Keys to High-Quality, Low-Cost Care: Empanelment, Attribution, and Risk Stratification


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Supplement sponsor: American Academy of Family Physicians

Fam Pract Manag. 2020 Sep-Oct;27(5):37-40.

Finding Success in Value-based Payment

Value-based payment (VBP) ties physician payment more closely to improving patient outcomes and reducing costs when compared to the volume-based, fee-for-service (FFS) system. Success in a VBP model relies on identifying and prioritizing patients at risk for poorer health outcomes and directing preventive and other health care services to those patients.

There are two mechanisms to assign patients to a physician or practice during the course of the year: attribution and empanelment.


Commercial and government payers assign patients to physicians or practices who are held accountable for their care and associated costs. This process is known as attribution.1 As VBP models evolve, attribution will continue to determine payment to primary care physicians in these models. Identifying which payers have attributed which patients to your practice, and the impact of each VBP program your practice participates in will help your practice effectively allocate resources to improve care and reduce costs.1 Payers use two types of attribution: prospective and retrospective. Prospective attribution allows physicians to know which patients are assigned to them at the beginning of the measurement year for the next 12-24 months.1 However, this attribution list may only be updated annually or quarterly, based on the payer contract. Retrospective attribution alerts physicians of their assigned patients at the end of the year, and payers measure performance based on a look-back period—typically the previous 12-24 months.1 Attribution methodologies differ by payer and contract. However, some combination of patient choice and/or a claims-based algorithm is typically used to assign patients to physicians. These include:

• Voluntary attribution: Process in which patients select their primary care physician

• Claims-based attribution: Methodologies differ for this type of attribution, but some payers assign patients based on which physician was responsible for the majority of a patient’s care. Others may assign the patient based on which physician administered the most recent wellness visit or which physician saw the patient most recently


Empanelment involves identifying and assigning individual patients to primary care clinicians and/or care teams with the goal of maintaining a consistent patient-provider relationship.2 Empanelment includes:

• Identifying the ideal panel per clinician (ideal panel may change due to patient population or staffing)

• Developing initial patient panels per clinician

• Refining the panels based on clinician input and ideal panel size

• Managing panel on an ongoing basis 2

Initial panels can be determined by examining a unique list of patients seen by a physician or care team during a defined look-back period — usually 18-24 months.

After the initial panel has been refined, panels should be reviewed on a systematic basis to ensure accuracy for other practice activities, such as supply and demand, risk stratification, care management, resource allocation, etc.

Goals of empanelment are to increase access to care, improve continuity of care, and implement care coordination. Focusing on meaningful relationships with individual patients ensures optimal care, leading to improved health outcomes and reduced costs.2

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