A Panel List Is Not Population Health Management
Most practices have a list of their diabetic patients. That's not population health management — that's a spreadsheet. Population health management means knowing which of those patients hasn't had an A1C in 6 months, which ones have an A1C above 9%, which ones are overdue for nephropathy screening, and which ones haven't been seen in your practice at all in the last 12 months.
The average practice has 342 patients who are overdue for at least one preventive care service. Finding them requires cross-referencing your encounter data against your panel — something that takes a dedicated analyst hours to do in a spreadsheet, or 30 seconds in Vizier.
For ACOs and value-based care organizations, the stakes are higher. Your shared savings calculation depends on quality measure performance across your attributed population. If you can't identify which patients are in your attribution roster and which care gaps they have, you're flying blind into your MSSP reconciliation.
Find Every Patient Who Needs You Before They Find the ED
High-Risk Patient Identification That Goes Beyond Diagnosis Codes
Vizier's risk stratification uses diagnosis code burden, utilization patterns, care gap accumulation, and chronic condition complexity to score your panel. Patients with multiple chronic conditions, high care gap burden, and low recent utilization are your highest-risk cohort — the patients most likely to deteriorate without proactive outreach.
The stratification isn't a static annual calculation — it updates with each data upload. A patient who was moderate-risk in January and added a heart failure diagnosis in March moves into the high-risk cohort and triggers the appropriate care management workflow.
We configure the risk stratification thresholds based on your patient population's characteristics, not a generic algorithm. A rural primary care practice's high-risk threshold looks different from an urban academic medical center's.
Disease Panel Views That Drive Clinical Action
Shared Savings Visibility Before the Annual Reconciliation
MSSP reconciliation happens once a year, but the quality measure performance and expenditure trending that determines your shared savings calculation unfolds over 12 months. Organizations that wait for the annual reconciliation report to understand their position have no opportunity to course-correct.
Vizier tracks MSSP quality measure performance on the same rolling basis as MIPS measures. When your beneficiary access and preventive care composite is trending below the benchmark in Q2, you have two quarters to improve it — not a year-end surprise.
Attribution analytics track which beneficiaries are assigned to your ACO, flag high-cost beneficiaries who are driving expenditure, and identify patients who haven't engaged with your network — the ones most likely to generate unplanned utilization outside your ACO.
From Panel Analysis to Active Disease Management in Four Weeks
What to Expect and When
Population health analytics configuration takes four weeks. The first deliverable — your initial care gap report — is typically the most immediately valuable: it identifies revenue recovery (missed AWV billing) and care quality opportunities simultaneously.
Run Your First Panel Analysis in the Consultation
Schedule a 30-minute consultation. Bring your patient panel data and we'll run a live care gap analysis to show you how many patients are overdue for what services — before any engagement begins.