Hawaii Insurer's Panel Cuts Reveal Attribution Clause Impact

In Hawaii, a single clause in a payer contract removed roughly 450 patients—about 40 percent of a clinic’s commercially insured roster—and eliminated an estimated $162,000 in annual payments, according to the latest reporting.

HMSA’s claims‑based attribution reshapes panels

The insurer, which covers more than 750,000 members statewide, told primary‑care providers in May that they had 60 days to shift from fixed monthly “transformation” payments back to fee‑for‑service. After Gov. Josh Green intervened, the deadline moved to January.

Four months later, the organization issued two additional 60‑day notices effective Sept. 1. The new rules state that any patient without a processed claim in the prior 18 months will be dropped from a provider’s panel and from the per‑member monthly payment. If a patient sees more than one clinician in a calendar year, only the clinician with the higher visit count receives reimbursement. It calls this “claims‑based attribution.”

Jenny Smith, HMSA’s president and chief operating officer, said the attribution method is intended to identify the primary‑care provider most involved in a member’s care and that a physician should see a patient at least once every 18 months to maintain quality. She added that coverage remains unchanged and members can continue seeing any plan provider.

The insurer also reported a 35 percent drop in primary‑care visits since the pandemic, while urgent‑care and emergency‑department use rose, suggesting that more claims data will give a clearer picture of member care.

Kaleo Correa, an advanced practice registered nurse who founded Waimea Primary Care on the island of Hawaii, was told that about 450 patients would leave her panel, nearly 40 percent of the clinic’s HMSA‑covered patients and roughly $162,000 a year. She told the Star‑Advertiser that at least 177 of those patients had been seen within that interval, but hundreds of claims have sat unprocessed since February, skewing the count.

Correa’s main objection is procedural. She cannot see the data HMSA used, nor can she prevent an attributed patient from being seen elsewhere. “It feels like the contract ate a chunk of the roster without letting us check the numbers,” she said.

Independent practitioner Katie Min in Honolulu expects to lose at least 50 patients but cannot model the impact because she does not know how the insurer classifies a primary‑care provider when a patient repeatedly visits another clinician for the same condition.

Hilo Family Medicine announced it will close on Sept. 30 after 27 years in operation. In a letter to patients, physicians David Nakamura and Melanie Arakaki wrote that the insurer’s drastic changes would cut operating revenue to the point where continuing care would be impossible.

These examples illustrate a broader issue: attribution clauses determine revenue in any per‑member arrangement, yet the data driving those decisions are often hidden from providers.

According to a July analysis by the Medical Group Management Association (MGMA), attribution ranks among the top provisions practices should clarify before signing a contract, alongside benchmarks, risk adjustment and data timing. The analysis warns that clauses allowing mid‑year policy or fee‑schedule changes can let payers redefine payments without renegotiation.