Glossary

Contracts reward keeping an attributed population healthy and out of the hospital. Performance is measured on three axes: quality, risk accuracy, and total cost of care.

Usually based on plurality of primary care visits over a lookback window. Attribution decides whose numbers a patient's cost and quality land in — so attribution churn moves every metric.

Savings = benchmark spend − actual spend, multiplied by a contractual sharing rate and often gated by a quality score. Upside-only contracts have no downside; two-sided contracts also share losses.

Set from historical spend, regional trend, and risk score. A rising RAF raises the benchmark, which is why risk accuracy and cost performance must be read together.

Groups of providers accountable for the quality and total cost of an attributed Medicare population. Tracks differ by how much upside and downside risk is taken.

The segment with the highest prevention return — cost is still avoidable. Contrast with high-cost members, where much of the spend is already committed.

Drives plan bonus payments and shared-savings quality gates. Composed of clinical measures, patient experience, and administrative measures.

Determines what share of the earned savings is actually paid. A high-savings, low-quality year can still pay very little.

CMS and payer measure files run roughly five months behind. Early indicators from EHR and claims data let teams act inside the measurement year instead of after it closes.

The single highest-leverage encounter in VBC: it closes preventive quality measures and creates the face-to-face needed to recapture chronic conditions. Scheduling AWVs early in the year is the most repeated recommendation in this platform.

Screenings, labs, immunizations, and follow-ups tied to contracted measures. Distinct from a risk opportunity, which is about documentation rather than a service.

Chronic conditions map to HCCs, each carrying a coefficient. HCCs must be documented and coded every calendar year; last year's diagnosis does not carry forward.

Built from demographics plus active HCCs. A RAF of 1.0 is an average beneficiary. Under-coding depresses the benchmark and understates the population's real acuity.

Preferred to the word 'gap'. Two kinds: recapture (an HCC coded in a prior year but not yet this year) and suspecting (evidence in labs, meds, or notes suggests an undocumented condition).

The highest-confidence opportunity type — the condition is chronic and the prior documentation exists. Requires a face-to-face encounter in the current calendar year.

Flagged from labs, medications, imaging, or note text. Always requires clinician confirmation — a suspect is a prompt for review, never a code to submit.

Codes must be supported by a signed, dated encounter note. Unsupported codes are recouped with penalties, which is why documentation quality matters as much as capture rate.

The standard normalized unit for comparing cost across populations of different sizes and enrollment periods. Nearly every cost view on this site is expressed in PMPM.

Medical costs ÷ premium revenue. Under a risk contract, an MLR under the target is the margin; over the target is a loss.

The single most-watched utilization metric in VBC — inpatient is the largest cost category and the one most responsive to primary care and care management.

Both a quality measure and a cost driver. Timely transitional care contact after discharge is the most reliable lever.

Lets care teams act within hours of a hospital event instead of learning about it months later in a claim. Drives the transitional care worklist.

Requires contact within 48 hours and a face-to-face visit within 7 or 14 days. Counts for quality credit and cuts readmissions.

Starts at the prior value, adds and subtracts named drivers, and lands on the current value. Adopted across this platform as the default way to answer 'what changed and why'.