part of value-based care and can affect the reputation and the reimbursement of providers who participate in a value-based program. However, there is no single attribution model that works for every patient care episode; the choice should be based on the context in which a model is used and supported by the evidence.

There are about 160 different attribution models, and picking the right one is key, according to Helen Burstin, M.D., MPH, NQF’s chief scientific officer. “There is no gold standard for attribution models, so it’s important to talk about which approach is agreed upon,” she says.

The guide and accompanying report on attribution, the first of its kind according to the NQF, recommend that payers and providers ask key questions about the attribution model being considered for a program:

  1. What is the context and goal of the accountability program?
  2. How do the measures relate to the context in which they’re being used?
  3. Which units would be affected by the attribution model?
  4. How is the attribution performed?

"It’s a discussion guide,” she says. “Are the measures reliable, is the sample size adequate, can providers control the outcome?” Burstin asks.

For instance, the guide might prove useful in managing the several payment initiatives that hold hospitals accountable for the cost of post-discharge care. There are different ways to do so and different ways to measure success. “That’s a classic attribution question,” says Burstin.

The guide also makes recommendations to improve standardization, transparency and accuracy among attribution models, according to the NQF, including:

  • The attribution guide should be used to evaluate the factors to consider in the choice of an attribution model.
  • Attribution models should be tested and subject to multistakeholder review.
  • The models should attribute results to the entities that can influence care and outcomes.
  • Attribution models used in mandatory public reporting or payment programs should meet minimum criteria.

The initiative was funded by the Department of Health & Human Services; NQF also will use the guide for measuring, Burstin says. “It has wide-ranging implications.”

Burstin hopes that stakeholders will use the guide as well as provide feedback to NQF. “The center of all of this is the patients and someone taking responsibility for their care,” she says.