Attribution, Benchmarks, and Quality: Three Foundational Drivers of MSSP Performance

Attribution. Benchmarks. Quality.

In the Medicare Shared Savings Program (MSSP), success is often oversimplified to a single idea: beat the benchmark.

While technically true, that perspective misses the bigger operational reality.

Organizations that focus only on cost performance often overlook the three foundational drivers that ultimately determine long-term MSSP success: attribution, benchmarks, and quality. These are not independent concepts.

They function together as an interconnected performance system that defines accountability, establishes financial targets, and determines how much value an organization ultimately realizes.

Organizations that operationalize this alignment consistently outperform those that manage these components in isolation.

Sources: CMS Shared Savings Program Performance Year Financial and Quality Results (PY 2023); NAACOS analysis of MSSP quality performance and shared savings retention.

Attribution Defines Accountability

Attribution determines which patients an organization is responsible for managing. While this may sound straightforward, attribution is one of the most dynamic and operationally important elements of value-based care.

Patient populations shift continuously based on patient behavior, provider relationships, referral patterns, utilization trends, and contract structure. In some models, attribution is prospective. In others, it is finalized retrospectively after care has already been delivered.

That means organizations are not managing a fixed population. They are managing a population that continuously evolves throughout the performance year.

High-performing organizations understand this and treat attribution as a strategic operational priority rather than a passive reporting function.

They focus on strengthening patient-provider relationships, improving continuity of care, identifying patients with fragmented care patterns, improving primary care alignment, and proactively engaging patients most likely to influence long-term outcomes and utilization.

Without a clear and continuously updated understanding of attribution, organizations struggle to prioritize interventions, allocate resources effectively, and align operational strategies to actual financial accountability.

Benchmarks Define Financial Reality

Benchmarks establish the financial target that organizations are measured against.

In MSSP, benchmarks are developed by CMS using historical expenditures, regional cost trends, risk adjustment methodologies, and population characteristics. Financial performance is then measured by comparing actual spending against that benchmark.

However, one of the biggest mistakes organizations make is treating benchmark performance as a retrospective exercise. Organizations do not have the luxury of waiting until reconciliation to evaluate performance.

Successful organizations continuously monitor utilization patterns, emerging cost drivers, avoidable admissions, post-acute utilization, specialist referral trends, chronic disease progression, and broader operational performance indicators throughout the year.

Why? Because many interventions require time to meaningfully influence outcomes, utilization, and total cost of care.

Organizations that consistently succeed in MSSP understand that performance management must occur continuously, not retrospectively.

Quality Is the Most Misunderstood Driver of MSSP Performance

This is where many organizations fundamentally underestimate the model. Reducing cost below the benchmark does not automatically guarantee financial success.

Quality performance directly influences shared savings eligibility and often affects the percentage of savings an organization ultimately retains. An organization can improve cost performance and still underperform financially if quality is not managed effectively. This is one of the most important operational realities in MSSP.

Improving quality is not separate from improving financial performance. The two are deeply connected.

Efforts such as reducing avoidable admissions, improving chronic disease management, strengthening transitions of care, improving medication adherence, increasing preventive care compliance, and closing care gaps do not simply improve clinical outcomes. They directly influence utilization patterns, patient experience, total cost of care, and long-term financial sustainability.

"Sustainable savings are typically achieved through better care, not less care."

These Three Drivers Must Be Managed Together

1. 01Attribution defines who is included. The right patient list is the precondition for every downstream investment.
2. 02Benchmarks define the financial target. The target is set by CMS; the work is managing against it continuously, not retrospectively.
3. 03Quality determines how much of the value created is ultimately realized. Cost performance without quality performance is a discount on your own savings.

When organizations manage these components independently, priorities become fragmented and operational impact weakens. When organizations operationalize them together, they can focus resources, workflows, and interventions around the patients and opportunities most likely to improve both population health and financial performance.

That alignment is what separates high-performing organizations from those struggling to generate sustainable results.

The Bottom Line

MSSP performance is not driven by cost reduction alone. It is driven by how effectively organizations align attribution, benchmarks, quality, operations, and execution into a unified performance strategy.

Organizations that operationalize this alignment consistently outperform those that focus on metrics without operational coordination.