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Query clinical evidence, utilization data, guidelines, or program outcomes
How does our cardiac rehabilitation program utilization compare to HEDIS benchmarks and regional peer plans, and what clinical factors are driving the variance?
10:05 AM
AP
Enterprise Brain Answered in 6.2s · 12 sources consulted
Program Overview
Your cardiac rehabilitation program currently serves 312 active members across Phase I, II, and III. Program costs YTD: $2.1M. This analysis benchmarks utilization against HEDIS cardiac rehabilitation measures and 14 regional peer health plans.
Utilization Comparison
Metric Your Plan HEDIS Benchmark Peer Median Variance
Enrollment rate (eligible members)68%55%52%+16%
Avg sessions per member31.428.026.8+18%
Extension requests (beyond 36)14.2%8.5%9.1%+67%
Phase III completion rate41%45%43%-4%
30-day cardiac readmission rate8.2%12.4%11.8%-31%
Avg cost per member$6,730$5,200$5,450+30%
Clinical Factors Driving Variance
1High Extension Rate (14.2% vs 8.5% benchmark)
Primary driver: Member population has higher comorbidity burden (avg 2.8 comorbidities vs 2.1 benchmark). 78% of extension requests involve members with diabetes or obesity as co-diagnoses, which are associated with slower functional recovery. Clinical evidence supports extensions for this population per ACC/AHA 2026 guidelines.
2Strong Enrollment Rate (68% vs 55% benchmark)
Your plan's automatic referral pathway from discharge captures 23% more eligible members than peer plans using opt-in referral. Higher enrollment is correlated with the lower readmission rate (8.2% vs 12.4%).
3Elevated Per-Member Cost ($6,730 vs $5,200)
Driven by combination of higher session utilization and above-market provider reimbursement rates. Valley Heart Associates (largest rehab provider, 47% of volume) bills at $187/session vs $152 regional average. Renegotiation opportunity identified.
Recommendation
The program delivers strong clinical outcomes (readmission rate 31% below benchmark) at above-benchmark cost. Recommended actions: (1) Renegotiate Valley Heart Associates rate to align with regional average — projected $340K annual savings. (2) Implement comorbidity-adjusted extension criteria to standardize approvals. (3) Maintain current enrollment pathway — clinical ROI is positive.
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Governance

Domain concepts resolved:
Utilization → sessions consumed and benefit extensions relative to plan benefit limits and clinical program parameters
HEDIS benchmark → NCQA Healthcare Effectiveness Data and Information Set, cardiac rehab measures CR-1 through CR-4
Peer plans → 14 regional health plans within the same CMS market area, anonymized for competitive data
Semantic model v3.4.1
3 concepts resolved · model v3.4.1
9 steps · 6.2 seconds
1Parsed query & intent
2Resolved program — cardiac rehabilitation
3Retrieved 12 sources across 7 systems
4Aggregated plan utilization (312 members)
5Loaded HEDIS cardiac rehab measures
6Benchmarked against 14 peer plans
7Computed variances
8Attributed clinical drivers
9Composed governed answer
Completed in 6.2 seconds
12 sources from 7 systems
Claims system — rehab sessions & costs (3)
Care management platform — enrollment & phases (2)
HEDIS measure library — CR-1 to CR-4 (1)
Peer benchmarking service — 14 regional plans (2)
Provider contracts — reimbursement rates (2)
Clinical guidelines — ACC/AHA 2026 (1)
Member risk profiles — comorbidity data (1)
EB-2026-0809-HP-02348
EB-2026-0809-HP-02348
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Recorded 09 Aug 2026 · 10:05 AM