Value-Based Care Metrics to Track and How to Improve Them
Value-based care metrics depend on the notes and codes behind them. This guide maps five metric categories to their data sources and shows how to improve each one at the encounter.
The quality committee meets a month before the measurement year closes, and the diabetes control rate sits below the contract target. Chart review shows many of those patients had their hemoglobin A1c checked and discussed, yet the result never reached the data source the measure reads.
Value-based care metrics are the quality, risk, cost, and experience measures payers use to tie payment to results. Most of them start in the clinical note.
In this article, we cover the core metric categories, where each one gets its data, and practical steps to improve them.
TL;DR: Value-Based Care Metrics at a Glance
Five points carry most of the weight:
Definition: Value-based care metrics measure clinical quality, risk, cost, and patient experience, and payers use them to set bonuses, penalties, and shared savings.
Categories: Track five groups together: clinical quality; risk adjustment and coding accuracy; cost and utilization; patient experience and access; and operational indicators that predict the other four.
Data sources: Each metric draws on claims, clinical data, surveys, or a mix, and most sources start with what the note records.
Leading indicators: Documentation completeness, chronic condition recapture, and coding accuracy precede outcome scores, so review them monthly.
Improvement: Close documentation gaps while the note is still open, then audit coding in both directions before encounters leave the system.
What Are Value-Based Care Metrics?
Value-based care metrics are the measures a payer uses to judge whether care delivered under a contract earned its reward. Each one links a result your teams can influence to a bonus, a penalty, or a share of savings.
Most of the measures you will meet come from three sources:
HEDIS measures: The National Committee for Quality Assurance (NCQA) maintains the Healthcare Effectiveness Data and Information Set (HEDIS), which includes more than 90 measures across six domains of care. Plans covering more than 235 million people report results against it.
Medicare hospital programs: Under the Hospital Value-Based Purchasing Program, the Centers for Medicare and Medicaid Services (CMS) withholds 2% of participating hospitals' Medicare payments. CMS returns that pool as incentive payments based on mortality and complications, healthcare-associated infections, patient safety, patient experience, and efficiency.
Contract-specific targets: Medicare Advantage risk contracts, accountable care arrangements, and commercial agreements add their own cost, utilization, and risk adjustment measures.
Scoring rules shape what you should watch. The hospital program gives each hospital the higher of an achievement score or an improvement score on every measure, so steady progress counts alongside standing.
Contract terms vary by payer, and Medicaid rules vary by state. Confirm which measures, thresholds, and attribution rules apply to each agreement before you build a dashboard around them.
Value-Based Care Metrics to Track by Category
Most organizations carry several contracts at once, each with its own set of measures. Grouping the measures by what they assess keeps your dashboard readable and shows where one fix improves several scores.
The five categories below cover the measures most contracts reward:
1. Clinical Quality and Outcome Metrics
Quality measures check whether patients received evidence-based care and whether their conditions improved. Outpatient contracts lean on chronic disease control and prevention, and inpatient programs add complications and readmissions.
Common clinical quality metrics include:
Chronic condition control: The share of patients with diabetes or hypertension whose most recent result falls within the measure's target range.
Preventive screening rates: The share of eligible patients who completed age-appropriate screenings, such as colorectal or breast cancer screening.
30-day readmission rate: Unplanned returns to the hospital within 30 days of discharge, measured by condition or across all causes.
Mortality and complications: Risk-adjusted outcomes after admissions and procedures, a core part of hospital programs.
Healthcare-associated infections: Infections acquired during care, tracked as a patient safety measure.
Readmissions carry direct financial weight for hospitals. The Hospital Readmissions Reduction Program measures 30-day unplanned readmissions for six conditions and procedures, including heart failure, pneumonia, and elective hip or knee replacement, and can reduce a hospital's base Medicare inpatient payments by up to 3%.
2. Risk Adjustment and Coding Accuracy Metrics
Risk adjustment metrics show whether the documented picture of your population matches how sick those patients are. Under the CMS-HCC risk adjustment model, diagnoses map to Hierarchical Condition Categories (HCCs) that set each patient's risk score and the payment tied to it.
Many outcome measures are risk-standardized as well, including the readmission measures above. Understated complexity can make your results look worse than the care your teams delivered.
Metrics worth tracking in this group include:
Risk adjustment factor (RAF) score: The average risk score across an attributed population, compared with the prior year and the contract benchmark.
Chronic condition recapture rate: The share of chronic conditions documented and coded last year that were addressed and documented again this year.
Diagnosis specificity rate: The share of diagnoses coded to the most specific code the record supports.
Documentation support rate: The share of submitted diagnoses with clear evidence in the note that the condition was monitored, evaluated, assessed, or treated.
Coding accuracy rate: The share of audited encounters coded correctly, counting missed codes and unsupported codes together.
Track removals with the same care as additions. A diagnosis the note doesn't support is an audit finding in waiting, so measure unsupported codes removed alongside newly captured conditions, following the practices behind defensible risk adjustment coding.
Our InstaCode is built for that kind of accountability. It delivers 95% coding accuracy with human-in-the-loop review, and AAPC- or AHIMA-credentialed DeliverHealth coders review every complex or flagged encounter.
Every encounter InstaCode codes is auditable, with a record of the AI's output, each human change, and the reasoning behind it.
3. Cost and Utilization Metrics
Cost metrics show whether better care is also using resources well. Most come from claims, so they lag the encounters they describe by weeks or months.
Typical cost and utilization metrics include:
Total cost of care: Spending per attributed patient, often expressed per member per month (PMPM), measured against the contract benchmark.
Emergency department (ED) visits per 1,000: A signal of whether patients can reach primary care when they need it.
Avoidable admissions: Hospital stays for conditions that timely outpatient care can often manage.
Average length of stay: The days an inpatient admission lasts, compared with expected stays for similar patients.
Post-acute spending: Costs after discharge, which often drive episode-based contracts.
Many cost benchmarks are risk-adjusted, which ties this category back to the one above. Diagnoses that never reach the claim can make a complex population look needlessly expensive.
4. Patient Experience and Access Metrics
Experience measures capture how patients perceive their care, and many programs weight them directly. The same Hospital Value-Based Purchasing Program scores patient experience alongside clinical outcomes, and health plans feel similar pressure through member surveys.
Experience and access metrics to watch include:
CAHPS survey scores: Results from the Consumer Assessment of Healthcare Providers and Systems family of surveys, covering communication, responsiveness, and overall rating.
Timely access: Days to the next available appointment for routine and urgent needs.
Follow-up after discharge: The share of patients seen within a set number of days after leaving the hospital or the ED.
Provider communication: Survey items on whether clinicians listened, explained clearly, and spent enough time with the patient.
Documentation shapes this category more than it first appears. A visit spent typing pulls clinicians' attention to the screen, while a documentation workflow that captures the conversation in the background lets them stay focused on the patient.
5. Operational Metrics That Predict the Rest
Outcome scores often arrive after the measurement period closes, so operational metrics in the mid-revenue cycle are your early signal. They show, month by month, whether the documentation and coding behind every other category are on track.
Leading indicators to review monthly include:
Documentation completeness rate: The share of signed notes that contain the elements your priority measures require.
Query rate: Clarification requests sent back to clinicians per 100 encounters, which shows where notes fall short.
Coding turnaround: Days from note signature to final codes.
Charge lag: Days from service to charge entry, a core measure of healthcare charge capture.
Open care gaps: Patients with unmet measure requirements, sorted by upcoming visits so the gap can close at the encounter.
Where Does Each Metric Get Its Data?
A metric can reflect only what reaches its data source. Mapping each metric to its source shows which gaps start in the note and which start somewhere else.
The table below maps common metrics to their main data source and the documentation detail each one depends on:
Metric | Main data source | What the note needs to show |
|---|---|---|
Diabetes or blood pressure control | Claims with reported results, or clinical data from the EHR | The most recent result, its date, and the plan |
Preventive screening | Claims and clinical records | Completed screenings with dates, including those done elsewhere |
30-day readmissions | Claims | The discharge plan, follow-up arrangements, and comorbidities that affect risk standardization |
RAF score and recapture | Diagnoses from qualifying encounters | Each chronic condition, its current status, and how it was addressed |
Total cost of care | Claims | Complete diagnoses and services, so risk adjustment reflects the population |
CAHPS scores | Patient surveys | Patient surveys Indirect: the visit experience your documentation workflow allows |
Documentation completeness | EHR and coding review | The specific elements each priority measure requires |
Nearly every row traces back to the electronic health record (EHR) note. Under value-based contracts, the clinical note is where the revenue cycle starts and where the quality score starts.
As our VP of Business Operations, Gautam Kumar, puts it, "Better clinical understanding leads to better operational and financial outcomes."
Closing those gaps is easier when the note is complete before anyone signs it.
DeliverHealth provides AI-powered clinical documentation and coding solutions for organizations from small and mid-size practices to large health systems. Our InstaNote turns each encounter, captured through ambient conversation or dictation, into a structured note with coding suggestions your providers review and approve before sign-off, and our InstaCode turns that documentation into accurate codes with credentialed coders on the exceptions.
Three details matter most for value-based work:
Ambient and dictation: Both capture modes are native across inpatient and outpatient care, so notes created after the patient leaves get the same structure as conversation-based visits.
Faithful capture: InstaNote's speech recognition is designed not to add anything that wasn't said, and your providers review every note before it enters the record.
Your formats: Templates follow your organization's and each provider's requests, so the elements your measures require have a consistent home in the note.
Book an InstaNote demo to follow a sample encounter in your specialty from capture to a structured, review-ready note.
How to Improve Value-Based Care Metrics
Improvement starts with focus. A few habits repeated every month move more metrics than a long list of one-time projects.
These five steps build on one another:
Rank Metrics by Contract Weight
List every measure across your value-based contracts, then rank them by the dollars and penalties attached. Measures that appear in several contracts, such as diabetes and blood pressure control, usually earn a place near the top.
Assign each priority metric an owner from quality, clinical operations, or revenue cycle. Every number on the dashboard then has someone accountable for moving it.
Map Each Metric to a Documentation Element
For every priority measure, write down the exact detail the note must contain, such as the most recent blood pressure reading with its date. Build those elements into your templates so clinicians capture them in the normal flow of the visit.
Revisit the mapping whenever measure specifications change, since measure stewards update their technical details on a regular cycle.
Close Gaps While the Note is Still Open
A gap caught before sign-off takes a moment to fix, and the encounter is still fresh in the clinician's memory. Each day after signature adds a query, a delay, and a higher chance the measurement period closes first.
Share open care gaps with care teams ahead of scheduled visits so the visit itself can close them. Wherever AI drafts the note or suggests a code, keep human control visible: clinicians sign every note, and credentialed coders review exceptions.
Recapture Chronic Conditions Every Year
Medicare Advantage risk scores draw on diagnoses documented at face-to-face encounters during each data collection year. A stable chronic condition still needs to be addressed and documented each year again to count.
Track recapture by condition and by provider to see where the drop-off happens. Schedule the visits that matter early in the year, so a missed encounter has time to be rescheduled.
Audit Coding in Both Directions
Sample coded encounters each month across your priority populations and check each one against the note. Count missed diagnoses and unsupported codes together, so the audit protects revenue integrity and compliance at once.
Feed what the audit finds back into templates and clinician education, then watch whether the same errors recur. Teams working to improve medical coding accuracy get the most from audits that close the loop before encounters leave the system.
Frequently Asked Questions
A few questions come up often when teams build a value-based measurement program:
What is the Difference Between HEDIS and Value-Based Care Metrics?
HEDIS is NCQA's standardized measure set that health plans use to report quality, and many value-based contracts borrow HEDIS measures as targets.
Value-based care metrics also cover cost, utilization, risk adjustment, and contract-specific operational measures.
How Often Should You Review Value-Based Care Metrics?
Review leading indicators such as documentation completeness, recapture, and coding accuracy every month, since they move first.
Review outcome and cost measures each quarter against contract targets, allowing for the lag in claims data.
Which Value-Based Care Metrics Matter Most for Hospitals?
Inpatient programs center on readmissions, mortality and complications, healthcare-associated infections, patient safety, and patient experience.
The Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program described above both adjust Medicare inpatient payments based on these results.
Can AI Improve Value-Based Care Metrics?
AI can reduce documentation and coding gaps that hold metrics back by structuring encounter notes and handling coding volume. Human controls keep that work accountable: clinicians review and sign every note, and credentialed coders handle complex and flagged encounters.
Results still depend on care delivery, contract design, and how consistently your teams act on the data.
Do Value-Based Care Metrics Differ by Payer?
Yes. Medicare, Medicare Advantage plans, state Medicaid programs, and commercial payers each set their own measure lists, benchmarks, and attribution rules, so check each payer's contract and measure specifications.
Turn Delivered Care Into Measured Results
Value-based contracts reward what the record can prove. High-performing organizations treat documentation and coding as part of their quality program and watch leading indicators long before the measurement year closes.
That work gets easier when documentation and coding support each other.
At DeliverHealth, we work in the mid-revenue cycle, where the clinical note becomes codes, quality data, and payment, and we help your teams catch gaps before encounters leave the system. InstaNote creates the note from ambient conversation or dictation, with coding suggestions your providers approve before sign-off, and InstaCode turns that documentation into accurate codes with credentialed human review.
A few details matter for teams carrying value-based risk:
Turnaround: InstaCode typically delivers billable codes within about 24 hours, so coding keeps pace with the measurement period.
Any documentation source: InstaCode codes from InstaNote, traditional dictation, operative reports, PowerScribe, or existing EHR notes, with no change to how documentation happens.
Current and compliant: InstaCode stays current on code updates and payer rules, and we sign a business associate agreement before handling any patient data.
Schedule an InstaCode demo to review sample notes aligned to your specialty, from the coded encounter to the audit trail behind it.
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