Performance Gaps in VBC | Katharine Johnston

Identifying Performance Gaps in Value Based Care

EXPLORE

Abstract

Value-based care rewards healthcare providers for achieving desired patient health outcomes, unlike traditional fee-for-service models that incentivized patient volume. What started with 1990s HMO experiments has evolved into sophisticated payment systems led by Medicare, Medicaid, and commercial insurers like UnitedHealth Group.

At Optum, a UnitedHealth Group subsidiary, I partnered with stakeholders to develop a comprehensive learning ecosystem for Measurement Year 2023 and Reporting Year 2025 of the STAR Ratings Program. The STAR Ratings Program helps beneficiaries rate quality based on member experience, care access, and health outcomes. Each measure is based on a scale of 1-5 with 5 being the highest. The higher the rating the more it can influence consumer choice and plan payments. The STAR Measures are published annually on Medicare.gov with the goal of driving quality improvement and transparency for seniors. These ratings also influence Medicare Advantage and Part D plans and directly impacts government reimbursement for large insurers.

This overview summarizes how I addressed business needs, diagnosed training problems, developed solutions, managed stakeholders, ensured instructional quality, and measured quantitative impact.

The example shown is one module from this larger learning ecosystem on this topic.

Project Title: Getting Started, Value-Based Incentive Compensation Models

Industry: Healthcare, Optum

Audience: Clinical Staff Leads and Hospital Administrators

Business Need:

Increase ROI- Currently, healthcare spending is rising while patient outcomes are declining, resulting in higher costs for worse results.
Increased STAR rating- An increase in STAR rating reflects improvements across multiple areas including patient satisfaction, overall quality of care, customer service, plan performance, chronic condition management, and rewards patients maintaining their health over time.
Training clinical providers on the changes to HOS, HEDIS, and CAHPS for STAR Year 2025 relating to Medicare Part C, and Medicare Part D

Solution Type: In person conferences (Optum's Sequoia Fellowship Program), eLearning modules, ILT, VLT, coaching feedback for clinical personnel, and patient experience monitoring

My Role: End-to-end designer (analysis, design, development, SME collaboration, evaluation)

Tools Used: Storyline, Adobe Creative Cloud Pro, TechSmith Camtasia

Outcome: Knowledge, behavior, and workflow improvement which will produce an improved STAR Measures for 2025.

Diagnostic Approach

I wanted to develop a plan that included a task analysis, data review, interviews, and an Agile project work map. I went through and audited any relevant value based care courses from previous years and looked for any knowledge gaps that I could address in the new update.

Task Analysis: This is synopsis of the task analysis. If you would like to view the original task analysis you can view the PDF here.

Overall Task: To execute high quality, cost effective, results driven care in a clinical setting that meets high standards for quality metrics.

Task Breakdown

Manage Quality Metrics & Clinical Performance
Optimize Patient Experience (CAHPS Performance Measure)
Reduce Hospital Readmissions and Emergency Utilization
Improve Medication Adherence
Conduct Preventive Care & Health Maintenance
Participate in Shared Savings & Risk Arrangements
Leverage Care Coordination Infrastructure
Adapt Practice Patterns for Value-Based Model

Success Factors

Prerequisites:

Valid medical license and board certification
EMR and Optum Pro Portal proficiency
Understanding of Medicare Advantage and STAR rating systems
Commitment to population health vs. individual episodic care

Tools & Resources:

Optum Pro Portal analytics and reporting platforms
Integrated EMR with quality measure tracking
Care team infrastructure (coordinators, navigators, pharmacists)
Clinical decision support tools
Performance dashboards

Performance Metrics:

STAR rating component scores (target: >3.5 average across measures)
Quality bonus incentives
CAHPS survey scores
HOS functional health improvement measures
Shared savings realization
Patient panel retention rates

Data Review: Optum Health Networks internal documentation systems including Optum Pro Portal back end and user interface, literature provided by The American Journal of Medicine (JAMA) and Centers for Medicare and Medicaid Services (CMS)

Interviews: Interviews conducted with Optum Department Chairs for Cardiology, Internal Medicine, and Internal Medicine, Interview with trainers and conference leaders for Optum's Sequoia Fellowship Program, Interviews with clinical administration at Optum Health

Workflow Mapping: This is an example to show workflow mapping associated with this project. Confidential or protected information has been removed. Note not all components are shown.

Evaluation of current training: current training is from STAR Year 2023, Measure Year 2021 and does not have current implementation structure or changes to legislation, missing new initiatives and measures

Gaps: Lower than optimal scoring in prescription and quality outcomes, changes in measurement weights, changes surrounding value base care definitions, changes to evaluation of Part D measures, new incentive structure and implementation of incentives

New standards and requirements are released from Centers for Medicare and Medicaid Service

Systems Based Learning

Selecting a Solution

After analyzing the content and collaborating with stakeholders the training needed to address organizational needs aligned to specific job duties across multiple clinical roles.

Solutions:

Virtual eLearning pathways
On-site conferences
Blended learning combining in-person sessions with instructional design support

Why The Approach Was Chosen:

We leveraged Optum's existing infrastructure, including:

Internal LMS systems
Established learning catalogues
Current web hosting services
Integration with Optum Pro Portals for seamless access

Trade-offs Considered:

Why we rejected external solutions:

Cost efficiency: Our clinical staff already had familiarity with internal systems, eliminating training overhead
Resource alignment: Optum's existing in-person training network could be utilized rather than building new capacity
Infrastructure advantage: Our platforms already reached clinical staff nationwide

Root Cause Solution:

This approach directly addressed the core challenge, delivering comprehensive, role-specific training at scale. This was accomplished by utilizing familiar systems, existing support networks, and proven delivery methods. The solution balanced breadth of content with logistical feasibility while controlling costs.

Modalities in Learning

A blended learning system was used that integrated multiple channels to support performance while directly addressing business goals.

Phase 1: In-Person Foundation

After consulting with stakeholders, an in person foundation was agreed upon. This foundation would be presented at Optum's Sequoia Fellowship. This conference focuses on soft skills development for clinical staff. The conference content aligned with our curriculum so working with this conference team made the most sense to explore. This team had their own trainers and thus we provided curriculum support.

Our in-person trainers served two critical roles:

Delivered targeted soft skills content in collaboration with the conference team
Established themselves as trusted partners and ongoing resources for clinical staff

This approach provided manager enablement by positioning trainers as accessible connection points for department leaders throughout the learning journey.

Phase 2: Digital Reinforcement (Post-Conference)

We transitioned to eLearning modules and learning paths post conference since our clinical providers are stationed throughout the country. Flying them back to meet in a physical location for on going training was not economically viable. Using eLearning pathways allowed clinical providers to access training in a setting that worked with their busy clinical schedules.

Phase 3: Systemic Reinforcement

Working with department heads, we created a reinforcement plan that included:

Incentive programs tied to STAR measure improvements
Manager toolkits for coaching conversations
Progress tracking systems

Modality Decisions Tied to Business Goals:

Each delivery method directly supported our business objectives:

In-person training created and built trust in relationships and immediate skill application
ELearning paths are scalable, consistent delivery and on-demand reference
Incentive systems enabled measurable outcomes in patient satisfaction, cost reduction, and ROI

This systemic approach ensured learning translated into improved STAR scores and tangible business results.

Process and Leadership

My Process:

I lead a team of instructional designers and coordinated with clinical SMEs, in-person trainers, and business stakeholders to create systems for this content.

My System:

Stakeholder Management & Timeline Negotiation

Established bimonthly stakeholder check-ins to maintain transparency on project status and proactively attend to business changes
Used these touchpoints to negotiate realistic timelines

Team Leadership & Progress Monitoring

Implemented weekly design team meetings to track progress against established goals, identify blockers early, and provide coaching support
Monitored completion status and quality indicators including designer workloads to ensure target goals were met

Conflict Resolution & De-escalation

When differences arose between instructional designers and in-person trainers, I developed a three step resolution process:

Private conversations with each party to understand underlying concerns without defensiveness
Clear goal articulation and reestablishing shared objectives and success criteria for both groups
Joint action planning focused on bringing parties together to co-create accountability structures and next steps

This approach addressed immediate conflicts and built collaborative capacity.

SME Relationship Management

Adapted my schedule to accommodate clinical SMEs' needs
Recorded SME sessions (with permission) to create reference libraries, reducing the need for repeated meetings
Used recordings to maintain consistency across multiple designers working with the same content

Scope Management

Delineated work strategically based on designer capacity, skills, and current workload rather than simply distributing tasks equally
This capacity-based approach prevented scope creep by making resource constraints visible and creating natural boundaries for project expansion

The Impact

This infrastructure enabled me to:

Deliver complex projects on schedule
Build trust with stakeholders through predictable, transparent communication
Develop team members' skills while maintaining quality standards
Resolve conflicts before they escalated
Protect team capacity while remaining responsive to legitimate business need

Instructional Rigor

Business Metric: Improve CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey scores

The CAHPS survey evaluates four critical dimensions of patient experience:

Care accessibility
Provider communication quality
Customer service interactions
Overall satisfaction (0-10 rating scale)

Based on comprehensive task analysis, I identified CAHPS score improvement as a key performance metric. To address this business need, I developed a training module focused on clinical outcomes that directly influence patient ratings.

Learning Objectives:

Apply compensation model concepts and research to incentivize patient-centered care
Interpret CAHPS metrics and identify performance gaps
Develop meaningful thresholds for measuring success
Create actionable success measures aligned with patient experience goals
Design basic parameters for effective incentive plans

Learning Science & Instructional Strategy

I created scripts reviewed by SMEs and developed them into an eLearning module that serves as on-demand performance support which enabled quick access to critical information at point of need.

Content Simplification & UX Rationale: I deliberately employed an academic presentation style that mirrors how clinical professionals are trained to process information which is clear, concise, and hierarchically organized.

This decision was driven by:

Recognition of severe time constraints faced by clinical staff
Need for rapid information retrieval in fast-paced healthcare environments
Familiarity with academic formats reduces cognitive load
Efficiency over aesthetic complexity aligns with clinical workflow demands

Design Principle: Simplicity as functionality—eliminating unnecessary visual complexity to honor clinicians' time and optimize learning transfer to practice.

Portfolio Demonstration

This module showcases:

Business and Learning Alignment: Direct connection between training objectives and measurable organizational outcomes
Iterative Design Process: SME collaboration through script reviews and feedback integration
Audience Centered Design: UX decisions grounded in understanding of clinical professionals' work context and learning preferences
Performance Support Framework: Just-in-time learning accessible within workflow rather than extracted training events

Business Impact

This learning ecosystem was designed to improve clinical performance and increase STAR ratings and as a result produced measurable improvements across multiple performance indicators.

Clinical Performance Metrics

Internal measurement systems within Optum Pro Portal tracked the following improvements:

Patient Statin Compliance: Increased adherence to prescribed statin medications
Increase in Screening: More patients were being screen for breast and colon cancers, increased adoption of home testing kits where appropriate
A1C Blood Testing: Enhanced completion rates for diabetes monitoring
Pharmacy Utilization: Greater use of Optum Rx for prescription fulfillment

Performance Metrics

While final numbers and figures are not available for public view, an estimate can be made based on internal reporting metrics. Data suggests a point value increase in the following domains:

Medicare Part C

Domain 1: Staying Healthy - Screenings, Tests and Vaccines

C01 - Breast Cancer Screening- up from 1 to 3

C02 - Colorectal Cancer Screening- up from 1 to 3

C03 - Annual Flu Vaccine- up from 1 to 2

C06 - Monitoring Physical Activity- up from 2 to 3

Domain 2: Managing Chronic (Long-Term) Conditions

C08 - Care for Older Adults - Medication Review- up from 2 to 3

C09 - Care for Older Adults - Pain Assessment- up from 2 to 3

C11 - Diabetes Care - Eye Exam- up from 1 to 3

C18 - Plan All-Cause Readmissions- up from 1 to 2

C19 - Statin Therapy for Cardiovascular Disease-up from 2 to 3

C20 - Transitions of Care- up from 1 to 3

Domain 3: Member Experience with Health Plan

C22 - Getting Needed Care- up from 1 to 2

C23 - Getting Appointments/Care Quickly- up from 1 to 2

C27 - Care Coordination- up from 1 to 2

Medicare Part D

Domain 2: Member Complaints and Changes in Performance

D04 - Drug Plan Quality Improvement-up from 3 to 4

Domain 4: Drug Safety and Accuracy of Pricing

D07 - Medicare Plan Finder Price Accuracy- up from 2 to 3

D08 - Medication Adherence for Diabetes- up from 1 to 2

D09 - Medication Adherence for Hypertension-up from 2 to 3

D10 - Medication Adherence for Cholesterol- up from 2 to 3

Improvements in scoring will reflect an increase in monetary payout to the insurer.

Operational Efficiency Gains
Through enhanced stakeholder collaboration and clearer accountability structures, clinical staff successfully allocated more time with patients and improved health outcomes.

Error Rate Reductions
Medical coding accuracy improved following training implementation, resulting in fewer documentation errors and improved claims processing.

Clinical Staff Development
Quality of care improvement metrics confirmed that training interventions positively influenced staff knowledge and clinical practices.

Leadership Development
Optum Sequoia Fellows demonstrated measurable growth in both leadership capabilities and professional behaviors.

Stakeholder Feedback

Leader feedback and participant responses remained consistently positive throughout the learning ecosystem rollout, validating the program's design and implementation approach.

Note on Data Protection

While the Centers for Medicare and Medicaid Services STAR ratings require extended processing periods (typically one year for complete scoring), and specific numerical data remain confidential due to organizational privacy requirements.

Takeaways

Project Scope & Stakeholder Engagement

The scale and complexity of this project exceeded my initial expectations. I anticipated collaboration with department heads and operational leaders across Optum Health, Optum Rx, and Optum Insight, however the stakeholder group expanded significantly to include data analytics teams and provider advancement teams.

What Surprised Me

The addition of these teams transformed the project's depth and impact. Coordinating schedules across this larger, more diverse group, brought critical perspectives I hadn't anticipated. Most notably, the data analytics and provider advancement teams provided concrete ROI metrics and quantifiable training impact data that strengthened design decisions. Their involvement shifted my understanding of how instructional design directly influences business outcomes and how to best connect learning interventions to measurable financial and operational results.

Key Insights & Professional Growth

Working with analytics professionals, proved invaluable. The data they provided eliminated the guesswork in our design approach. This cross-functional collaboration elevated the quality and precision of the courses in ways that wouldn't have been possible with a siloed design team. For future projects, I would actively advocate for early engagement with analytics teams and make them core partners rather than supplementary stakeholders.

What I Would Streamline Next Time

The collaboration with the Optum Sequoia Fellows team why fruitful could be streamlined in the future. I would establish better coordination protocols in the beginning and be more deliberate in the integration of in-person trainers and instructional designers. Having clearer roles and responsibilities would create greater synergy and ensure consistent messaging across delivery modalities.

Data I Wish I Had Earlier

Access to baseline analytics and ROI projections at the project's outset would have refined initial design strategy and helped establish targeted success metrics.

Post-Rollout Refinement

Following implementation, my priority is obtaining CMS (Centers for Medicare & Medicaid Services) data and compare it to our internal metrics. This comparison will provide a comprehensive assessment of the program's true efficacy and reveal opportunities for iterative improvements.

Impact & Lessons Learned

This project reinforced the importance of interdisciplinary collaboration. The expanded stakeholder ecosystem added strategic value that directly improved learning outcomes and business impact. Moving forward, I would approach cross-functional partnership as an essential ingredient for designing training solutions that deliver measurable organizational results.