Solutions for Clinical Directors

Population Health Data
at Provider-Level Granularity

Managing a value-based care contract means knowing your A1C control rates, blood pressure benchmarks, and care gap closure rates — not just for the population, but by provider, by panel, and by patient. Vizier delivers that visibility without an analytics department.

See a Live Demo →Patient Outcomes Analytics
63%national HbA1c control benchmark — know where your diabetic panel stands today
Clinical Outcomes Benchmarks

Outcomes That Value-Based Contracts Measure — Tracked in Real Time

Value-based care contracts tie payment to specific clinical outcomes. HbA1c control below 8%, blood pressure below 140/90, and LDL below 100 mg/dL are the most commonly measured endpoints. Vizier tracks each metric at the population level and by individual patient — so intervention decisions are based on data, not chart reviews.

HbA1c Control (< 8%)
National benchmark: 63% of diabetic patients
Track to benchmark; flag patients > 9%
Blood Pressure Control (< 140/90)
National benchmark: 70% of hypertensive patients
Identify BP-uncontrolled cohort for intervention
LDL < 100 mg/dL
National benchmark: 52% of high-risk cardiovascular patients
Statin adherence correlation analysis
CHF Ejection Fraction Documented
National benchmark: CMS requires 100% for ACC/AHA measures
Flag charts missing EF documentation
COPD Spirometry Assessment
National benchmark: > 80% of diagnosed COPD patients annually
Identify patients without 12-month spirometry
Depression Screening (PHQ-9)
National benchmark: 85%+ of adult patients annually
NQF 0418 tracking and documentation gap alerts
Chronic Disease Population Management

Diabetes, Hypertension, and CHF Panels Managed by Risk Tier

Risk stratification separates your chronic disease panel into three tiers: high risk (HbA1c greater than 9%, uncontrolled BP, recent hospitalization, 3+ chronic conditions), medium risk (partially controlled, gap in preventive care), and low risk (controlled, up-to-date on screenings). Each tier requires a different care management protocol.

For a typical 5,000-patient panel, Vizier typically identifies 340–480 high-risk patients who qualify for Chronic Care Management (CCM) billing under CPT 99490 but are not currently enrolled. At $62 per enrolled patient per month, that represents $252,960–$357,120 in annual revenue — attached to the same population management work your care team is already doing.

CHF Population Alert
21.9%
national 30-day readmission rate for heart failure — the single highest-penalty condition under HRRP
Risk Stratification Framework
High Risk8–12% of panel
HbA1c > 9%, SBP > 160, hospitalization in past 90 days, 3+ active chronic conditions
Protocol: Outreach within 48 hours, CCM enrollment, care coordinator assignment
Medium Risk25–35% of panel
HbA1c 8–9%, SBP 140–160, care gap present, 2 chronic conditions
Protocol: Proactive outreach, care gap closure scheduling, 90-day check-in
Low Risk55–67% of panel
HbA1c < 8%, BP controlled, up-to-date on preventive care
Protocol: Annual wellness visit, standard recall schedule
Provider Performance Comparison

Compare Providers on Quality, Throughput, and Care Gap Closure

Provider performance comparison goes beyond patients per day. Vizier tracks each provider's quality score (aggregate performance across measured conditions), care gap closure rate (percentage of gaps closed at the point of care vs deferred), chronic disease control rates by panel, and revenue per provider hour — contextualized by panel complexity.

When one provider's A1C control rate is 58% and another's is 79% with comparable panel demographics, that gap is worth investigating — not as a performance management conversation, but as a workflow and protocol sharing opportunity. Vizier shows you that gap; your clinical leaders decide how to close it.

Care Coordination Analytics

Identify Where Care Coordination Is Failing Before Patients Are Readmitted

Care coordination failures are visible in the data before they produce adverse outcomes. Vizier tracks follow-up appointment compliance after discharge (the HEDIS FUH measure: 7-day and 30-day follow-up rates), specialist referral completion rates, medication fill rates for high-risk patients, and care plan documentation completeness.

7-day post-discharge follow-up (HEDIS FUH)
National avg: 38.9%
30-day post-discharge follow-up (HEDIS FUM)
National avg: 67.2%
Specialist referral completion rate
High-performing orgs: > 85%
Medication fill rate — high-risk patients
Target: > 90% within 48 hrs
8%
HbA1c threshold benchmark — patients above this level need intensified management protocols
<140/90
Blood pressure control target for hypertensive patients in value-based care contracts
23%
Average care gap closure rate improvement when providers see real-time patient-level gap data
$500+
Quality bonus per member per year for CMS Advantage plans moving from 3 to 4 stars
Related Solutions

Clinical Intelligence Across the Care Continuum

Population Health Clarity

See Your Patient Panel the Way Value-Based Contracts See It

Upload an EHR data export and see your A1C control rates, blood pressure benchmarks, care gap closure rates, and provider performance comparison — in under 48 hours.