Succeeding in value-based payment: How can small practices navigate patient attribution

In an interview with Medical Economics following the ACP Internal Medicine Meeting 2025, Joshua M. Liao, MD, discusses the foundational importance — and complexity — of patient attribution in value-based care models.

“At the most foundational level, what you're trying to do is find a real and appropriate connection between a patient and… a clinician or group of clinicians,” said Liao, professor of medicine and public health with tenure, Walter Family Distinguished Chair in internal medicine, director and principal scholar, program on policy evaluation and learning at the University of Texas Southwestern Medical Center.

He explained how independent and small practices face unique challenges in achieving that connection without the benefit of clear assignment tools, like those used in health maintenance organizations (HMOs). “If you assigned a patient to a clinician and vice versa, there would be clear, symmetrical, bi-directional awareness of what that connection is,” he said.

Instead, attribution often depends on the number of services delivered — a method that creates uncertainty. “That's not something that's knowable until the end, potentially,” Liao said.

Liao identified three major hurdles:

1. Uncertainty around service volume and attributed patients
2. Lack of visibility into where patients receive care outside the practice
3. The risk of attribution shifting due to low visit counts.

“If it’s two or three visits, if [a patient] sees the doctor one more time, that’s massive,” he noted. “So… you end up having the same problem where the attribution will flip based on one or two visits alone.”