CMS Hierarchical Condition Category (HCC) 2014 Risk Scores Are Lower for Rural Medicare Beneficiaries than for Urban Beneficiaries
The Centers for Medicare & Medicaid Services (CMS) use Hierarchical Condition Categories (HCC) and demographic information to calculate beneficiary risk scores, which predict expected Medicare spending by beneficiaries. CMS-HCC risk scores may be underestimating expected health care utilization among rural beneficiaries compared to urban beneficiaries. Incorrect estimation of expected health care utilization can lead to important financial losses for providers.
The NC Rural Health Research Program conducted the study, CMS Hierarchical Condition Category (HCC) 2014 Risk Scores Are Lower for Rural Medicare Beneficiaries than for Urban Beneficiaries, to investigate potential differences in rural and urban CMS-HCC risk scores by rurality, census region, and beneficiary race or ethnicity.
Previous studies across a variety of health measures suggest that rural Medicare beneficiaries are sicker than urban beneficiaries. However, this study finds that average risk scores are lower for community‐dwelling and institutional setting beneficiaries in rural counties as compared to urban counties. In addition, the more rural an area, the lower the risk score. Furthermore, in both rural and urban counties, average risk scores are generally higher for Black and Indigenous beneficiaries as compared to beneficiaries of other races, and average risk scores are lowest for beneficiaries residing in the West census region as compared to other census regions. Among community dwelling beneficiaries, risk scores are generally lower in rural counties when stratifying by census region and beneficiary race or ethnicity. An analysis of average utilization by health care setting for community‐dwelling beneficiaries in metropolitan, micropolitan, and non‐core area counties in the year prior to the calculated risk score revealed some differences in utilization count data, primarily in hospital outpatient and office‐based settings. Thus, observed differences in risk scores in rural versus urban counties may be driven in part by differences in the intensity or types of health care interventions received. However, this study cannot rule out a role for coding practices and resources as a potential additional driver of the observed differences.
For more on HCCs:
- Association of CMS‐HCC Risk Scores with Health Care Utilization among Rural and Urban Medicare Beneficiaries
- Average Beneficiary CMS Hierarchical Condition Category (HCC) Risk Scores for Rural and Urban Providers