Cohere Health®, a clinical intelligence and operations platform for health plans, announced new performance results. The company said Cohere Health can help plans uncover hidden HEDIS gaps within existing clinical data. Its clinical evidence extraction engine, Cohere Capture™, identifies and validates care gap closures already present in clinical records. As a result, health plans can improve care quality and financial performance. The AI-powered solution has helped clients close one in four high-value care gaps. It has also supported stronger Medicare Advantage Star Ratings and improved member health outcomes.
According to the company, clients achieved an average 15% improvement in Stars performance per measure. The platform also closed 107 gaps for every 1,000 members with records. Additionally, clients achieved a minimum 5:1 return on investment through the performance-based approach. These results show how health plans can use existing clinical evidence more effectively.
“Moving from 3 to 4 Stars represents $57 million in additional CMS payments per 100,000 members, but plans cannot get there with seasonal chart review alone,” said Matt Parker, chief product officer at Cohere Health. “Cohere Capture helps health plans uncover gap closures in the data they already have, giving them a more scalable way to improve quality performance with the clinical rigor required to hold up under audit.”
Cohere Capture Supports Better Star Ratings
Better Star Ratings can support stronger member care and financial performance. For Medicare Advantage plans, higher quality ratings can also affect CMS bonus payments and rebates. Those funds can support additional member benefits and health programs. Plans can also use quality improvements to help manage healthcare costs. Cohere Health said Cohere Capture can deliver these opportunities at scale. The solution searches existing health plan systems for documented care gap closures.
Therefore, plans can identify opportunities without adding significant administrative work. The approach also avoids traditional per-chart review economics. The healthcare quality measurement environment continues to change rapidly. CMS is removing nearly a dozen administrative measures from the quality measurement landscape. As a result, health plans will need to focus more heavily on member outcomes and experience. Plans will also need stronger clinical data to address complex care gaps.
These care gaps can become more difficult to close when administrative measures carry less weight. At the same time, overall performance continues to improve across quality measures. Therefore, health plans must continue optimizing their quality strategies to maintain performance. Meanwhile, NCQA is shifting away from seasonal chart review. The organization is moving toward year-round digital quality measurement through Electronic Clinical Data Systems (ECDS). This shift could make manual abstraction approaches increasingly difficult to sustain. Consequently, health plans need scalable technology that can work with clinical data continuously.
AI Helps Health Plans Find Hidden Clinical Evidence
Cohere Capture operates on the Cohere Unify™ connected clinical intelligence platform. The solution can ingest structured and unstructured clinical data from multiple sources. These sources include prior authorization notes, imaging reports, and EHR data. The platform uses AI models trained specifically around quality measure logic. It then identifies care gap closures and denominator exclusions. The system routes those findings directly into health plans’ HEDIS systems.
Importantly, every finding connects back to the original source documentation. This approach provides clinical evidence that supports the identified findings. The platform also assists human reviewers through a precision clinical AI assistant. Therefore, health plans can combine automation with human clinical oversight.
Performance-Based Model Targets Actionable Findings
Cohere Capture also uses a different commercial approach from traditional vendors. Instead of charging for every reviewed chart, the solution uses a pay-for-performance model. The model connects costs to measurable results. As a result, the system focuses on identifying findings that can create actionable opportunities. For existing Cohere Health utilization management clients, additional opportunities can come from data already moving through Unify.
This approach can create new gap closure opportunities without requiring new data integrations. Therefore, existing clients can use their available clinical information more efficiently. The company designed the solution to support quality improvement at scale. It also addresses the growing need for digital quality measurement and clinical data analysis. Cohere Capture is now available to Medicare Advantage health plans. Interested plans can request a no-cost proof of concept. The proof of concept allows plans to evaluate the solution using their own gap lists and data sets. Health plans can learn more through coherehealth.com/quality.
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News Source: PRNewswire.com
