Marketing Claim
- "We improve the health of our patients"
- "Our members are healthier than average"
- "We deliver better care"
No metric. No comparator. No timeframe. Not verifiable.
Not all healthcare claims are equal. Here is how to tell the difference.
Marketing Claim
No metric. No comparator. No timeframe. Not verifiable.
Verified Outcome
Metric YES. Comparator YES. Timeframe YES. Population YES.
| Metric | What it measures | Why it matters | Source |
|---|---|---|---|
| HEDIS | Clinical quality across 90+ measures | Industry standard for plan and provider comparison | ncqa.org/hedis |
| CMS Star Ratings | Medicare Advantage plan quality | Affects reimbursement and enrollment | cms.gov |
| Medical Cost Ratio (MCR) | Medical expenses divided by premium revenue | Core financial health metric in VBC | SEC filings and earnings reports |
| PMPM | Cost or utilization per member per month | Normalizes across different population sizes | Plan contracts and ACO reports |
| 30-day Readmission Rate | Percent of patients readmitted within 30 days | Key quality and cost indicator | cms.gov |
| Shared Savings | Savings generated vs. spending benchmark | Primary ACO performance metric | cms.gov |
| MSSP Benchmark | CMS-set spending target per ACO | Context for shared savings claims | cms.gov |
Controlling High Blood Pressure
Why it matters% of patients with hypertension whose BP was adequately controlled
HbA1c Control for Diabetes
Why it matters% of diabetic patients with good glycemic control (HbA1c below 8%)
Breast Cancer Screening
% of women who had a mammogram in the past 2 years
Colorectal Cancer Screening
% of adults with recommended colorectal cancer screening
Adults with Annual Checkup
% of adults who had a preventive visit in the past year
Children with Primary Care Provider
% of children with an established primary care relationship
Ambulatory Care
Outpatient visits per 1,000 member months
Inpatient Utilization
Hospital discharges per 1,000 member months
Emergency Department Visits
ED visits per 1,000 member months
Breast Cancer Screening
% of female members who received a mammogram
Colorectal Cancer Screening
% of members with recommended screening
Annual Flu Vaccine
% of members who received a flu shot
Diabetes Care
Why it mattersBlood sugar and cholesterol control rates
Controlling Blood Pressure
% of members with hypertension under control
Medication Adherence
% of members who consistently fill prescriptions for chronic conditions
CAHPS Survey
Member satisfaction with their plan and care
Getting Needed Care
% of members who got appointments and care when needed
Complaints to CMS
Rate of grievances filed per 1,000 members
Appeals Upheld
% of coverage denials overturned on appeal
Call Center Performance
Hold times and accuracy of information provided
Pricing Accuracy
Correct application of cost-sharing rules
Score 1 to 2
Limited Evidence. Claims lack numeric metrics, comparators, or come from self-reported sources only.
Score 3
Moderate Evidence. Some quantifiable metrics present but limited population definition or timeframe.
Score 4 to 5
Strong Evidence. Peer-reviewed, CMS, or audited sources with defined population, timeframe, and comparator.