Patient Outcomes Analytics

Patient Outcomes Analytics:
Clinical Quality & Population Health

A1C control rates, blood pressure management, preventive care compliance, and HEDIS measure performance — tracked at the patient, provider, and population level. Quality bonuses in value-based contracts are directly tied to how well you measure and manage these outcomes.

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HEDISMeasure performance tracked across full CDC bundle
Chronic Disease Management

Clinical Benchmarks That Drive Payer Contracts and Quality Bonuses

The clinical benchmarks that matter most in value-based contracts are the same ones measured by HEDIS: A1C control (target <8% for most patients), blood pressure control (<140/90 mmHg), LDL cholesterol at goal, and tobacco cessation rates. These four metrics appear in virtually every Medicare Advantage contract and ACO quality bonus framework.

Vizier tracks every chronic disease patient against these benchmarks in real time — not at year end. Patients approaching an A1C visit who are not at goal are flagged for intensification review before the next encounter. Providers see their panel-level control rates daily, not quarterly.

Population health stratification divides your patient panel into controlled, at-risk, and uncontrolled segments for each chronic condition — enabling targeted outreach, care management enrollment, and resource allocation decisions grounded in actual clinical data.

Diabetes A1C ControlA1C <8%
≥60% of diabetic patients at goal
HEDIS CDC measure — directly tied to MA star ratings
Hypertension ControlBP <140/90 mmHg
≥65% of hypertensive patients at goal
NQF 0018 — high priority MIPS quality measure
LDL CholesterolLDL <100 mg/dL (high-risk)
Statin adherence ≥80% PDC
Proportion of Days Covered is the pharmacy compliance metric
Tobacco UseCessation counseling offered
100% of tobacco users screened and offered cessation
NQF 0028 — achievable 100% MIPS measure
HEDIS CDC Bundle

Comprehensive Diabetes Care: Seven Measures, One Bundle

The HEDIS Comprehensive Diabetes Care (CDC) bundle is the most widely used multi-measure quality framework in the US. All seven measures are reported for Medicare Advantage and most commercial plan quality contracts. Your performance on CDC directly influences your Medicare Advantage star rating — a half-star improvement can be worth millions in quality bonus payments.

Vizier tracks every component of the CDC bundle at the patient level, identifying which patients are passing all seven measures, which are failing one or two, and which patients need the most care coordination resources to move across the performance threshold.

CDC-1
HbA1c Testing
≥90% of patients with diabetes have HbA1c tested annually
CDC-2
HbA1c Poor Control (>9%)
Inverse measure — lower rates indicate better management
CDC-3
HbA1c Control (<8%)
Target: >60% of diabetic patients achieving control
CDC-4
Blood Pressure Control (<140/90)
Target: >65% of patients with diabetes meeting BP target
SPC
Statin Therapy for Diabetes
Patients 40–75 with diabetes on moderate/high-intensity statin
CDC-6
Retinal Eye Exam
Annual dilated eye exam by ophthalmology or optometry
CDC-7
Urine Microalbumin Screening
Annual screening for renal complications
Value-Based Care Performance

Medicare Advantage Star Ratings and ACO Bonus Frameworks

Star rating performance for Medicare Advantage plans is directly tied to HEDIS, CAHPS, and HOS measure results. A 4-star plan receives a 5% quality bonus on all MA payments. A 5-star plan earns an additional enrollment period and marketing advantage.

Patient Attribution Models

Understand which patients are attributed to your practice under Medicare Advantage, ACO, and commercial value-based contracts — and what quality obligations come with each attribution model.

Preventive Care Compliance Rates

Panel-wide compliance rates for every preventive service by age group, condition, and payer. Drill down to individual patients who are overdue and generate targeted outreach lists.

Care Coordination Metrics

Track care coordination touchpoints: transition of care visits, follow-up calls within 7 days of hospital discharge, specialist referral completion rates, and care plan update frequency.

Patient Outcomes Analytics

Track Clinical Quality at the Patient and Population Level

See your HEDIS measure rates, chronic disease control benchmarks, and value-based contract performance — updated daily, not quarterly. Know which patients need intervention before their next lab result arrives.