Unfairness toward rural beneficiaries in Medicare's hierarchical conditions categories score.

ABSTRACT: Risk adjustment is used in healthcare payment to mitigate the payer incentive to select for healthier populations and to improve fairness of quality assessment. The Centers for Medicare and Medicaid Services (CMS) has used a spending-based metric, the CMS Hierarchical Condition Category (HCC) score, to determine risk. However, the HCC score is potentially confounded by access and utilization differences, which are related to income and rurality. In this study, we investigate how related HCC scores are to mortality, a more objective indicator of clinical risk state, and whether that relationship differs between rural and urban populations. We examined calibration of the HCC spending model by calculating the predicted-to-observed spending ratio within deciles of the HCC score. We then compar

SUBMITTER: Parikh RB 

PROVIDER: S-EPMC12456169 | biostudies-literature | 2025 Sep

REPOSITORIES: biostudies-literature