Prescient Healthcare
Value-Based Care

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

Network
Risk visibility across admitting hospitals
not a single facility
Weekly
Proactive outreach cadence
ahead of escalation
1
Worklist into existing care management
no separate system

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

Pillar Signals

Risk-band data from sepsis, advanced illness, and AMR pillars.

System Rollup Engine

Signals aggregate to unit, facility, and system level.

Leadership View

Executive and quality teams see risk concentration, not just individual alerts.

Quality & Board Reporting

The same data feeds existing reporting structures.

The Approach

How the Deployment Unfolded

  1. Phase 1
    Network-wide connection

    Risk signal was unified across the network's admitting hospitals via HL7 FHIR, including facilities on different EHRs.

  2. Phase 2
    Care-management integration

    The advanced-illness worklist was integrated into the plan's existing utilization and care-management workflows.

  3. Phase 3
    Weekly network risk review

    Utilization and care-management teams began each week with a prioritized view of members showing rising risk across the network.

  4. Ongoing
    Cost-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

High-risk members identified proactively
Baseline
35%
With Prescient
68%
30-day readmission, managed cohort
Baseline
15.1%
With Prescient
11.3%

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.

Every metric is benchmarked against the health system's own pre-deployment baseline — not an industry average — so the impact reflects that system's patients, units, and workflows. See our outcome methodology →

Key Takeaways

What Made It Work

1

Population-level risk visibility spanned every admitting hospital, not a single facility.

2

The worklist fed existing utilization and care-management workflows — no separate system.

3

Proactive outreach targeted rising risk ahead of a high-cost escalation.

4

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.
Medicare Advantage Medical Directorparticipating health plan

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.

Explore the pillar

Frequently Asked

Questions About This Scenario

The Hospital System Intelligence Layer unifies risk signal across facilities and EHR systems via HL7 FHIR, supporting population-level visibility for Medicare Advantage and other value-based care arrangements spanning multiple admitting hospitals.

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