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.
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.
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.
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.
Clinical Intelligence Across the Care Continuum
FAQ
Clinical Director Questions on Outcomes and Population Health
How does Vizier track A1C control rates at the provider panel level?+
Vizier identifies each provider's panel of diabetic patients (ICD-10 E10.x, E11.x, E13.x) and reports the percentage with most recent A1C below 8 (control), at or below 9 (acceptable), and above 9 (poor control per NCQA). National benchmark is approximately 63% in good control. The panel cohort is filtered by attribution so each provider sees only their own patients, and Vizier also flags patients overdue for A1C measurement.
Can Vizier identify care gaps across multiple HEDIS and MIPS measures simultaneously?+
Yes — Vizier maintains a per-patient care gap roster across roughly 40 common quality measures (CDC, CBP, COL, BCS, retinal eye exam, USPSTF screenings, AWV, immunizations, statin therapy, and more). For each patient, the gap roster shows which measures are open, the action required to close them, and the revenue impact if closure is tied to a billable visit (G0438 AWV, G0439 subsequent AWV, CCM codes 99490/99439/99491).
How does provider performance comparison work?+
Vizier ranks providers within a panel or specialty on standardized clinical and operational metrics: A1C control rate, BP control rate, care gap closure rate, screening rates, no-show rates, E&M coding distribution, and prescribing patterns. Outliers (1.5+ standard deviations from peer mean) are flagged. Comparisons are panel-mix-adjusted so high-acuity panels are not penalized for population complexity.
Can Clinical Directors see population health metrics across multiple practices or sites?+
Yes. Vizier aggregates data across all attributed practices, clinics, or sites and lets Clinical Directors drill from the system-level rate to the site, panel, and individual patient. Useful for VBC contract leaders managing 50+ provider populations under MSSP, Medicare Advantage, or commercial risk arrangements.
How does Vizier handle chronic disease registries?+
Vizier maintains continuously refreshed registries for major chronic conditions (diabetes, hypertension, CKD, CHF, COPD, asthma, depression, opioid use disorder) directly from EHR and claims data. Each registry includes condition-specific quality measures, last-touched date, and gap status. Patients are added to and removed from registries automatically as their problem list and encounter data change.
Does Vizier support ACO and MSSP quality reporting?+
Yes. Vizier computes the CMS Web Interface and APP (Alternative Payment Model Performance Pathway) measures used for MSSP quality reporting — including diabetes A1C poor control, CBP, BCS, COL, fall risk screening, statin therapy, and tobacco screening. Pre-submission, you see your projected quality score, the patients pulling each measure down, and the action items required to improve.
See Your Patient Panel the Way Value-Based Contracts See It
Connect your EHR live, or upload an export — see your A1C control rates, blood pressure benchmarks, care gap closure rates, and provider performance comparison in under 48 hours.