Shifting to the left: Innovating prospective risk adjustment

In this Q&A, Arati Swadi, VP of Risk Adjustment at Optum, shares insights into the company’s current Prospective Solutions, its vision for the future and the ways it is tackling industry challenges. Arati highlights how the extensive offering and provider footprint is creating efficiencies that improve the experience of health care providers, health plans and members.

At Optum, our Prospective Solutions approach is centered on our flagship product — the In-Office Assessment Program. This program is designed to proactively support early detection and ongoing assessment of patient health conditions. By combining actionable insights, innovative technology and a dedicated field team, health plans can offer providers a powerful tool to strengthen relationships and improve patient outcomes.

The program is backed by a collaborative, multidisciplinary field team with over 750 field agents who provide specialized guidance and training for providers who may need additional support. With a provider-first approach and data-driven strategies, the In-Office Assessment Program helps deliver better risk and quality outcomes for members, providers and health plans. For over a decade, it has delivered measurable success for both payers and providers.

The core concept behind Prospective Solutions is what I call "shifting to the left," which brings interventions closer to the point of care. Today, we’re digitally connected with over 29,000 providers nationwide, embedding analytics directly into their workflow. This integration allows us to identify risk and quality gaps in real time during the patient visit, making it easier for providers to act immediately. We also provide tools and reporting that show what gaps were closed and what actions were taken, giving both providers and payers full transparency into engagement and outcomes. What truly differentiates us is scale and a multipayer, provider-centric approach that creates a seamless, member-focused experience that drives better quality and risk adjustment outcomes.

Great question. Our integration strategy prioritizes easing the provider’s workflow. The In-Office Assessment is designed to fit directly into the workflow and minimize disruption. The gaps appear directly in the EMR, allowing providers to review and close them during the patient's visit without leaving their system. For scenarios where full EMR integration isn't possible, we offer Practice Assist, a point-of-care tool that streamlines the preparation of gaps and necessary documentation prior to a visit.

On the payer side, the process is just as seamless: Payers share data with Optum; we run analytics and services on our infrastructure and then push insights downstream to providers. Everything is fully compliant with HIPAA requirements, and from the provider’s perspective, it’s payer-agnostic, where they see a consistent experience regardless of payer. Behind the scenes, we maintain strict data segregation. The result is a win-win: Payers get gap closures, providers get efficiency and members receive better care.

We reduce administrative burden by staying in the provider’s workflow. Our integration with EMRs and digital partners means providers don’t have to switch screens or systems — they can close gaps during the visit. This addresses one of the biggest pain points we hear consistently. In addition, when complete payer data is integrated with Optum’s analytics, providers gain a comprehensive view of each patient within their workflow, empowering them to close care gaps more efficiently.

The key to bringing data and insights directly into the provider’s workflow is being highly flexible and configurable. As the risk adjustment landscape continues to evolve, so do the needs of payers and providers, with many now investing in their own analytics or working directly with EMRs. Even in those cases, they partner with Optum because we offer a holistic solution they can’t get elsewhere. We strategically adapt to existing infrastructures: Whether it is pushing gaps directly into EHRs for a provider engagement team, augmenting their existing analytics or leveraging our network and connectivity. This modular approach helps provide a smooth integration into provider workflows. Our differentiation comes down to scale, innovation and strong partnerships. While others deliver gaps at the point of care, Optum does it at scale with over 29,000 providers nationwide. That connectivity drives consistency, efficiency and better outcomes across multiple payers and provider organizations.

Collaboration starts with shared tools and reporting that align payers and providers around the same member data. While the underlying data is the same, we present it differently for each audience. Payers see it in their language and providers in theirs. Our analytics serve as the common thread, and our provider engagement field team bridges both sides. They've been in the field for over a decade, listening to providers and bringing feedback back to us so we can adjust programs and share insights with payers. That feedback loop is how our In-Office Assessment solution has evolved over time — by listening to both sides and finding the balance.

Our Prospective Solutions are central to our vision for risk and quality growth and key to moving closer to value-based care. We’re making significant investments in AI, advanced analytics and tools that can help tackle future challenges. What sets us apart is our scale, combined with innovation and the strong partnerships we've cultivated. We conduct pilots that span multiple payers and health systems, giving us confidence that innovations will work across the market and reflecting the trust built through these partnerships. That scale allows us to validate solutions in a way that’s truly representative, positioning Optum to lead innovation in this space.

Risk adjustment and quality improvement programs are the foundations of value-based care because they help provide financial stability for providers and health systems. Accurate risk scores drive appropriate reimbursement and Star bonus payments and supports risk-sharing contracts with payers. Once that foundation is in place, health systems can focus on affordability, utilization and improving outcomes, which is making the shift from volume-based to value-based care possible.

Our vision is to keep pushing the industry forward by continuing to “shift to the left” and innovating beyond the In-Office Assessment Program, truly leading the transformation of prospective risk adjustment. As health care moves toward value-based care and providers take on more shared-risk contracts, there is a huge opportunity to expand beyond point-of-care solutions. Optum is at the forefront of pre-visit enablement, so providers have gap information before the patient arrives, and immediate AI-driven interventions after visits to identify remaining gaps, as an opportunity to inform providers in real time. 

We’re also moving beyond primary care to include specialists like cardiologists and neurologists, which is critical as CMS models evolve. Ultimately, our approach is proactive, tech-enabled and collaborative. Optum is supporting providers before, during and after the visit and across specialties — to help deliver better outcomes for members and payers.

When I started in this industry, risk adjustment was almost entirely payer-driven and retrospective. Providers weren’t part of the conversation — it was mostly coders pulling charts. Today, providers are integrated into the process through Prospective Solutions, actively engaged and continuously learning. I believe Optum has been a leader in driving that change. That evolution, combined with the ability to connect all sides of health care through advanced analytics and services, is what makes this work so exciting and impactful to me.