Value-based care
Let the care team
do the caring.
Your team is not short of clinical judgement. It is short of hours, spent chasing gaps, coding conditions and making calls that never connect. IASORA does that work on your own record and stops at a clinician before anything is filed.
TEAM · CJR · MSSP / ACO · EOM · KCC
A care gap on a report costs you money. A care gap closed and verified is the only thing the contract pays for.
Why performance stalls
The list is not the problem. The follow-through is.
Three things go wrong between attribution and reconciliation, and none of them are analytics failures.
Sickest is not the same as movable.
A stratification that sorts by acuity puts your care managers on patients whose trajectory is already fixed. IASORA ranks by how much risk is still changeable, so finite capacity goes where it can still bend the number.
A gap with no owner is a gap that stays open.
Each identified gap becomes a task with a named owner, a due date and an escalation path. Requested, in progress, blocked, done. Nothing sits in a worklist that nobody is measured on.
One more letter will not move the needle.
Outreach runs across SMS, WhatsApp and AI voice, and every loop is tracked to closure rather than to sent. If the patient does not respond, it escalates to a person instead of quietly ending.
The work itself
The six levers a value contract actually turns on.
Every one of these is an agent that runs on your record, does the work, and stops at a human before anything is filed.
Risk adjustment and HCC capture
A monthly sweep that surfaces suspected conditions, substantiates them against the record, and queries the provider where the evidence is thin. Suspect to substantiated, with the evidence attached.
Quality gaps and measure reporting
Preventive, screening and chronic gaps detected against evidence-based rules, then closed and verified. HEDIS and MIPS cohorts build on the same engine, so the measure and the work agree.
Care coordination
A daily continuity sweep across open tasks, care plans and care teams, with an owner and a due date on every item and escalation when a loop does not close.
Clinical documentation integrity
Notes read for specificity and gaps so the record reflects the care delivered, with provider queries raised on the condition rather than in a month-end audit.
Cost and utilisation
Avoidable spend and utilisation outliers across the attributed panel, sized by setting, so the conversation is about a number someone can act on.
Medication and pharmacy coordination
Adherence check-ins on the care plan and pharmacy coordination on every new or changed prescription, so a therapy change does not quietly fail between the visit and the fill.
The models, running
Five payment models. One execution engine.
Each film below follows a single episode or performance year through the product, beat by beat, on the surfaces your team would actually use. These are recordings of the software, not animations of a concept.
Transforming Episode Accountability Model
Hospital accountable · surgery through 30 days after discharge · mandatory from 2026
Five surgical categories, a 30-day window anchored on discharge, and a hospital carrying the cost of everything that happens in it, including the parts that happen somewhere else. The episode is won or lost in the handoffs.
The film follows one patient across eight beats: identify the risk before the knife, plan the discharge, close the open care gaps, coordinate the transition from hospital to physician to post-acute, follow the patient home, catch the deterioration, escalate it, and finish on episode performance.
47 seconds. The handoff across settings is beat five.
Comprehensive Care for Joint Replacement
Hospital accountable · 90-day lower-extremity joint replacement episode
The same execution problem as TEAM at a different window, and the difference is worth being precise about in front of a buyer who runs both.
The episode opens 30 days before the incision, not at it. An HbA1c above threshold, pre-operative anaemia, an INR of 3.8, a patient with no confirmed support at home: this is the cheapest point in a 90-day episode at which to change its cost. Then the window runs long enough that post-acute destination and late readmission dominate the spend, so beat five sits at day 45 rather than day 9.
42 seconds. Opens at pre-operative optimisation, not at the anchor.
Medicare Shared Savings Program
Accountable entity · total cost of care across a performance year · quarters, not days
Eight beats of a performance year, from the day attribution opens to reconciliation. The accountable entity is the ACO itself, so the film names the entity rather than a patient, and the markers are quarters.
It ends where these conversations always end: PMPM drawn against the benchmark, the shared savings position, and the quality gates that decide whether you keep any of it. One of those gates is failing in the film, at 34.6% avoidable ED against a 30% target. We left it failing, because that is what the data says, and a demo that only ever shows green teaches a buyer nothing.
47 seconds. Every screen is live data from our demo workspace, nothing injected.
Enhancing Oncology Model
The oncology practice is accountable · six-month episodes from initiation of systemic therapy
Specialty value-based care changes who carries the risk. Here it is the practice, not the hospital, and the model brings its own trigger, its own measures and its own penalised utilisation.
The film opens on the eligible population defined by the model's own logic, then follows one patient: 86 years old, lung carcinoma, on carboplatin and pemetrexed, severe fatigue reported between cycles, febrile neutropenia in the ED on day 75. That ED visit during the treatment window is spend the practice carries, and the ePRO that preceded it is the signal that could have prevented it.
Seven beats. The accountable entity is the practice, and the card says so.
Kidney Care Choices
The nephrology practice is accountable · CKD stage 4 to 5 and ESRD
The whole economics of this model turn on one decision made months before it appears in a claim. A planned home dialysis start costs roughly $76,000 in the first year. A planned start on a matured fistula, about $88,000. An unplanned inpatient start on a central venous catheter, about $109,000.
The difference is a vascular access referral placed while eGFR is still falling. That is a workflow problem, not a clinical knowledge problem, which is exactly the kind IASORA exists to close. The film sits in the decision window, on a patient whose eGFR has fallen from 29.9 to 25 over fifteen months with no access plan in place.
Six beats. The money is made before the start, not after it.
Being precise about the films
What is computed, and the one thing we need from you.
These are recordings of our demo workspace, not a customer's results. The patients are real records that pre-date every model shown; the programmes, contracts and performance panels are live reads from the product. Here is exactly where the line sits.
Computed today, from data you already hold
- Risk stratification and rising-risk ranking, with every weight and threshold visible
- Care gap detection, ownership, escalation and verified closure
- Closed-loop outreach across SMS, WhatsApp and AI voice, tracked to closure
- Episodes built from an anchor admission and a configurable window
- Cost by setting: anchor stay, post-acute, readmission, professional, ED, pharmacy
- A benchmark target price from a trimmed mean of your own historical episodes, risk-adjusted
- Quality gates, PMPM trend, avoidable utilisation and the shared savings position
The one integration ask
- Under TEAM and MSSP, CMS sets the target price and reconciles against it. Ours is a benchmark computed from your own history, and every surface labels it that way.
- To reconcile against the real number, we ingest your CCLF claims files into the same engine. That is the integration, and it is the only one this story depends on.
- Where claims coverage is thin, the engine falls back to an encounter proxy and labels the metric as a proxy rather than presenting it as spend.
How this is different
Your analytics vendor stops where this starts.
| Population health analytics | IASORA |
|---|---|
| Ranks the population by acuity | Ranks by how much risk is still movable |
| Produces a care gap list | Turns each gap into owned, escalating work |
| Reports outreach as sent | Tracks every loop to closure or escalation |
| Refreshes overnight from a warehouse | Reacts to the live clinical event stream |
| Hands the worklist to your care managers | Agents do the work behind a human approval gate |
| Tells you the contract position after the quarter | Reconciles continuously, gates and all |
| Sits beside the EMR as another screen | Writes finished work back into the record |
Who this is for
Four people have to agree, and each needs a different answer.
Health systems and IDNs, physician groups, ACOs and IPAs, and the management services organisations that carry the contract on their behalf. Whoever holds the risk, these four have to see the same number.
VP, Value-Based Care
The contract position, continuously
- PMPM against benchmark, live
- Quality gates with the failing ones visible
- Shared savings modelled at your share
- Which interventions moved the number
Chief Medical Officer
A score you can defend
- Every weight and threshold visible
- Clinical rules escalate, not a black box
- Human approval gate on every agent action
- Full audit trail on each decision
Care Management
Capacity spent where it counts
- A ranked worklist, not a spreadsheet
- Outreach that runs itself between calls
- Escalation when a loop does not close
- One board across settings
Chief Financial Officer
Where the cost actually is
- Spend by setting inside every episode
- Avoidable utilisation, sized
- Leakage and network performance
- A pilot that proves it on your own data
What it runs on
The same record the rest of the platform writes to.
Value-based care is not a separate product here. It is what happens when population health, risk and automation share one FHIR-native chart.
Population Health
Care gap detection, cohorting and the closed loop from gap to verified outcome.
Explore Population Health →Risk Stratification
Transparent, continuously re-gauged scores with every contribution visible.
Explore Risk Stratification →Automation & Insights
The agents that do the work, always behind your approval gate.
Explore Automation →Prove it on your own population
A scoped pilot runs four to six weeks against your data and your contract, and ends on a number you can take to the board. The pilot fee credits toward the agreement.
Get started
Bring your contract. We will run it against your data.
A working session with our team, on the model you are accountable for, not a generic demo.