Risk Management and Healthcare Policy (Jun 2023)
Drivers of Individual and Regional Variation in CMS Hierarchical Condition Categories Among Florida Beneficiaries
Abstract
Molly Jacobs,1 Earl Morris,2 Zuhair Haleem,1 Nicholas Mandato,3 Nicole M Marlow,1 Lee Revere1 1Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA; 2Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA; 3Department of Biology, University of Florida, Gainesville, FL, USACorrespondence: Lee Revere, Email [email protected]: To explore hierarchical condition categories (HCC) risk score variation among Florida Fee for Service (FFS) Medicare beneficiaries between 2016 and 2018.Data Sources: This study analyzed HCC risk score variation using Medicare claims data for Florida beneficiaries enrolled in Parts A & B between 2016 and 2018.Study Design: The CMS methodology analyzed HCC risk score variation using annual mean county- and beneficiary-level risk score changes. The association between variation and beneficiary characteristics, diagnoses, and geographic location was characterized using mixed-effects negative binomial regression models.Data Collection: Not applicable.Principal Findings: Counties in the Northeast [marginal effect (ME)=− 0.003], Central (ME=− 0.021), and Southwest (ME=− 0.009) Florida have relatively lower mean risk scores. A higher number of lifetime (ME=0.246) and treatable (ME=0.288) conditions were associated with higher county-level risk scores, while more preventable conditions (ME=− 0.249) were associated with lower risk scores. Counties with older beneficiaries (ME=0.015) and more Blacks (ME=0.070) have higher risk scores, while having female beneficiaries reduced risk scores (ME=− 0.005). Individual risk scores did not vary by age (ME=0.000), but Blacks (ME=0.001) had higher rates of variation relative to Whites, while other races had comparatively lower variation (ME=− 0.003). In addition, individuals diagnosed with more lifetime (ME=0.129), treatable (ME=0.235), and preventable (ME=0.001) conditions had higher risk score variation. Most condition-specific indicators showed small associations with risk score changes; however, metastatic cancer/acute leukemia, respirator dependence/tracheostomy, and pressure ulcers of the skin were significantly associated with both types of HCC risk score variation.Conclusion: Results showed demographics, HCC condition classifications (ie, lifetime, preventable, and treatable), and some specific conditions were associated with higher variation in mean county-level and individual risk scores. Results suggest consistent coding and reductions in the prevalence of certain treatable or preventable conditions could reduce the county and individual HCC risk score year-to-year change.Keywords: risk score, hierarchical condition category, HCC, medical coding
