Key Performance Indicators (KPI) Explained

Coverage

Coverage Rate

% of residents enrolled/covered (point-in-time + annual “covered ≥1 month”)

State/county; age; income; race/ethnicity; disability; immigration category per program rules

Coverage

Uninsured Rate

% residents not covered (point-in-time + annual)

Same as above

Coverage

Underinsured Rate

% covered but facing high-cost burden (define threshold: deductible/OOP vs income; skipped care due to cost)

Same as above

Utilization

Avoidable ED Utilization

% of ED visits classified as avoidable/non-emergent (use a consistent grouper) + avoidable ED visits per 1,000

Region; payer/eligibility group; time of day; “no usual source of care”

Outcomes

Preventable Hospitalizations (ACSC)

ACSC admissions per 1,000; cost of ACSC admissions; top ACSC drivers (CHF, COPD, diabetes, etc.)

Region; race/ethnicity; rural/urban; comorbidity risk bands

Access

Primary Care Access Time

Median days to next available new-patient appointment; % seen within X days

Region; plan/provider group; specialty; telehealth vs in-person

Affordability

Prescription Affordability

Cost-based nonadherence rate; % reporting rationing; median OOP per Rx; % hitting OOP cap

Drug class; income bands; chronic conditions; seniors

Admin simplicity

Administrative Cost Ratio

Admin costs as % total program spend (and per-member-per-month admin)

Federal vs state ops; vendor; function (eligibility, claims, appeals)

Network

Provider Participation Rate

% providers (by type) accepting program patients + network adequacy measures

PCP, mental health, OB, specialists; rural/urban; appointment availability

Member rights

Appeals Resolution Time

% appeals resolved within SLA (e.g., urgent 72 hrs; pre-service 30 days; post-service 60 days) + backlog

Appeal type; reason codes; vendor/state; vulnerable populations

Integrity

Fraud Detection Yield & Error Rates

True positive yield; false positive rate; improper payment rate; recovery ROI

Program type; provider category; service category; geography

Equity

Health Equity Disparity Indices

Disparity gaps in access/outcomes (e.g., index score, rate ratios/differences)

Race/ethnicity; income; disability; geography; language