Managing Population Risk for a Medicare Advantage Network
Medicare Advantage network · Value-based care · multiple admitting hospitals · 6 min read
A Medicare Advantage medical director used Prescient's network-wide risk visibility to identify high-risk members earlier across the plan's admitting hospitals and coordinate care-management outreach before an escalation became a high-cost claim. The advanced-illness worklist fed directly into the plan's existing utilization and care-management processes.
At a Glance
- Organization
- Medicare Advantage network
- Scope
- Covered population across admitting hospitals
- Teams involved
- Utilization review & care management
- EHR environment
- Multiple EHRs across the network
- Pillars deployed
- Advanced Illness + Intelligence Layer
- Cadence
- Weekly network risk review
Representative example. This is an illustrative case study built from an anonymized customer archetype to show the shape of a Prescient engagement and its reporting. The scenario and all figures are representative examples, not published results from a named customer.
Results at a Glance
What Changed
Illustrative figures — representative of the reporting structure, not published results.
The Challenge
Where they started
In a value-based arrangement, accountability spans an entire covered population across many admitting hospitals — not a single encounter or facility. High-cost, high-risk episodes were frequently identified too late for care management to intervene effectively.
Coordinating advanced-illness identification with utilization review and care management across a network of hospitals — often on different EHRs — was operationally difficult, and rising risk in one admitting facility wasn't visible to the plan until it became a claim.
- Accountability spanned an entire covered population across multiple admitting hospitals, not a single encounter or facility.
- High-cost, high-risk episodes were often identified too late to intervene effectively.
- Coordinating advanced-illness identification with care management and utilization review across the network was difficult.
The Solution
Network-wide risk visibility feeding care management
Prescient unified risk signal across the network's admitting hospitals via HL7 FHIR — including facilities on different EHRs — giving the plan a single, population-level view of rising risk.
The advanced-illness worklist fed directly into the plan's existing utilization and care-management workflows, so teams could prioritize proactive outreach to members showing rising risk before an escalation turned into a high-cost claim.
How data flowed in this deployment
Risk-band data from sepsis, advanced illness, and AMR pillars.
Signals aggregate to unit, facility, and system level.
Executive and quality teams see risk concentration, not just individual alerts.
The same data feeds existing reporting structures.
The Approach
How the Deployment Unfolded
- Phase 1Network-wide connection
Risk signal was unified across the network's admitting hospitals via HL7 FHIR, including facilities on different EHRs.
- Phase 2Care-management integration
The advanced-illness worklist was integrated into the plan's existing utilization and care-management workflows.
- Phase 3Weekly network risk review
Utilization and care-management teams began each week with a prioritized view of members showing rising risk across the network.
- OngoingCost-of-care review
Utilization patterns and risk concentration fed into monthly total-cost-of-care discussions with plan leadership.
The Results
Measured Against Their Own Baseline
Population risk management — illustrative before/after
Illustrative example only, not a published result — measured against the plan's own pre-deployment baseline.
High-risk members identified proactively
Illustrative adoption curve as network-wide visibility reached the care-management team.
Key Takeaways
What Made It Work
Population-level risk visibility spanned every admitting hospital, not a single facility.
The worklist fed existing utilization and care-management workflows — no separate system.
Proactive outreach targeted rising risk ahead of a high-cost escalation.
FHIR-based integration unified risk even across hospitals on different EHRs.
We're accountable for a population, not a bed. Seeing rising risk across every admitting hospital in one place — early enough for care management to actually reach the member — is what value-based care needs and rarely has.
Representative quote illustrating the kind of feedback this engagement is designed to produce — not attributed to a named individual.
The Platform Behind This
Hospital System Intelligence Layer
One risk layer across every unit, every EHR, every patient.
Frequently Asked
Questions About This Scenario
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