Healthcare organizations have access to more clinical and quality data than ever before. But data alone does not necessarily mean improved outcomes. Converting data insights into action requires a coordinated approach that aligns analytics, quality, and operations around a common goal.
One national health payer sought to improve performance across several respiratory HEDIS measures by identifying opportunities to improve prescribing behavior and close care gaps. The organization recognized that traditional reporting alone would not drive meaningful improvement. It needed a scalable, repeatable model that would turn clinical insights into targeted action.
The challenge
The organization wanted to improve performance across three respiratory HEDIS measures associated with appropriate antibiotic prescribing and testing:
-
AAB: Avoidance of antibiotic treatment for acute bronchitis/bronchiolitis, the percentage of episodes not resulting in antibiotic dispensing.
-
CWP: Appropriate testing for pharyngitis, the percentage of pharyngitis diagnoses dispensed an antibiotic and received strep test
-
URI: Appropriate treatment for upper respiratory infection, the percentage of diagnoses not resulting in antibiotic dispensing
While the data identified opportunities for improvement, the challenge was determining how to effectively influence provider behavior and measure outcomes at scale. To succeed, the organization needed a way to:
-
Identify prescribing opportunities using standardized HEDIS methodologies
-
Target providers most likely to benefit from intervention
-
Deliver meaningful, actionable outreach
-
Measure the impact of those interventions over time
- Create a model that could expand beyond an initial pilot market
The solution
A medical director from the organization approached their internal Quality team for support in improving adherence across these three respiratory HEDIS measures.
The payer launched a targeted prescriber outreach initiative using Cotiviti’s Quality Intelligence solution, including Quality Reporter, the user interface for Quality Intelligence, to gain population-level insight into measure performance and track progress toward goals.
This enabled the team to evaluate relationships between measure performance and provider practice patterns, then use that data to identify the providers most appropriate for targeted intervention.
Providers then received personalized communications containing performance results, educational resources, and standards-of-care guidance designed to encourage evidence-based prescribing practices. The initiative initially launched in a single market to validate the approach before expanding to additional regions. Performance was measured before and after outreach to evaluate effectiveness and identify opportunities for refinement.
Results and moving forward
Between 2022 and 2023, a significant number of previously non-compliant prescribers within the targeted market improved performance by an average of 23%. Measure-level improvements included gains in Avoidance of Antibiotic Treatment (AAB) and Appropriate Testing for Pharyngitis (CWP), helping narrow performance gaps against benchmarks.
The success of the pilot led to expansion into four additional markets in 2025. Building on those positive results, the payer planned to extend the initiative nationwide in 2026 ahead of the cold and flu season.
To sustain success, they also established a repeatable operating model supported by defined ownership, standardized targeting criteria, annual measurement cycles, documented playbooks, and centralized management of results and outreach materials. What began as a pilot evolved into an operational framework for continuous quality improvement.
Key results*
- 23% average improvement among previously non-compliant prescribers between 2022 and 2023
- 4 additional markets, successfully expanded from a single pilot market
- Nationwide rollout planned for 2026 based on demonstrated program impact
Key solution benefits
- Converted quality analytics into actionable provider outreach campaigns that supported identification of potential care gaps
- Established a repeatable, scalable framework for measuring and improving quality performance
- Enhanced collaboration between analytics, quality, and operational teams through clear processes and ownership models
Key differentiators
- Standardized HEDIS-based targeting methodology for identifying improvement opportunities
- Personalized provider outreach that combined performance insights, educational resources, and standards-of-care guidance
- Sustainable operating model supported by documented playbooks, reusable templates, and ongoing measurement frameworks
Looking to empower your teams and identify more quality improvement opportunities? Discover how with Quality Intelligence.
*The results depicted are based on an individual client’s experiences and circumstances. Results may vary depending on factors including but not limited to usage and application.
