Your health plan likely knows far less about you than you think.
If you ask a health plan, “Who is my primary care provider?”, they can usually give you a definitive answer (assuming, of course, you’re assigned to one). It may take some time, but the system is designed to handle that exact question. Ask instead, “Who is my cardiologist?”, and things get murkier. They might be able to find out, but it’s often a manual process, sometimes involving Excel spreadsheets and workarounds rather than a structured system.
This is the problem of attribution. In advertising, we ask which ad (or click, in digital ad speak) led to which purchase. In healthcare, we ask which provider was responsible for which outcome. In the age of value-based care, attribution is more important than ever. It’s the backbone of alternative payment models and the key to designing, implementing, and paying for new care models.
The Attribution Problem
Every alternative payment model follows the same flow: trigger → attribution → action → payment. Something happens that suggests a provider should act for a specific patient, and the provider is paid for that action.
But while that sequence sounds simple, it’s often too complex and burdensome to implement. When it’s done poorly, the consequences are real: distorted incentives, unfair provider rewards or penalties, and fragmented care for patients.
The Center for Medicare and Medicaid Services has a goal of 100% value-based care participation by 2030. While many PCPs already participate, fewer than 5% of specialists are meaningfully involved in alternative payment models today. Without solving attribution, we won’t be able to scale new care models for specialists or get the right patient into the right model at the right time (let alone pay for it accurately).
Where Today’s Model Came From
Back in the late 1970s and early ’80s, healthcare costs were soaring, demand was surging, and providers were incentivized to maximize billable volume. Employers, the government, and families were desperate to rein in spending.
The solution at the time was gatekeeping. Just as healthcare costs rise with the intensity of care, the idea was to build a dam, or restrict access to specialists unless necessary. This would lower costs and reduce pressure on specialist providers. Preferred networks could be built, and plans could extract lower prices from the providers who made it into the network.
This approach exploded in popularity. By the mid-1990s, over 70% of Americans were in gate-kept HMOs. These models did succeed in slowing cost growth—at least until public backlash over denied care and mounting administrative complexity reversed their momentum.
But they left behind a lasting legacy: a deeply entrenched attribution infrastructure built around PCPs. Gatekeepers needed to be selected and paid differently, so systems were created to identify the PCP via claims data and assign patients accordingly.
As value-based care took hold in the 2010s, new risk-sharing models were layered onto this system. But instead of redesigning it, we built on top of it, creating a tangled, fragile patchwork of claims systems, actuarial models, and accounting processes.
Why the Model is Breaking
Health plans can tell you who your PCP is because everything was built around that question. But they can’t tell you who your specialist is because that provider was originally seen as “beyond the gate” — a cost to manage, not a partner in care.
The current infrastructure, while functional for PCPs, is stretched to its limits. It’s a Jenga tower of spreadsheets, retroactive rules, and tacit workarounds, where no one wants to pull the wrong block.
For payors and providers aiming to evolve beyond today’s limitations, the system presents four major challenges:
- Single-threaded attribution: A patient can only be attributed to one provider at a time.
- Specialists are excluded: They must act like PCPs to receive attribution.
- It’s unresponsive: Attribution is often retroactive and slow to adapt to patient needs.
- It’s rigid: Everything must connect to legacy claims systems and medical loss ratio calculations.
Trying to manage today’s complex patients with HMO-era infrastructure is like routing Uber rides with a 1990s phonebook.
What the Future Needs
At Juxtapose, we’ve spent years talking to leaders across the healthcare ecosystem to understand where the system must go. We’ve come to believe five things are essential:
- Specialty care must be prioritized.
PCP risk contracts have plateaued, and they don’t control or even know which specialists their patients see. Yet specialists are often now the front door to care. - Multi-attribution must become standard.
Complex patients interact with multiple providers. We need infrastructure that can attribute patients to more than one provider or program to support coordination and incentives. - Patient-centered calculations are critical.
In a world of overlapping panels and heterogenous payment models, the focus must shift from contracts to patients. Today, any shared patients between providers require manual reconciliation. That won’t scale. - More models will emerge as costs drop.
Right now, models are expensive to build, few in number, and typically focused on PCPs. As design costs fall, we’ll see fragmentation within and across specialties (e.g., eating disorders vs. OCD; cardiology vs. endocrinology). - Payors must lead the transition.
Specialty vendors are innovating, but they can’t fix core infrastructure at the payor level. Health insurers must take responsibility for risk pooling and care network design and lead the shift to more flexible, patient-centric systems.
This future is exciting: one where we finally move off the rigid, claims-based rails of fee-for-service and build a more dynamic, connected care model. But to get there, we must start with attribution. Without it, the rest can’t scale.
Originally shared in the July 2025 issue of the Inception Point newsletter.
