Hawaii insurer's panel cuts show what an attribution clause can do to a practice

One clause in a payer contract decides which patients count as yours. In Hawaii, that clause just took roughly 450 patients off a single primary care panel, close to 40 percent of that clinic's commercially insured patients, and about $162,000 a year in payments with them.

Attribution is the quietest term in a value-based contract and the one practices raise most often, Jenn Block, PhD, MBA, who leads the value-based care initiative at the nonprofit Ten Ten Ten, told Physicians Practice in July. "Every decision is based on numbers that most practices have never pulled, or asked to pull from their payer partners," Block said.

What changed in Hawaii

Hawaii Medical Service Association, which insures more than 750,000 people statewide, told primary care providers in May that they had 60 days to move off fixed monthly "transformation" payments and back to fee-for-service, according to reporting by the Honolulu Star-Advertiser. After Gov. Josh Green intervened, the insurer pushed the transition to January.

Four months short of that date, the newspaper reported, HMSA issued two more changes, again on 60 days' notice, both effective Sept. 1. Patients without a processed claim in the previous 18 months come off a provider's panel and out of the monthly per-member payments. And when a patient sees more than one primary care provider in a calendar year, only the provider with the higher visit count is reimbursed. HMSA calls the approach claims-based attribution.

Jenny Smith, HMSA's president and chief operating officer, told the newspaper in a statement that attribution is meant to identify the primary care provider most involved in a member's care, and that the insurer believes a physician should see a patient at least once every 18 months to maintain care quality. Coverage is unaffected and members may keep seeing any provider in their plan, she said. HMSA also said patients have had 35 percent fewer primary care visits since the pandemic while urgent care and emergency department use rose, and that more claims data will give it a clearer picture of the care members receive.

What it looks like from the practice side

Kaleo Correa, an advanced practice registered nurse who founded Waimea Primary Care on Hawaii island, was told about 450 patients would leave her panel, nearly 40 percent of the clinic's HMSA-covered patients and roughly $162,000 a year. She told the Star-Advertiser that at least 177 of them had been in within the past 18 months, and that hundreds of her claims have sat unprocessed since February, which would skew the count. Her objection is less the dollar figure than the mechanics. She cannot see the data the payer used, and she has no way to keep an attributed patient from being seen somewhere else.

Katie Min, an independent physician in Honolulu, told the paper she expects to lose at least 50 patients but cannot model the number, because she does not know how HMSA classifies a primary care provider when a patient sees another physician repeatedly for one condition. Hilo Family Medicine, meanwhile, has told patients it will close Sept. 30 after 27 years. In a letter quoted by the newspaper, physicians David Nakamura and Melanie Arakaki wrote that drastic changes by a large insurance company would cut operating revenue and make it impossible to keep providing care.

Why this is not only a Hawaii story

Attribution sets revenue in any arrangement that pays per member rather than per visit, and it is usually decided by claims data a practice does not control and often cannot see in advance. MGMA's July analysis of risk and payer contracting puts attribution at the top of the provisions leaders should pin down before signing, alongside benchmarks, risk adjustment and data timing, and argues those terms usually matter more than the headline shared savings percentage.

The same analysis flags the exact clause Hawaii providers ran into: what happens when a payer changes a policy, a measure specification or a fee schedule in the middle of a contract year. A practice that cannot answer that question has agreed to a payment amount the payer can redefine without reopening the contract.

What to check in your own contract

• The attribution method, prospective or retrospective, and how often the panel refreshes
• Whether you get an attribution roster you can audit against your active panel, in what format and on what cadence
• Any look-back window that drops a patient from the panel, and whether it runs on processed claims or dates of service
• How a patient seen by more than one clinician is assigned, and how the payer defines a primary care provider
• The notice period for methodology changes, and whether a change of that size lets you terminate
• Reconciliation detail specific enough to reproduce the payer's math, plus audit and dispute rights

Practices that have never asked for an attribution roster should start there. The gap between the panel a payer pays on and the panel a practice actually sees is the number that determines whether the rest of the contract works, and it is one of several terms worth auditing before a renewal.

Hawaii's remaining transition deadline is Jan. 1, and the state is one of six participating in CMS's AHEAD model, which is built on the prospective primary care payment HMSA is stepping back from. Practices on the mainland have until their next renewal to find out whether their own attribution language would allow the same thing.