Quality & Performance

Star Ratings, Quality Withholds & Performance-based Contracts

Caremetrics’ Quality Improvement tools are designed to help payers and providers achieve higher scores in Pay-For-Quality programs—resulting in higher revenue earned through quality incentives, bonuses and earn-back of premium withholds.

Where consumer populations are medically-complex, disabled and economically disadvantaged, there is an inherent challenges to achieving accurate quality scores under Pay-For-Quality contracts.  Standardized surveys and measurement tools are normative and generally do not adequately adjust for the unique characteristics and communication challenges of complex populations, especially for Medicaid MLTC/MLTSS, SNP and dual eligibles MMP plans.

Our solution combines prospective root-cause analytics with population data and our longitudinal consumer-centric database to create timely, customized alerts and guidance designed to accelerate payer and provider performance in high-priority quality areas.

Caremetrics Quality Improvement solutions are continuously calibrated to optimize scores across the changing landscape of Pay-For-Quality programs, incorporating logic that reflects industry-leading quality measurement tools, such as HEDIS™, Health Outcomes Survey (HOS®), CAHPS® surveys, Member Experience Surveys and others.

The beneficial impact of Caremetrics tools is enhanced by our ability to capture clinical content when available, and to get an early-and-often view of potential opportunities for quality and outcome improvement.

Our solutions push actionable interventions to care coordinators, network clinicians, consumers and their families or community caregivers. We prioritize the recommended interventions to achieve highest impact, and measure the overall results to evaluate efficacy.

We prioritize the recommended interventions to achieve highest impact, and measure the overall results to evaluate efficacy.

Caremetrics Quality and Performance tools are specifically designed to enhance performance in the following Pay-For-Quality programs:

  • Medicare Advantage and SNP five-star quality ratings bonus program
  • Premium Withholds in Dual Eligible financial alignment demonstrations
  • Quality bonuses in Medicaid and MLTC/MLTSS contracts
  • Other performance-based contracts.