ACO Quality Measures Transformation: From Bottom to Top Quartile

The Challenge: Value-Based Care Penalties Threatening Survival

An Accountable Care Organization (ACO) serving 75,000 Medicare patients was facing financial penalties under value-based care contracts. Their quality measure performance was consistently in the bottom quartile, resulting in lost bonuses and reputational damage. The root cause was clear: incomplete patient data meant they couldn't identify care gaps, close them proactively, or properly document care coordination efforts.

The Value-Based Care Crisis:

• Quality scores: Bottom 25th percentile across HEDIS/MIPS measures
• Financial impact: $2M in lost value-based bonuses annually
• Documentation gaps: Unable to prove care coordination efforts
• Competitive disadvantage: Losing attributed patients to higher-performing ACOs

The Strategic Solution: Complete Data = Complete Performance

Stream Health's comprehensive record consolidation provided the ACO with the complete patient data required to succeed in value-based care. With NP-verified summaries and automated gap-in-care identification, the ACO could systematically identify and close quality measure gaps across their entire attributed population.

The Systematic Approach:

• Phase 1: Consolidate all patient records from 1,300+ sources
• Phase 2: NP verification creates audit-ready documentation
• Phase 3: Automated gap-in-care analysis for all HEDIS/MIPS measures
• Phase 4: Systematic outreach to close identified gaps

The Transformation: Bottom Quartile → Top Quartile in 12 Months

Within one year, the ACO moved from bottom-quartile performance to top-quartile across key quality measures. This transformation unlocked $3.8M in value-based care bonuses while improving patient outcomes and care coordination.

Quality Measure Performance:

• Diabetes control (HbA1c <8%): 48% → 87% (39-point improvement)
• Blood pressure control: 52% → 89% (37-point improvement)
• Colorectal cancer screening: 61% → 94% (33-point improvement)
• Depression screening & follow-up: 38% → 82% (44-point improvement)
• Overall ACO performance: Bottom quartile → Top quartile

Financial Impact:

• $3.8M in value-based care bonuses (year 1)
• $2M penalty avoidance
• 92% of eligible patients enrolled in appropriate care management programs
• Projected $5M+ annual recurring revenue from sustained quality performance

Operational Excellence:

• Systematic gap-in-care closure process implemented
• Audit-ready documentation for all care coordination efforts
• Automated patient outreach for overdue preventive services
• Real-time quality measure dashboards for clinical teams

Results reflect aggregated, anonymized performance data typical of a 75K-patient ACO transitioning from bottom to top quartile. Individual results depend on starting performance and patient population.