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benchmark expenditure

bnchmark_exp_amt
quality·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The expected total cost of care for an attributed patient population established at the beginning of a value based contract period, representing the spending target against which actual expenditures are compared to determine shared savings or shared losses at contract settlement. Benchmark expenditure is calculated from historical claims data for the attributed population adjusted for risk score changes, regional trend factors, and quality performance. CMS calculates Medicare Shared Savings Program benchmarks using three years of historical Medicare expenditure data for each ACO participant population, updated annually with national trend adjustments.

Performing below the benchmark generates shared savings distributed to ACO participants while performing above the benchmark in two-sided risk models triggers shared losses. Healthcare data teams model benchmark expenditure calculations to project in-year performance, identify utilization patterns driving variance from benchmark, and estimate final settlement amounts to support provider financial planning and care management investment decisions.

Standard Abbreviation

bnchmark_exp_amt

Category

quality

Production DDL — FACT_QUALITY_MEASURE

FACT_QUALITY_MEASURE.sql
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
    qlty_key        INTEGER        NOT NULL  -- surrogate key,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    plan_key        INTEGER        NOT NULL  -- FK to DIM_PLAN,
    meas_yr         SMALLINT                 -- measurement year,
    hedis_meas_cd   VARCHAR(20)              -- HEDIS measure code,
    denom_ind       CHAR(1)                  -- denominator eligible,
    numer_ind       CHAR(1)                  -- numerator met,
    excl_ind        CHAR(1)                  -- exclusion indicator,
    gap_open_ind    CHAR(1)                  -- care gap open,
    star_rtg_nbr    DECIMAL(3,1)             -- star rating,
    qlty_scr        DECIMAL(5,2)             -- quality score,
    perf_thrsh_pct  DECIMAL(5,2)             -- performance threshold,
    raf_scr         DECIMAL(10,3)            -- risk adjustment factor,
    outreach_cnt    SMALLINT                 -- outreach attempts,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →

Why This Term Matters

Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.

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