Dynamic Attribution for Specialists: A Phase-Switching Hybrid Contract for Total Cost of Care

Most population-based total cost of care (TCOC) models under-incentivize specialist engagement (Wiler et al., 2024), while CMMI struggles with overlapping and conflicting incentives (Kannarkat et al., 2023). Building on promising population-based payment experiments in the Netherlands (Remers et al., 2023), this idea designs a hybrid contract where accountability “switches” across care phases (e.g., diagnostic work-up, acute intervention, recovery) based on prospective attribution rules and predicted episode trajectories. Specialists receive clear performance metrics and advanced payments when they become the accountable party; primary care resumes accountability when appropriate, with a predefined, transparent handoff. The study would test this in specialties with high spend and clear episode structure (cardiology, orthopedics), evaluating effects on leakage, duplicative testing, post-acute utilization, and patient outcomes. Novelty: rather than bolt specialists onto a primary care-led budget, we re-architect attribution to align financial responsibility with clinical locus of control—directly addressing the role clarity and data timeliness conditions identified by Wiler et al. (2024) and the incentive-conflict critiques of Kannarkat et al. (2023). Impact: higher specialist participation, fewer mixed signals, and more coherent care pathways under TCOC.

References:

1. Strengthening the Center for Medicare and Medicaid Innovation's Approach to Constructing Alternative Payment Models.. Joseph T Kannarkat, Soleil Shah, Natasha Parekh, F. Crosson (2023). Milbank Quarterly.
2. Towards population-based payment models in multiple-payer systems: the case of the Netherlands. T. Remers, Erik Wackers, Simone A van Dulmen, Patrick P T Jeurissen (2023). International Journal of Integrated Care.
3. Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models. J. Wiler, Lawrence R Kosinski, Terry L Mills, James Walton (2024). Annals of Internal Medicine.