Population

A binary indicator showing whether a member met the defined threshold for medication adherence, typically 80 percent proportion of days covered, for a specific chronic medication class during a HEDIS measurement period. This flag rolls up to plan-level medication adherence star ratings measures for Medicare Advantage plans.

The proportion of days covered score, expressed as a percentage, measuring how consistently a member fills and presumably takes a chronic medication during a defined measurement period. PDC is the standard HEDIS methodology for medication adherence quality measures covering diabetes, hypertension, cholesterol, and other chronic conditions, and is calculated as covered days divided by total days in the measurement period.

A flag identifying a member with a body mass index of 30 or greater, meeting the clinical definition of obesity, derived from either claims-based ICD-10-CM diagnosis codes in the E66 range or direct BMI measurements documented in clinical encounters. Obesity is a significant risk factor for diabetes, cardiovascular disease, and joint disorders in population health models.

A flag indicating that a member has been referred to palliative care services, used in seriously ill population analytics to measure palliative care access rates and to identify high-cost members who may benefit from goals-of-care conversations to align care with patient preferences and reduce unwanted intensive interventions.

The average monthly healthcare expenditure calculated by dividing total paid claims by the number of member months in a defined population and period, a standard normalization metric used in health plan financial reporting, actuarial analysis, and benchmarking across populations of different sizes and timeframes.

A flag indicating that a member has received the recommended pneumococcal vaccination series, used in immunization rate tracking for elderly and high-risk populations where pneumococcal pneumonia prevention is a significant population health and quality measure goal.

A code identifying the primary data source used to derive a member's population health risk profile, such as medical claims, pharmacy claims, laboratory results, health risk assessment, electronic health record, or remote patient monitoring data. Data source tracking is essential for understanding the completeness and reliability of risk stratification inputs.

A code identifying the specific type of population health intervention delivered to a member, such as telephonic care management, remote patient monitoring enrollment, health coaching, community health worker visit, or medication therapy management, used to analyze intervention effectiveness by type across population segments.

A unique identifier assigned to a population health management program or intervention record, used to link members enrolled in specific disease management, care coordination, or wellness programs to their associated outreach activities, clinical interventions, and outcome measurements across the care continuum.

The end date of the defined measurement period used for population health reporting, quality measure calculation, or value-based contract performance evaluation, used in conjunction with the start date to define the data window for population analytics and ensure consistent period definitions.

The start date of the defined measurement period used for population health reporting, quality measure calculation, or value-based contract performance evaluation, used to bound the claims and clinical data included in population analytics and ensure consistent period definitions across reporting.

An identifier for the specific version of the predictive risk model, stratification algorithm, or analytics engine used to generate a member's risk scores, tier assignments, or care gap calculations. Model version tracking is essential for reproducibility, audit trails, and understanding score changes driven by model updates versus actual member health status changes.

The total number of outreach contact attempts made by a population health program or care management team to engage a member, across all channels including telephonic, mail, email, and in-person contact, used to measure outreach intensity and calculate contact rates by program and population segment.

A flag indicating that at least one successful contact was made with a member through a population health outreach program, distinguishing between attempted outreach and actual member engagement. Contact rates are a key program performance metric used to benchmark outreach effectiveness across channels and populations.

A code identifying the specific population health or disease management program in which a member is enrolled, such as a diabetes management program, cardiac rehabilitation program, oncology navigation program, or complex care management program, used to track program reach and aggregate outcomes by program type.

A code identifying the population segment or cohort to which a member belongs for analytics or program targeting purposes, such as a Medicare Advantage chronic condition cohort, a Medicaid high-utilizer segment, or a commercial wellness program eligible group. Population segmentation enables targeted analytics and program design tailored to specific member needs.

A composite quality score derived from HEDIS and CAHPS measure performance across a defined member population, aligned with CMS Medicare Advantage star ratings methodology. Star rating scores determine Medicare Advantage quality bonus payments and are a primary driver of plan revenue and market competitiveness.

A flag indicating that a member had a qualifying follow-up visit with a primary care provider or specialist within a defined window after discharge from an inpatient admission, corresponding to multiple HEDIS transition of care measures and a key intervention in readmission prevention programs.

A model-generated estimate of the total medical, pharmacy, and ancillary expenditures expected for a member over a defined future period, typically 12 months, derived from predictive analytics models incorporating claims history, diagnosis burden, demographic factors, and social determinants. This field is a primary input for risk-based contract pricing and care management program targeting.

An indicator identifying an inpatient admission that could potentially have been avoided through timely and effective outpatient care, based on Agency for Healthcare Research and Quality Prevention Quality Indicators. Common preventable hospitalization diagnoses include uncontrolled diabetes, hypertension, asthma, and congestive heart failure exacerbations that escalated due to inadequate ambulatory management.