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Payer Quality Analytics 2017

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Payer Quality and Risk Analytics 2018 Payer Quality and Risk Analytics 2018
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Payer Quality and Risk Analytics 2018
Different Options for Different Needs

author - Peter Van Mondfrans
Peter Van Mondfrans
June 14, 2018 | Read Time: 4  minutes

Ever-evolving HEDIS metrics continue to demand payer attention, but annual quality reporting alone is not an effective way to close care gaps or reduce costs. Health plans have repeatedly expressed a need for more frequent HEDIS reporting and deeper analytics capabilities that enable them to empower proactive care interventions and improve outcomes for their members. KLAS asked 84 health plans which vendors go beyond the required HEDIS check boxes to help clients forecast risk and improve quality.

Industry Insight & Context

As healthcare continues to evolve from volume-based to value-based reimbursement, accurate, timely, and progressively complex risk adjustment is having a growing impact on both plan revenue and care quality. While quality initiatives are often prompted (or required) by CMS and government regulation, payers are becoming increasingly proactive in prioritizing improvements in quality performance.

As part of ongoing efforts to increase market transparency for payers that outsource some or all of their risk-adjustment work, KLAS has identified 30 vendors—some new, some emerging, and some perennial—that offer solutions to the difficult challenges of identifying risk, predicting cost, finding gaps in care, and crafting intervention strategies to maximize outcomes. This year KLAS has expanded the scope of this research to include both payer quality and risk analytics solutions.

market overview


Different Options for Different Needs

Client-Reported Vendor Performance: Change Healthcare Rises to the Top, Inovalon Falls to the Bottom

Change Healthcare’s proactive service model and robust quality and risk analytics result in industry-leading overall satisfaction and retention. Frontline users express a desire for more customization, an improved ETL process, and the ability to more frequently ingest and process client data. Clients using MedInsight (a Milliman Company) report tangible outcomes and an enhanced ability to close care gaps. The tool’s complexity drives requests for more training and smoother implementations. Verscend Technologies’ product quality and usability are primary drivers of current client satisfaction; declining performance year over year is a result of high turnover among support and account management personnel and a perceived absence of executive involvement. While some interviewed Inovalon customers appreciate the vendor’s experience and reporting functionality, others lament a lack of innovation and post-implementation support; 59% see Inovalon as part of their long-term plans, down from 70% last year. Optum customers’ high expectations are largely unrealized; issues with chart population, retrieval and risk reporting, and support have all contributed to late CMS submissions and drops in HEDIS ratings.

overall score vs part of long term plans

MedInsight and Verscend Technologies Seen as Progressive in Analytics; General Dynamics IT Falls Behind

Payers using MedInsight or Verscend Technologies are significantly more likely than others to regard their solutions as progressive or very progressive. One of MedInsight’s differentiators is the Milliman Advanced Risk Adjusters (MARA) suite of tools, which can be leveraged for predictive analytics from both a concurrent and retrospective standpoint. Though Verscend does not currently support predictive capabilities in their HEDIS/quality offerings, the vendor is recognized as an industry innovator in predictive analytics, and some users speak positively of their ability to forecast a member’s likelihood of hospitalization. While interviewed General Dynamics IT customers express satisfaction with core functionality and nearly 80% include GDIT in their long-term plans, performance scores have declined in every measure. Customers feel they are not being heard or supported due to what they perceive as a lack of investment and innovation—GDIT is considered the least progressive of the vendors fully rated in this metric. Limited data on SCIO Health Analytics indicates innovative, user-friendly risk adjustment functionality, top-tier customer support, and high optimism regarding SCIO Health’s reporting for continuity-of-care gaps.

product has needed functionality vs delivers new technology

Verscend Technologies and General Dynamics IT, Now a Single Offering, Show Progress toward On-Demand Regulatory Reporting

HEDIS reporting—the traditional focal point of payer quality analytics solutions—is often considered a commodity in today’s healthcare environment, where the focus is increasingly on outcomes. Verscend Technologies’ dependable five-day turnaround consistently meets customer expectations, though feedback is mixed on whether this is fast enough for consistent monthly reporting. Likewise, most of the General Dynamics IT customers KLAS surveyed are pleased with the vendor’s reporting capabilities, responsiveness, and reliability in meeting deadlines. 70% of respondents using Change Healthcare are generally content with the vendor’s responsiveness, standard and custom reports, audits, and quality checks. Over half of interviewed MedInsight users choose not to use MedInsight for regulatory reporting, often because the vendor’s standard reports don’t meet regulatory requirements.

vendors ability to deliver regulatory reporting on demand

Among the Niche Risk Adjustment Vendors, Talix, Cognisight, Health Fidelity Offer Full or Near-Full Capabilities

risk adjustment framework
author - Jess Wallace-Simpson
Jess Wallace-Simpson
author - Robert Ellis
Project Manager
Robert Ellis
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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.