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National Quality Forum
Draft Report: Improving Attribution Models
May 14, 2018 

NAACOS appreciates the opportunity to provide feedback on the National Quality Forum (NQF) Draft Report, Improving Attribution Models. As the largest association of ACOs, representing more than 5 million beneficiary lives through over 300 Medicare Shared Savings Program (MSSP) ACOs, Next Generation, and commercial ACOs, attribution is a critical issue for our membership. NAACOS is an ACO member-led and member-owned non-profit organization that works on behalf of ACOs across the nation to improve the quality of Medicare delivery, population health and outcomes, and health care cost efficiency. Given the importance attribution plays in the ACO model we appreciate the opportunity to provide our feedback on this draft report. 

We support the NQF’s effort to further explore attribution model design and how to develop a multi-stakeholder review process for attribution models within NQF’s endorsement and selection process. We appreciate the work the committee has completed to date in identifying and evaluating the various attribution methods being used in value-based programs. NAACOS urges NQF to prioritize alignment as a key area of emphasis in future efforts around this topic. We agree with the report’s findings that changing attribution rules can significantly alter how a provider performs on cost and quality metrics. This has been the case in the ACO program and we encourage the NQF to address alignment in future study/reports. 

There are two areas which may impact attribution that we would like to see continued focus and study by the NQF: social determinants of health and team-based attribution models. These are key areas that deserve further attention and study and we recommend expanding on this work. Particularly team-based attribution models, which as the report mentions, deserves further study. We support the NQF’s recognition that given the lack of evidence and the challenges to testing such models, it is critically important that stakeholder support and input have been gained before implementing or endorsing an attribution model. 

We are pleased to see NQF aiming to explicitly and thoroughly address attribution in its review processes. We agree that including criteria for the evaluation of attribution models would enhance the NQF evaluation criteria. The NQF must also explicitly and thoroughly address attribution in the Measure Applications Partnership (MAP) Measure Selection process and we recommend revisions to explicitly consider the attribution model of a performance measure in light of its potential use. 

Attribution models have a large impact on value-based programs and the measures used to evaluate performance in such programs. We agree that accurate and fair attribution is essential to the success of efforts to reform healthcare payments and improve quality. We thank the NQF for their continued focus in this area and welcome the ability to continue to share input on these efforts moving forward. 



Allison Brennan
Vice-President of Policy