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Hierarchical Condition Categories
2017
Linda Poulos CPC CPCI
Barbara Johansen MSN, RN, CPC, CRC
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Life Insurance Actuarial Science: Influence on HCC Risk Adjustment
Congressional Acts Passed for Implementation of Risk Adjustment
The HCC Model Basics: Categories, Hierarchy, RAF, Co-Morbidities
Risk Adjustment Coding, Documentation, Compliance, CMS RADV Audit
Organization of the HCC Model Based on 10 Principles
HCC Model Changes Over the Years
2017 CMS Final Call Letter on Risk Adjustment
Full Encounter Data for Risk Adjustment by 2020
Managed Care Organizations’ 5 Star Program
Medicare Chronic Care Initiatives
Congressional MACRA ACT: Movement Away from FFS, Quality versus Quantity
Questions and Discussion
Life Insurance
Industry’s Influence on
HCC Risk Adjustment
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Original Concept of Risk Adjustment
HCC Model: Implemented in 2004
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What was it based on?
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Let’s Understand The Concept of “Risk
Adjustment”
“Risky Business”
The concept long applied in the insurance
industry
 “Risk Adjustment” is a fundamental
component of actuarial science
“Defines Categories of Individuals Who Face
Similar Risks For Some Insurable Risk”
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“Medicare’s Use of Risk Adjustment”
Gerald F Kominski, PHD Consultant
8/21/07 National Health Policy Forum
George Washington University
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Age
Gender
Health Status- Presence of Chronic Disease or
Behavior Indicators ex: cigarette smoking
Actuarial life tables quantify the relationship between
risk factors and the probability of dying (insurable
loss) during a particular time period…such as the
next 12 months
Result: Life Insurance Premium
Medicare is one of the world’s largest
provider of Health Care…..Annual budget is
in the billions…..
Provides Health coverage to over 40 million
beneficiaries “entitled”
 Elderly age
 Disability
 ESRD
1. Traditional Fee For Service (FFS)
“Straight” Medicare Patient (billed per visit)
2. M + C (Medicare + Managed Care)
Private Health Care Plans ex: SCAN
**Medicare pays managed care plans a monthly
“capitated” rate to take care of their members
Guess What It Is Based On ??!!
Historically…Medicare paid managed care
organizations “expenditures” based on..
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Geographic Area (County: Adjusted Average Per
Capita Cost)
Age
Sex
Medicaid Enrollment (indicating economic need)
Separate County factors for: Disabled
Both over 65 yrs. (aged) and under 65 yrs.
End Stage Renal Failure Entitled
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This methodology (AAPCC) explained only about
1% of the variation in expenditures for caring for
these Medicare beneficiaries
Not everything was equal
It Did Not Pay “Differently” for the sicker the
patients were
“Research showed that the Medicare program
expenditures to “managed care groups” was
increasing because their enrollees were healthier than
the FFS enrollees….and the county AAPCC approach
did not account for this favorable selection”
Risk Adjustment of Medicare Capitation Pay
Using the CMS-HCC Model
Greg Pope et al
2004 Health Care Finance Review
Congressional Acts Passed for Implementation
of HCC Risk Adjustment
United States Congress passes….
“Mandated the implementation of accurate payment
to Medicare Managed Care organizations based on
risk adjustment methodology…incorporating this
by 2000
“Health Status”
Start of HCC!!
1998….To support this congressional
mandate…”managed care organizations” were
required to report inpatient data (hospital) diagnoses
2000….Medicare implemented the PIP- DCG model
to support hospital data submission:
Principal Inpatient Primary Dx. Diagnostic Related Cost
Group
This model was the result of a 20 year research project by Boston University &
Health Care Economics….funded by CMS. Estimates cost for following year from
inpatient data
Major Model Shortcoming
Only illnesses that result in hospital
admissions are counted?
This limited the information on the “health
status” of each member because the majority
of members were seen more frequently in the
ambulatory care setting
SO…….
Benefits Improvement & Protection Act
Mandates Ambulatory Data be submitted by
“Managed Health Care Organizations” in addition
to hospital data
To accomplish this Medicare selected the
HCC Risk Adjustment Payment Model
*This is a simplified version of Diagnostic Related Group
Cost Model
2004 Implementation of the HCC Risk
Adjustment Model for ambulatory care!
It incorporated inpatient hospital, outpatient
hospital, and physician encounters in
predicting “cost of care”.
It was phased in gradually over four years
from
2004-2007 (30%,50%75%100%)
2007- 100% of payment to Medicare
Advantage Plans was now based on the CMSHCC Model
for diagnostic health status reporting
Basic Structure of the CMS
Risk Adjustment Model
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Reimbursement is higher for sicker patients
and lower for healthy patients.
The patient’s health status is re-determined each year. Outreach efforts
and patient visits are extremely important.
Risk Adjustment is based on diagnoses reported through claims
(encounter data) with high importance on assessing, documenting and
coding all conditions at each visit.
Physicians, NP, PA are vital to submitting Risk Adjustment Codes (HCC’s)
Hierarchical Condition
Category
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• “Additive” Model
Includes all qualifying diagnoses
• “Prospective” Model
2017 payment based on 2016
Dates-of-Service
“Categories”: Similar conditions,
or Similar cost of treatment Have
the same value (Risk Adjustment
Factor)
Adjusts payments based on health
status
• Chart documentation and
diagnostic coding are “Key” to
Risk Adjustment
• Health status is re-determined each
calendar year
Risk Adjustment Model
8,830 ICD-10 HCC’s
79 HCC Categories
Individual Patient
RAF SCORE
The Total RAF Score is based on:
1. Demographics: Age & Gender
2. Additional Demographic risk factors are
added for Medicaid status & if patient was
eligible for Medicare due to a Disability
3. Diagnoses: Total of all Chronic Conditions
and Disease Interactions reported in a given
year
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Arranged by similar disease process
Ex: infection
Similar Body System
Ex: cardiac
Single Disease Entity
Ex: polyneuropathy
*Diagnoses are grouped clinically and are related
cost of care for these conditions
to the
HCC
Disease Group
Hierarchy
8
Metastatic CA
Acute Leukemia
9,10
9
Lung and other
Severe Cancers
10,11,12
10
Lymphoma and
other Cancers
11,12
11
Colon, Bladder,
Other
12
12
Breast, Prostate,
Other Tumors
17
Diabetes Acute
Complications
18,19
18
Diabetes with
Chronic Comp.
19
19
Diabetes
without Comp.
Drop
Associated Below
Interaction
Chronic Conditions
 INT 1
Cancer & Immunity
 INT 2
CHF & Diabetes
 INT 3
CHF & COPD
 INT 4
CHF & Renal
 INT 5
CHF & Heart Arrhythmias
 INT 6
COPD & Cardio Resp. Failure
**CMS applies extra risk points at the end
of the year for disease interactions
Guidelines for Supportive Documentation
and Coding in Risk Adjustment
Proper
documentation
is essential to
reimbursement!
Diagnostic
Coding
helps drive the
RAF scores
RAF
scores
drive the
reimbursement
ICD-10-CM: Diagnostic Coding and Reporting Guidelines
for Outpatient Services
Code for the diagnosis, condition, problem or other reason for encounter/visit.
List first the ICD-10-CM Code for the diagnosis, condition, problem, or other reason for
encounter/visit shown in the medical record to be chiefly responsible for the services
provided. List additional codes that describe any coexisting conditions. In some cases
the first-listed diagnosis may be a symptom when a diagnosis has not been established
(confirmed) by the physicians
Code all documented conditions that coexist.
Code all documented conditions that coexist at the time of the encounter/visit and require
or affect patient care treatment or management. Do not code conditions that were
previously treated and no longer exist. However, history codes may be used as
secondary codes if the historical condition or family history has an impact
on current care or influences treatment.
Co-Existing and Related Conditions
CMS recommends the official coding guidelines from ICD-10-CM published at
www.cdc.gov/nchs/icd10.htm and the Coding Clinic publications (AHA) as the best
guidance for risk adjustment diagnostic coding.
Co-Existing conditions include chronic ongoing conditions such as diabetes (HCC 17-19),
Congestive Heart Failure (HCC 85), atrial fibrillation (HCC 96), , Chronic Obstructive
Pulmonary Disease (HCC 111). These diseases are generally managed by ongoing
medication and have the potential for acute exacerbations if not treated properly,
particularly if the patient is experiencing other acute conditions. It is likely that these
diagnoses would be part of a general overview of the patient’s health when treating coexisting conditions for all but the most minor of medical encounters. Co-Existing
conditions also include ongoing conditions such as Multiple Sclerosis (HCC 77),
Hemiplegia (HCC 103),
All Conditions Coded
Appropriately
Some Conditions Coded
Low Level of Specificity
0.457
No Conditions Coded
0.457
76 year old female
Medicaid status
0.131
Medicaid status
0.131
Medicaid status
0.131
0.508
Diabetes w/o
complications (HCC
19)
0.162
No diabetes coded
X
0.316
No vascular disease
coded
X
Diabetes w/ vascular
complications (HCC
15)
Vascular disease w/
complications (HCC 104)
0.610
Vascular disease w/o
complications (HCC 104)
76 year old female
0.457
76 year old female
CHF (HCC 80)
0.410
CHF not coded
X
CHF not coded
X
Disease Interaction
(DM + CHF)
0.154
No Disease Interaction
X
No Disease Interaction
X
Total RAF
2.27
Total RAF
1.066
Total RAF
0.588
PMPM Payment
$2,205
PMPM Payment
$1,035
PMPM Payment
$571
Annual Payment
$26,460
Annual Payment
$12,420
Annual Payment
$6,852
Documentation:
In the face-to-face visit note has the medical condition been:
Monitored
Evaluated
Addressed/Assessed
Treated
The medical record must thoroughly document all conditions
evaluated and reported.
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Evaluative documentation would include statements such as:
Stable on meds
Condition worsening – medication adjusted
Tests ordered – documentation reviewed
Condition improving
Acuity- acute, chronic, intermittent
Severity- mild, moderate, severe
Etiology- trauma, diabetes, renal failure, exercise
or infection induced
Location- where is it- be specific about which joint,
chest, femur, posterior thorax
Laterality- which side is it? Left, right, both?
Detail: Present on admission status, associated
symptoms (hypoxia, loss of consciousness),
additional medical diagnoses, initial versus
subsequent encounter
Basic Chart Documentation Requirements
 The physician’s signature and credentials must be on each
chart
entry as a condition of payment from CMS.
 The patient’s name and the date of service must be on each
page of the patient chart.
 The medical record must be completed and legible.
 Only standard medical abbreviations should be used.
 The medical record must support all diagnoses coded for the
date of service and must be able to stand alone for audit on
reported diagnosis codes.
Risk Adjustment Data Validation Audits
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Compliance
Supportive Documentation for reported diagnostic codes
Auditing Endeavors-Physician Education
Increase in yearly RADV audits by CMS using outside contracted
companies similar to the current RAC audit program
The structure of the HCC Model is based on
10 principles to guarantee flexibility and
longevity
1. Diagnostic categories should be clinically
meaningful…have a set of ICD10 codes that
relate to specified disease or medical
conditions:
Ex: HCC 108 Vascular Disease
I71.9 Abdominal Aneurysm without rupture
I70.201 Atherosclerosis of native arteries of extremities, rt leg
I70.90 Unspecified Atherosclerosis, PVD
2. Diagnostic HCC Categories should predict
medical expenditures….and diagnoses should
be reasonably homogeneous with respect to
the effect on cost
Ex: Diabetes
HCC 19 E11.9 Type II diabetes mellitus without complications
HCC 18 E11.40 Type II diabetes with diabetic neuropathy
3. Diagnostic categories should have
adequate sample size to permit accurate &
stable estimate of expenditures
Example
Sufficient # of codes under each HCC Category
All 8,830 ICD HCC codes are mapped under 79 HCC categories
The HCC Model is not meant to be an all
Inclusive model for chronic illness
4.
In creating an individual clinical profile (HCC RAF
Score), hierarchies should be used to characterize
the person’s illness level (acuity)within these
disease conditions per HCC Category
Ex: Each new problem adds to a patient’s total score (disease
burden)
The more severe manifestation of a given disease condition
reported during the year defines the impact on cost (trumps
the lower)
5. The diagnostic classification should
encourage and reflect more specific coding:
Example:
Generalized diagnostic codes grouped under less severe or lower
paying diagnostic HCC Categories
General Category- G20 HCC 32 Parkinson’s Disease
Specific Category- I70.241 HCC 107 Atherosclerosis Of native
arteries of left leg with ulceration of thigh
6. The diagnostic classification does not reward
coding proliferation from a financial standpoint.
Example:
Assessing and reporting the same condition several times in a
given year (E11.9 Diabetes Type II uncomplicated)…does not
mean reimbursement is calculated on the number of times
reported…
E11.9….E11.9…..E11.9…..E11.9…..E11.9
7. Providers should not be penalized for reporting
the same diagnoses many times during the year.
Ex: No penalty for submitting the same codes
continuously…”the more codes the better“
“Better to report more…than under-report conditions”
8.
The classification system should be internally
consistent when placing new codes within the risk
adjustment model
Ex: Each year new codes are added to the model….therefore
the classification system for placing these codes within the
model should be consistent with the structure of the
hierarchy…based on cost of care for related conditions
** CMS deletes codes from the model also!
9. HCC Diagnostic Categories should provide
assignment ability of all ICD-10-CM codes to the HCC
Risk Adjustment Model.
Example:
When codes are added…the model should be able to place any
ICD-10 under one of the established HCC categories
10. Ambiguous diagnostic categories should
be excluded from the payment model
Example
Each category should be explicit in its description without room
for “interpretation or confusion”
Headings are descriptive for the conditions listed within them
Example: Renal Failure HCC 131
The HCC Model has changed over the
years…..the biggest change happened in
2014 PY (Payment Year)
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Payment Years: 2004-2013 (2003-2012 DOS) HCC V12
Model maintained the Same Design 70 Categories, Average of
3000 risk adjusted codes.
Payment Year 2014 (2013 Dates-of-Service) New V22 of HCC
Model, rearranged HCC’s, New Category Headings (79), codes
moved around, additions and deletions, uproar by Healthcare,
CMS settled on a blended model: 25% V12 /75% V22
Payment Year 2015 (2014 Dates-of-Service) CMS settled on
blended model of 67% V12/33% V22
Payment Year 2016 (2015 Dates-of-Service), 100% V22
Model, ICD-10 begins 10-1-2015.
Payment Year 2017 (2016 Dates-of-Service), introduces six
member groupings for risk adjustment, Medicaid eligible
incorporated into a grouping, complexity added to HCC
“CMS introduces six member categories to the
HCC Model for 2016 Dates-of-Service in an
effort to provide more accurate payment for
differences in risk adjustment health status”
Gorman Consultant Group “White Paper” April 2016
“CMS finalized its new risk adjustment model that will include
separate coefficients for partial benefit dual-eligible
beneficiaries, full benefit dual-eligible beneficiaries and nondual-eligible beneficiaries:
Risk Scores will be calculated separately for the following
community groups:
1.
Non-dual aged
2.
Full benefit dual aged
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Partial benefit dual aged
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Non-dual disabled
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Full benefit dual disabled
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Partial benefit dual disabled
*This will correct two problems with the current HCC Model, underPayment of full dual-eligible and underpayment of those at high cost end
CMS plans to move away from the RAPS format
for HCC data submission to full encounter data
submission by 2020
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Encounter Data System (EDS) will eventually replace the original Risk
Adjustment Processing System (RAPS) and FFS for submission of
HCC Conditions by 2020. Rational: Too expensive to run two
programs!
Blend Transition slowly over several years:
2016 Payment Year- (2015 Dates-of-Service)- 90% RAPS/FFS
10% EDS/FFS
2017 Payment Year- (2016 Dates-of-Service)- 75% RAPS/FFS
25% EDS/FFS
**As the industry shifts to value-based payments
encounter data will become a heavily weighted variable in the
equation for determining payments for provider risk scores
RAPS Submission of HCC Diagnoses to CMS Since 2004
 Face-To-Face E&M CPT
 Practitioner Name
 Patient Name
 Date-of-Service
 Diagnostic Codes
Full Encounter Data Submission of HCC DX to CMS
 Complete Invoice Information
 All CPT Codes for Face-to-Face E&M Visit
CMS mandates a point system (Report Card) for rating
the effectiveness of Managed Care Health
organizations in providing quality care to their
members and providing consumer awareness.
Domain I: Staying Healthy-Screening Tests and
Vaccines:
Adult BMI Assessment
Breast Cancer Screening
Glaucoma Screening
Annual Influenza Vaccine
Pneumonia Vaccine
Domain II: Managing Chronic Long-Term Conditions
Comprehensive Diabetes Care
Rheumatoid Disease Modifying Anti-Rheumatic Drug Therapy
Management for Patients with Cardiovascular Conditions
Controlling High Blood Pressure
Osteoporosis Management in Woman After Fx
Medication Management
CMS initiates a Comprehensive Primary Care
approach to managing chronic illness in the
Medicare population!
Rationale:
TODAY, 133 MILLION AMERICANS- ONE THIRD OF THE TOTAL POPULATION-SUFFER FROM
AT LEAST ONE CHRONIC DISEASE
70 PERCENT OF ALL DEATHS RESULT FROM “CHRONIC DISEASES”
85 PERCENT OF ALL HEALTHCARE DOLLARS GO TO TREATMENT OF CHRONIC DISEASES.
MORE THAN TWO-THIRDS OF MEDICARE DOLLARS ARE SPENT ON PATIENTS WITH FIVE OR
MORE DISEASES.
SOLUTION:
RESEARCH STUDIES HAVE DEMONSTRATED THAT CARE MANAGEMENT REDUCES TOTAL
COSTS OF CARE FOR CHRONIC DISEASE PATIENTS WHILE IMPROVING THEIR OVERALL
HEALTH. DESPITE THESE IMPRESSIVE RESULTS, PATIENTS RECEIVING CARE MANAGEMENT
SERVICES REMAIN THE EXCEPTION, NOT THE RULE.
THE RESULT:
CHRONIC DISEASE PATIENTS ARE TOO OFTEN LEFT TO MANAGE FOR THEMSELVES BETWEEN
EPISODES OF CARE. THAT PATTERN OF SPORADIC CARE TRANSLATES INTO HIGHER
COMPLICATION RATES WHICH, IN TURN, MEANS MORE SUFFERING AND COSTLY CARE.
NEW OPPORTUNITIES:
THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) ACKNOWLEDGED THE
ADDITIONAL WORK INVOLVED IN MANAGING A PATIENT FOLLOWING A HOSPITAL DISCHARGE
WAS NOT COVERED BY EXISTING REIMBURSEMENT. CMS THEREFORE CREATED A NEW
PAYMENT FOR TRANSITIONAL CARE MANAGEMENT (TCM). CPT Codes 99495 & 99496
NEW MEDICARE PAYMENT FOR CCM
WITH THE PUBLICATION OF THE PROPOSED 2015 MEDICARE PHYSICIAN FEE SCHEDULE, CMS
CONFIRMED ITS INTENT TO PAY FOR CHRONIC CARE MANAGEMENT, OR CCM, BEGINNING…
JANUARY 1, 2015
CCM PAYMENTS WILL REIMBURSE PROVIDERS FOR FURNISHING SPECIFIED
NON-FACE-TO-FACE SERVICES TO QUALIFIED BENEFICIARIES OVER A 30-DAY PERIOD.
CMS DEFINES THE SCOPE OF CCM SERVICES TO INCLUDE ESSENTIAL
ELEMENTS
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Regularly updated comprehensive patient centered plan of care (with copy to
patient)
Continuity of care through access to established care team for successive
routine opportunities
Regularly scheduled preventive services and medication monitoring
24/7 patient access to care team to address acute chronic care needs; 24/7
care team access to patient’s full electronic medical record
Opportunity for patients to communicate with care team by telephone,
secure messaging and other asynchronous communication modalities
Management of care transitions facilitated by electronic exchange of health
information
Documented coordination with home and community-based providers
required to support patient’s psychosocial needs and functional deficits
ELIGIBLE FOR CCM- Beneficiaries diagnosed with 2+ chronic conditions expected to persist at least 12 months (or
until death) that place individual at significant risk of death, acute exacerbation/decompensating, or functional
decline.
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WHO CAN BILL- Physicians, advanced practice registered nurses, physician assistants, clinical nurse
specialists, and certified nurse midwives., Other non-physician practitioners and limited-license practitioners
are eligible
BILLABLE CCM UNIT- CCM services may be billed once every 30 days provided that at least 20 minutes of
non-face-to-face care management services are furnished during that time period.
20 MINUTE SERVICE- Time may be aggregated to total 20 minutes but if two persons are furnishing services
at the same time, only the time spent by one individual may be counted. Time of less than 20 minutes over a
30 day period may not be rounded up to meet this requirement.
ROLES OF STAFF- CMS states it would expect that the 20 minutes or more of CCM services to be provided by
clinical staff be directed by a physician or other qualified healthcare professional.
LEVEL OF SUPERVISION- To count toward the 20-minute requirement, clinical staff must furnish services
consistent with the “incident to” requirements, except direct supervision (i.e. physician present in some suite
of offices and immediately available to provide assistance or direction) is not required. Instead, the services
may be provided under general supervision (no physical presence requirement). Such supervision may be
provided by a physician other than the billing physician.
ONLY ONE PROVIDER BILL- CMS will pay for only one claim for CCM per beneficiary for a 30 day period.
CMS “movement” away from Medicare “Fee-ForService” reimbursement….focusing on
performance improvement based on preventive
measures, quality outcomes, and management
of chronic illness
*Quality versus Volume”
Goals:
1. Strengthen primary care through multi-payer payment reform and care delivery
transformation
2. Empower practices to provide comprehensive care that meets the needs of all
patients
3. Improve quality of care, improve patients’ health, and spend health dollars more
wisely
Participants and Partners:
 5 year model: 2017-2021
 Up to 5,000 practices in up to 20 regions
 Two tracks depending on practice readiness for transformation and commitment
to advanced care delivery for patient’s with complex needs
Payment Redesign Components:
 PBPM risk-adjusted care management fees
 Performance-based incentive payments for quality, experience, and
utilization measures that drive total cost down
Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
On April 27, 2016, CMS published a highly anticipated Proposed Rule
that makes significant changes to the way ambulatory care clinicians
will be reimbursed by Medicare. Under the rule, payment “adjustments”
to a provider’s Medicare reimbursement would begin in 2019, but those
bonuses and penalties would be based on performance in 2017! This is
Quality over Quantity
Medicare
Savings
a multi-year
pilot Shared
program.
Program
Merit Based
Payment
MIPS
Merit-Based Incentive
Payment System
Alternate Model Payment
APMS
Alternative Payment
Models
Incentives:
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Promote value-based payment systems
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Test new alternative payment models
Increase linkage of Medicaid, Medicare FFS, and other payments to value
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Bring proven payment models to scale
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Care Delivery:
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Encourage the integration and coordination of services
Improve population health
Promote patient engagement through shared decision making
Information:
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Create transparency on cost and quality information
Bring electronic health information to the point of care for
meaningful use
ACO (Accountable Care Organization)- ACO’s are groups of clinicians, hospitals, and
other health-care providers that choose to come together to deliver coordinated,
high-quality care to the Medicare patients they serve
Advance Payment ACO Model- The Advance Payment Model is providing upfront and
monthly payments to 35 ACOs participating in the Medicare Shared Savings
Program.
The following qualify as “APM’s” in 2017:
 Medicare Shared Savings Program (Track 2)
 Medicare Shared Savings Program (Track 3)
 Next Generation ACO Model
 Comprehensive ESRD CARE (Large Dialysis Organization arrangement)
 Comprehensive Primary Care Plus (CPC+)
 Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
THANK YOU!!
QUESTIONS??
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2017 CMS-HCC Model Updates and Implementation, July 2016
[email protected].
“Value-Based Care: CMS Priorities in Health System Transformation”, Ashby
Wolfe, MD Chief Medical Officer, California, Centers for Medicare and Medicaid
Services, ICE Conference, December 2016, San Francisco
Quality Payment Program, https://qpp.coms.gov
‘The MACRA Proposed Rule on MIPS and APMs: Summary and Key Takeaways’, A
White Paper, Impact Advisors LLC, May 2016
Medicare Shared Savings Program Final Rule Overview, June 2015,
http://www.ecfr.gov/cgi-bin/retrieve
“A Summary and Analysis of the Final Rate Announcement and 2017 call letter
for Medicare Advantage Part D”, A White Paper, Gorman Health Group, April 2016
“CMS Risk Adjustment Payment Methodology: The Role of Physicians and
supporting Staff”, Pam Holt, Secure Horizons by United Healthcare, 2006
Risk Adjustment: https:// www.cms.gov/MA/risk
“Health Care Financing Review: Risk Adjustment for Medicare Capitation
Payments Using the CMS HCC Model”, Pope et al, 2004 Summer