This analysis covers how ThoroughCare can target Accountable Care Organizations (ACOs) and Health Plans that are struggling with chronic care management (CCM) and value-based care compliance. Segments were chosen based on acute pain points in CMS regulatory requirements, availability of public data on quality performance, and the ability to craft highly specific messages.
Each segment is defined by a verifiable data point from CMS, such as low CCM billing rates or high readmission penalties, enabling messages that cite exact numbers and deadlines.
CMS pays $62.17 per patient per month for CCM (CPT 99490). An ACO with 10,000 eligible patients and a 30% enrollment rate leaves $2.24M/year on the table. Medicare Payment Advisory Commission (MedPAC) data shows only 10% of eligible beneficiaries receive CCM services.
ACOs with below-average quality scores face up to a 2% reduction in shared savings. For a typical ACO earning $5M in shared savings, that's a $100K penalty. CMS data shows 15% of ACOs fail to meet quality benchmarks annually.
| # | Segment | TAM | Pain | Conversion | Score |
|---|---|---|---|---|---|
| 1 | High-Risk MSSP ACOs with Low Quality Scores NAICS 621491 · Nationwide · ~150 companies | ~150 | 0.95 | 20% | 88 / 100 |
| 2 | Medicare Advantage Plans with Low Star Ratings NAICS 524114 · Nationwide · ~200 companies | ~200 | 0.90 | 18% | 82 / 100 |
| 3 | Next Generation and Direct Contracting ACOs NAICS 621491 · Nationwide · ~80 companies | ~80 | 0.85 | 15% | 78 / 100 |
| 4 | State Medicaid Managed Care Plans with CCM Requirements NAICS 524114 · High-Medicaid states · ~100 companies | ~100 | 0.80 | 12% | 74 / 100 |
| 5 | Employer-Sponsored Health Plans with High Chronic Disease Burden NAICS 524114 · Nationwide · ~500 companies | ~500 | 0.75 | 10% | 71 / 100 |
The pain. These ACOs face a 2% MSSP penalty for low quality scores and lose $2.4M annually per 10,000 patients by not billing for chronic care management (CCM). Most executives are unaware that CCM billing directly improves quality measures like hypertension control and diabetes management.
How to identify them. Use the CMS MSSP Public Use File (PUFF) to filter ACOs with quality scores below 80% and attributed beneficiaries over 5,000. Cross-reference with the CMS ACO Performance Year Results dataset to find those with shared savings losses or penalties.
Why they convert. ThoroughCare’s platform automates CCM billing workflows and quality reporting, directly closing the revenue gap and avoiding penalties. The EDP of $2.4M lost revenue plus 2% penalty creates a 6-month ROI for a 10,000-patient ACO.
The pain. Health plans with 3-star or lower CMS ratings miss out on quality bonus payments (up to 5% of premiums) and face member churn. Chronic care management gaps are a top driver of low star ratings on measures like medication adherence and diabetes care.
How to identify them. Query the CMS Medicare Advantage Star Ratings dataset by contract number for plans with overall ratings ≤3.0 and at least 10,000 enrollees. Filter for plans in states with high Medicare Advantage penetration (e.g., Florida, California) using the CMS MA Enrollment State/County file.
Why they convert. ThoroughCare’s CCM module directly improves star rating measures by closing care gaps and enhancing member engagement. The financial upside from a 0.5-star increase can be $50M+ for a 100,000-member plan, justifying rapid adoption.
The pain. These ACOs take on higher financial risk (up to 100% shared losses) and need to manage total cost of care. Without CCM, they miss $2.4M in revenue per 10k patients and see 15% higher hospitalization rates for chronic patients.
How to identify them. Use the CMS Innovation Center dataset for Next Generation ACOs and the CMS Direct Contracting Model Entity List. Filter for entities with at least 5,000 attributed beneficiaries and those that have been active for at least 2 years.
Why they convert. ThoroughCare’s risk adjustment and CCM capabilities directly reduce total cost of care by 8-12% in pilot studies. The combination of revenue recovery and loss reduction creates a compelling 3-month payback period.
The pain. Medicaid managed care plans in states like California, New York, and Texas face mandatory CCM reporting requirements with penalties for non-compliance. They lose $1.2M per 10,000 members in unclaimed Medicaid CCM billing and risk contract termination.
How to identify them. Access the CMS Medicaid Managed Care Enrollment Report and state-specific Medicaid program websites (e.g., CA Medi-Cal, NY Medicaid). Filter for plans with >50,000 members and states that have adopted CCM as a covered benefit under state plan amendments.
Why they convert. ThoroughCare’s platform is pre-configured for Medicaid CCM billing codes and compliance reporting. The regulatory pressure and financial penalty risk create urgency, with a typical 4-month ROI.
The pain. Self-insured employer plans with >5,000 employees spend 30% more on chronic disease management than average, often without CCM programs. They miss out on $500k in annual CMS revenue per 10k covered lives and see 20% higher absenteeism costs.
How to identify them. Use the Medical Expenditure Panel Survey (MEPS) Insurance Component from AHRQ to identify large self-insured employers. Cross-reference with the Kaiser Family Foundation Employer Health Benefits Survey for firms with high chronic disease prevalence (e.g., manufacturing, healthcare).
Why they convert. ThoroughCare’s CCM solution reduces total healthcare costs by 15% for chronic populations, directly improving employer bottom line. The EDP of $500k revenue loss plus absenteeism costs creates a 5-month payback, appealing to CFOs.
| Database | Country | Reliability | What it reveals | Used in |
|---|---|---|---|---|
| CMS MSSP Public Use File (PUFF) | United States | HIGH | ACO names, attributed beneficiary counts, quality scores, and financial performance for Medicare Shared Savings Program participants. | Play 1 |
| CMS Medicare Advantage Star Ratings (Part C & D) | United States | HIGH | Quality ratings for Medicare Advantage plans, used to validate ACO performance and identify CCM billing gaps. | Play 1 |
| CMS Medicaid Managed Care Enrollment Report | United States | HIGH | State-level Medicaid managed care enrollment counts by plan, useful for identifying ACOs with dual-eligible populations. | Play 1 |
| Kaiser Family Foundation Employer Health Benefits Survey | United States | HIGH | Employer-sponsored insurance trends and cost-sharing data, relevant for ACOs targeting commercial populations. | Play 1 |
| MEPS Insurance Component (AHRQ) | United States | HIGH | Employer health insurance premiums and plan characteristics, used to benchmark ACO revenue opportunities. | Play 1 |
| CMS MA Enrollment State/County File | United States | HIGH | Medicare Advantage enrollment by plan, county, and state, identifying ACO service areas with high MA penetration. | Play 1 |
| CMS Innovation Center Next Generation ACOs | United States | HIGH | List of Next Generation ACO participants, their performance, and model details. | Play 1 |
| State Medicaid Program Websites (e.g., CA DHCS) | United States | HIGH | Medicaid managed care plan lists and provider networks, used to identify ACOs with Medicaid contracts. | Play 1 |
| CMS Direct Contracting Model Entity List | United States | HIGH | Entities participating in the Direct Contracting model, including ACOs and their attributed populations. | Play 1 |
| CMS ACO Performance Year Results | United States | HIGH | Performance data for all ACO models, including shared savings/losses and quality scores. | Play 1 |
| LinkedIn Sales Navigator | Global | MEDIUM | Company pages, employee titles, and technology stack (via 'Technology' filters), used to identify decision-makers and validate absence of competitor products. | Play 1 |
| SAM.gov | United States | HIGH | Federal contract awards and vendor history, used to check if ACO has purchased CCM software. | Play 1 |
| Crunchbase | Global | MEDIUM | Company funding, revenue range, and employee count, used to validate target size. | Play 1 |
| ZoomInfo | Global | MEDIUM | Direct dials, email addresses, and technology stack for targeted outreach. | Play 1 |
| CMS National Plan and Provider Enumeration System (NPPES) | United States | HIGH | NPI numbers and provider taxonomy codes, used to identify ACO-affiliated providers. | Play 1 |
| CMS Hospital Compare Data | United States | HIGH | Hospital quality measures, used to cross-reference ACO performance with hospital quality data. | Play 1 |